A practical approach earns plaudits

December 14, 2017 Ella Ewens

Back by popular demand, Eye Institute’s 2017 Annual Scientific Conference once again included some in-depth workshops on the Saturday, followed by the conference proper on the Sunday.

Hands on with gonio and more

A gonioscopy refresher was highlighted as an additional education need after the inaugural workshops on OCT in 2016. Unsurprisingly then, there was a significant increase in the turnout for Saturday’s workshops on gonioscopy and indirect ophthalmoscopy, where delegates were given the opportunity to gain valuable experience on these different clinical techniques.

Drs Shanu Subbiah and Jay Meyer ran the gonioscopy refresher, sharing practical tips and tricks on how to perform the technique. A video slit lamp with a large viewing screen, kindly provided by the Ophthalmic Instrument Company (OIC), allowed presenters to show delegates the elusive anterior chamber angle structures. While in the other workshop, Dr Peter Hadden treated delegates to an insightful session on how to view the peripheral retina and perform indirect ophthalmoscopy with indentation.

CL pearls, lasers and corneal implants

Numbers jumped from about 70 delegates to more than 250 for Sunday’s main conference, which included overseas keynote speaker, Associate Professor Mark Roth, a Melbourne-based clinical optometrist with a degree in pharmacology and clinical editor of Optometry Pharma.

A/Prof Roth kicked off proceedings with a lecture on the management of contact lens problems. Amongst his clinical pearls was the importance of taking a thorough history before jumping to the slit lamp. “Ask your patient about potential water contamination.” Then, he recommended using a systematic approach to examining the patient’s eyes, starting with white light before using fluorescein, and always looking at the lids and both eyes. A/Prof Roth reminded his audience that microbial keratitis is rare and painful and usually associated with mucopurulent discharge and a single lesion. “Care should be taken, however, to cover yourselves for the worse case scenario - a gram-negative bacterial infection.”

Dr Nick Mantell was next with an interesting update on refractive laser and how far it’s come over the last 20 years. “Good outcomes are the norm now.” While the newer small incision lenticule extraction (SMILE) technique shows great promise, with faster recovery and less chance of ectasia, he said.

The Eye Institute has a new excimer laser, which is one of the fastest on the market, he added. At 1050 pulses per second, the laser takes only eight seconds for a +3.00 DS correction, which previously took more than 30 seconds. This fancy new gadget also features ‘seven-dimensional tracking’, incorporating all positions of gaze plus the seventh dimension of time by predicting where the eye will move next.

Later in the day, Dr Adam Watson, discussed surface laser vision, used where a patient has a thin cornea or where corneal scarring means a flap cannot be made. Newer techniques only remove the epithelium that’s required, producing quicker healing for the patient, he said. He also discussed the use of Keraring implants for keratoconus. These corneal implants work by adding bulk to the cornea and shortening the central arc. They are suitable for moderate keratoconus and can be combined with cross-linking in 80% of cases.

Grappling with glaucoma

Dr Graham Reeves looked at biomarkers and surrogate endpoints in understanding glaucoma, and why we should be careful interpreting clinical trials. In glaucoma, the clinically relevant endpoint could be a loss of vision, reduced quality of life and functional disability. He then discussed the benefits and shortcomings of using intraocular pressure and visual field imaging as surrogates to the endpoint for glaucoma.

In a later session, Glaucoma NZ chair Professor Helen Danesh-Meyer, with trademark clarity, provided some practical tips about angle closure glaucoma and its risk factors. If it’s wide you probably don’t need gonioscopy and, if its closed, gonio might not provide much information; it’s the cases in between where it can be useful, she said.

Disc swelling, or not, and a tumour test

Prof Danesh-Meyer also tackled optic disc swelling, asking: “Is it really swollen? Are both nerves really swollen? Is there any optic nerve dysfunction? Is the cause local or systemic disease?” She explained how to pick from an armoury of tests, some available to optometrists, such as a CT scan, fundus autofluorescence, OCT and B-scans, before concluding an urgent referral is always required for a bilateral disc swelling.

Dr Peter Hadden, meanwhile, led us on a fascinating journey through rare intraocular tumours, reminding us that lung and breast cancer are the most common types of cancer and lung can show up first in the eye. He advised practitioners who spot an intraocular lesion to describe it - colour, location etc. - photograph it, OCT it, B-scan it, consider systematic associations and then refer or follow it.

Cornea and cataracts to paediatrics and dry eye

Dr Simon Dean shared some cases of cataract surgery complications, dispelling the myth that cataract surgery is a quick and simple procedure that Fred Hollows can do for 20 bucks! “If the cataract is very dense and brunescent, it’s like a chunk of leather.”

Later Dr Dean, discussed the importance of corneal sensation and its receptors for heat, chemicals, cold and osmolarity. He introduced his non-contact corneal aesthesiometer (NCCA), which uses an air puff and a cooling stimulus to measure corneal sensation and may yield more information about nerve fibre pathways involved in ocular surface health and disease (see NZ Optics’ Dry Eye Special Feature in the September 2017 issue).

Dr Shanu Subbiah presented on paediatric red eye providing some useful tips on examining children. Make eye contact with the child as they enter the room and see if they look at you; have the parent hold the child; take a careful history; take note of recent trauma or even a sore throat for potential adenoviral conjunctivitis, he said. He recommended viewing the New Zealand formulary (nzfchildren.org.nz) if considering eye drops on patients under three.

One of the big topics of the year, dry eye, and its diagnosis was tackled by A/Prof Roth, who also introduced the concept “pain without stain” where neuropathic ocular pain is over represented. He suggested using a dry eye questionnaire such as McMonnies or the Ocular Surface Disease Index (OSDI). He didn’t recommend Schirmer’s test, unless you particularly dislike the patient, suggesting instead the phenol red test. Lissamine green is also useful for identifying dead and devitalised cells and he suggested examining with white light first before blue light.

The latest recruits on MIGS, bacteria and uveitis

Dr Watson introduced the Institute’s latest recruits, Drs Narme Deva, Jay Meyer, Graham Reeves and William Cunningham, all of which now share in the ownership of Eye Institute to ensure better team-work, a sharing of skills and increased subspecialist areas to maximise patient outcomes, he said. These latest recruits then took to the podium presenting talks on their areas of interest and specialism.

Dr Reeves discussed current and up and coming minimally invasive glaucoma surgery (MIGS) techniques, where he touched on the latest, exciting development in the world of glaucoma, the Xen Gel Stent (see p3). While Dr Meyer tackled the tricky problem of what to do when chloramphenicol doesn’t work. “Acute viral or bacterial conjunctivitis should resolve in three weeks. If greater that that, it’s usually something else,” and you should rule out chronic follicular chlamydial conjunctivitis if the condition is grumbling on for weeks, he said.

While optometrists can now prescribe oral azithromycin, Dr Meyer recommended this should be managed by the patient’s GP, who can confirm diagnosis and treat partners as well. “Always look at the eyelids” was a recurring theme, as Dr Meyer explained differentials for papillae; vernal keratoconjunctivitis takes two forms, the arcus-esque limbal type or the palpebral form.

Dr Deva discussed ‘Anterior Uveitis (and) things that make you go hmmmm?’ Her first red flag is patients outside the normal age range of 20-50 years. She reminded optometrists to remember to quiz the patient about anything that may affect their immune system, such as chemo and immunosuppressant drugs, and provided examples of systemic conditions and their clinical appearance.

Poppers maculopathy, MD and a cure for dry eye?

Dr Nick Mantell returned with a look at popper maculopathy - the acute or chronic form of toxicity associated with yellow foveal spots caused by the recreational akyl nitrate family of drugs. 10% of the population have used this drug, with use more prevalent in those over 40, he said, with 10% of users developing visual problems. Of those, 60-70% get better, however 25-30% remain vision affected and do not improve.

Dr Deva said she struggled to pack everything she knows about macular degeneration (MD) into a 15-minute presentation so she formatted her approach into three pairs of shoes. First, her ‘go-to shoes’; well-trialled and go with everything. This trusty pair is the evidence-based approach to MD - ‘treat and extend’ with Avastin for a maximum of three months, considering a switch if there’s no response. Next were the ‘the shoes you should never have bought’; the ones that remind you of an error once made. These, explained Dr Deva, are the inflammatory lesions, vitelliform macular dystrophy and central serous choroidopathy, those differentials which will not respond to Avastin. Lastly, were her ‘trending shoe section’ where she touched on the use of retinal prostheses and future anti-VEGF drugs that may be beneficial, especially if they are required less often.

A/Prof Roth concluded the lectures for the day, confessing the ‘cure to dry eye’ that he had offered earlier was a false promise to keep delegates until the end of the day! He redeemed himself, however, by providing numerous tips on how to manage the episodic, early chronic phase of dry eye, explaining his preferred treatment was a short-term ‘rescue dose’ of steroids, ciclosporin and concurrent lipid-based lubricants. He also discussed new treatments looming, such as combined doxycycline and omega-3 treatments, hormonal compounds and autologous serum drops, made from a person’s own blood components. Exciting stuff, indeed.

In summary

What made this conference stand out was not only the full schedule of varied and informative talks, but also the warm and approachable style of the presenters. It’s reassuring to know that even after all their years of training, ophthalmologists still refer to things as ‘pale dots in the retina’ and admit they too can sometimes ‘freak out’ when there’s a tricky patient in the chair. This conference showed that we should be really proud of our optometry–ophthalmology relationship in New Zealand.

Next year’s conference will be held on 3-4 November, 2018, including the now popular in-depth practical workshops on the 3rd and the optometry and parallel dispensing opticians/practice managers conferences on the 4th.