SCC 2022 – an education masterclass

Moving on to Covid’s impact on eyecare, A/Prof Lim said she is pivoting to locally injected periocular steroid therapy, intravitreal injections, or Ozurdex (dexamethasone) to manage the virus’ ocular manifestations. She also stressed that systemic corticosteroids prednisolone >10mg/day can be fatal to a Covid patient. Post-Covid infection, there is a role for shared care for the patient, requiring local management of non-infectious uveitis (involving repeated depot steroid injections) and intraocular pressure (IOP) monitoring.

So, when should a patient be referred to a specialist? A/Prof Lim advised at first presentation, always ask for systemic symptoms (acutely unwell patients should be sent to the emergency department). Patients with new associated systemic symptoms should be referred for review within 1-2 weeks, she said, adding that it could well be syphilis, which has been on the rise for some time and is reaching epidemic proportions since Covid. Finally, all complicated cases that include reduced visual acuity (VA), poor visualisation of the fundus/poor dilation, raised IOP, or presence of cystoid macular oedema and associate corneal pathology, require urgent referral (within 2-3 days).

Myopia interventions

Paediatric specialist Dr Loren Rose, a senior lecturer at Macquarie University and founding member of Myopia Australia, covered the expanding field of myopia management in children.

Young high-myopes require referral to a paediatric ophthalmologist to rule out connective tissue syndromes (Marfan, Stickler) or retinal disorders (retinitis pigmentosa, congenital stationary night blindness) before interventions can begin, she said.

Myopia intervention has three components: lifestyle, with more natural light and less near work (recommendation is two hours’ extra outdoor time every day); refractive (she stressed accurate refraction is vital, with some evidence suggesting undercorrecting speeds up progression); and pharmacological (low-dose atropine).

The patient’s risk profile and progression provide guidance for when to start treatment, Dr Rose said. In her practice, the myopia treatment algorithm starts with glasses (consider dual-focus lenses if high risk) and a six-month follow-up. If axial length (AL) is greater than 0.1mm/6 months, (spherical equivalent change of 0.5D or greater), start atropine 0.01%. Dr Rose said it’s important at this point to continue monitoring AL as it will indicate if 0.01% atropine is effective and when to stop treatment. While adjusting an individual’s dose is recommended, she said she bypasses 0.025% as its side effects are similar to that of the 0.05% dose but less effective. At this stage, she recommends introducing Miyosmart (DIMS) lenses and MiSight dual-focus contact lenses, if requested.

The significant interest in myopia management was evident by the many questions put to Dr Rose, with some asking how long you should treat. Dr Rose said there’s no upper age limit – if you can measure elongation, you can treat. Myopia tends to stabilise around 16 years of age, but sometimes it’s 14 and sometimes 18, she said. Although it varies, it can be reassuring for parents to know it will stabilise.

Strabismus and botulinum toxin

Sydney-based Dr Shanel Sharma, a lecturer with the University of New South Wales and University of Sydney, offered a thought-provoking session on the assessment and treatment of strabismus in adults and children, with a special focus on the role of botulinum toxin (BoNT).

Dr Sharma said while you always need to consider all other strabismus treatment options (do nothing, glasses +/- prisms, surgery, occlusion), BoNT is valid for many patients and can dramatically improve their quality of life. Sharing case presentations of BoNT-treated children, she said many have excellent alignment many years later, sometimes for life. She concluded the optometrist’s vital role in caring for strabismus patients includes assessing who needs referral, explaining the likely treatment options and providing long-term support.

What’s new in AMD?

CERA’s deputy director Professor Robyn Guymer, Melbourne University, explored the new avenues for treating geographic atrophy (GA) and age-related macular degeneration (AMD), including more detailed imaging, likely to be approved soon.

Starting with nAMD, the stats show we are not administering sufficient injections during the first year, with seven yielding the best VA result, Prof Guymer said, adding undertreatment is causing vision loss. Even if we succeed in preserving VA in the short-term, real-life data show a drop off over time, which might be less significant with a longer lasting anti-VEGF agent. Neither do we have anything to address the formation of fibrosis or atrophy, Prof Guymer added.

Enter faricimab (Vabysmo), approved by Australia’s Therapeutic Goods Administration in August and now awaiting inclusion in the Pharmaceutical Benefits Scheme. In addition to blocking VEGF, it targets the Ang2 signalling associated with retinal vascular destabilisation and microvascular inflammation, elevated in eyes with nAMD. Faricimab, currently in Tenaya and Lucerne phase 3 clinical trials, is promising as it potentially offers a longer-acting drug while reducing scarring and atrophy, she said. Two-year results also suggest it might be possible to allow longer intervals between treatments (from 1-2 months to 3-4 months), but this remains to be confirmed by real-life data.

A different strategy to tackle the nAMD treatment burden is an implantable, reservoir-based slow-release platform. It sits in the sclera, delivering modified ranibizumab (Lucentis) and only needs refilling every six months, said Prof Guymer. Clinical phase 3 results from US Archway study indicated this system achieved its primary endpoint, being as effective as monthly injections. While short- and long-term safety issues might limit widespread availability, Prof Guymer said it may have a place for patients requiring a high frequency of intravenous injections (IVI).

A new era

We are at the dawn of a new era, Prof Guymer said, with GA treatments targeting the complement pathway being most common and in the later stages of trials. While frequent IVI is the delivery mode, other options are being explored, including long-duration therapy and gene therapy, she said. Wrapping up an afternoon of intense learning, Prof Guymer highlighted the challenge to the profession is to confidently diagnose GA and the early signs of atrophy on OCT to enable conversations with patients about these forthcoming treatments. She also encouraged optometrists to refer GA patients for imaging and baseline diagnosis and to participate in the many active trials (see CERA’s website).

Specsavers’ professional development manager Michelle Du did an excellent job chairing the clinical sessions, fielding many questions from an active audience. Impressively, over the two days, there was barely a technical glitch. The regional social events were also well attended, offering an opportunity to catch up and compare notes while enjoying good food and drinks. Even though we all love live events, it’s hard to see how a hybrid conference could have improved on this one.

Changing lives through better sight

SCC2022 also provided an opportunity to celebrate individual achievements and company-wide milestones. Dr Ben Ashby, Specsavers ANZ director of optometry, thanked Specsavers' optometrists for their work and delivered an update on the company's five-year ambition plan launched in 2020. Many results already represent world-leading outcomes, he said. "SCC also provided an opportunity to celebrate individual achievements and company-wide milestones, with Dr Ben Ashby, Specsavers ANZ director of optometry, thanking all Specsavers optometrists for their great work. Delivering an update on the five-year ambition plan launched in 2020, he said many results already represent world-leading outcomes. “It’s not a job done yet, but we are in a very good place at the two-year mark.”

• Industry-leading health outcomes goal of 95% detection rate of avoidable blindness is at 93%
• Growth and access to care goal of one million new patients and 70,000 with treatable eye disease is at 170,000 people (17%) – slower than expected due to Covid
• 135 new partnerships
• Goal of being loved by every customer – 98% of patients feel cared for
• More than 500 new graduates have joined Specsavers
  

Other notable achievements included 150,000 previously undetected glaucoma cases picked up and registering 500,000 Australians with KeepSight, which reminds diabetic patients to get eye checks. Specsavers also reached the milestone of having donated AU$5million to the Fred Hollows Foundation over 10 years.