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Report

RANZCO 2017: Myopia, collaborative care, and beyond

27/03/2018By Lewis Williams PhD
Part two of LEWIS WILLIAMS’ report into the RANZCO’s Annual Scientific Congress delves into the latest advice for myopia treatment and surgery, while also discussing the importance of collaborative care, and the future of corneal cross linking.

The purpose of RANZCO’s scientific congresses is to share and discuss the latest innovations, techniques, and advances in eye healthcare. With topics such as glaucoma, cataract, cornea, uveitis, and surgical retina featured in the program, delegates were able to add a wealth of knowledge to their existing areas of expertise.

However, the Congress also provided RANZCO with an opportunity to update its members on the progress of the College itself – especially with regard to changes made to the Vocational Training Program in the wake of the Australian Medical Council (AMC)’s 2016 Accreditation Report.

Feedback matters

Dr Ruth Ferraro, RANZCO’s current deputy CEO and head of education, was charged with providing the update on the College’s approach to ophthalmology registrar education with a focus on its Vocational Training Program (VTP).

VTP uses the CanMEDS model (Royal College of Physicians and Surgeons of Canada), a framework to identify and describe the abilities a physician needs to meet effectively, the healthcare needs of the people they serve.

According to Ferraro, assessment and feedback have been shown to drive learning that, importantly, is defensible legally. Teaching is only 3–4% about asking questions, yet 82% of questions asked as part of assessments require only simple recall (rote learning).

Ruth Ferraro
Ruth Ferraro

When delivered and documented properly, feedback that focuses on tasks, processes, and self-regulation has been shown to improve overall performance by 26%. A focus of the RANZCO VTP is early intervention in those cases rated as being borderline or inferior, and endeavours are made to achieve consistency between numerical ratings and qualitative feedback.

Each piece of feedback relates to the behaviours and conditions applicable to a single episode or encounter. To achieve that end, trainees are oriented towards the feedback process early in their training and a stated goal is the promotion of self-regulation. Ultimately, trainees are encouraged to seek feedback and to develop the ability to judge their own work.

RANZCO also uses so-called spiral learning, i.e. tasks that are increasingly challenging, in which processes and their mechanisms are calibrated to encourage the trainee to become both a seeker, and a provider, of feedback as part of the workplace assessment process.

Bonnie An Henderson
Bonnie An Henderson

Ferraro likened the process to “teaching the trainee how to fish”, and said a desired outcome is for the educator and the trainee to become allies. Additionally, clinical debriefs have been shown to improve the recipient’s performance by an average of 20–25%.

The AMC’s 2016 Accreditation Report and its recommendations guided RANZCO’s development of those processes, while Ferraro also referred to the CFEP Surveys reporting system, which provides feedback to health professionals and their organisations.

Primarily, this feedback concerns the quality of the service(s) they deliver and the relationship they have with the patients, based on evidence gathered from the patients themselves.

Myopia surgery

American ophthalmologist and Clinical Professor at Tufts University School of Medicine, Dr Bonnie An Henderson, gave her views on when to perform anterior segment surgery to correct myopic complications. She divided the approaches into corneal and intraocular, and promptly advised her audience to avoid surgery in high myopes if at all possible.

David Andrews
David Andrews

Corneal approaches include: PRK, LASIK, SMILE, LASEK, and intrastromal rings. However, she revealed that LASEK and PRK have fallen out of favour while SMILE, a femtosecond laser procedure, is increasing in popularity and professional acceptance. An intraocular approach is the implanting of a phakic IOL, preferably in those over 21 years of age.

A prerequisite to surgery is a refractive state that is stable over at least the 12 months preceding any procedure, and Henderson warned that diabetics and those with an ocular history of problems warranted further consideration before venturing into the operating theatre.

Collaborative care

RANZCO CEO Dr David Andrews gave the audience an update on college initiatives related to collaborative care with allied health professions, especially optometry.

In relation to the existing memorandum-of-understanding between RANZCO and Specsavers ANZ, he announced that it was expected that all Specsavers ‘stores’ would be equipped with OCTs by the end of 2018. That step was partly driven by the MOU and the partners’ agreement to focus on glaucoma, an underdiagnosed problem of great clinical significance and of increasing prevalence in Australia.

Referring to the guidelines relating to diabetic retinopathy, he noted that OCT was not included as yet, and therefore the guidelines ‘needed reworking’. He also described the situation regarding RANZCO’s NZ theatre of operation as being ‘different’.

Despite the MOU with Specsavers being in place for some time, Andrews revealed that currently, only three RANZCO fellows are participating.

KEYNOTE SPEAKERS

Fiona Wood AM

Michael Belin

Geoffrey Cohn OAM

Noel Alpins

Jonathan Crowston

Trevor Sherwin

Graduation address

Director of the Burns Service of Western Australia, Professor Fiona Wood AM, gave the opening address at the RANZCO Graduation and Awards Ceremony and President’s Reception held, once again, in Winthrop Hall at the UWA.


According to Wood, regardless of the level of practice achieved, medicine is about “the people you serve, a privilege to serve in fact, and the motivation to get up each morning to be the best you can be. A voice to be heard and preferably, a loud one at that.”

She likened each case to being a case study with n=1 subjects, i.e. just the patient as the subject and the practitioner as the researcher and, despite the apparent simplicity of such a ‘study’, she claimed that each interaction has the power to change a life – the patient’s and/or the practitioner’s.

Referring to a topic dear to her heart and professional career, burns, she offered her thoughts on the concept ‘that there is no such thing as coincidence’ – something she takes guidance from professionally. Expanding on this concept, Wood referred to a case of hers from 2003 – an eight-year-old boy with burns to 80% of his body, who survived only to die as a result of a tumour at age 11.

His death was no coincidence and, following a study of 30,000 burns victims matched to 120,000 normals acting as a control group, Wood was able to show that surviving burns increases the risk of cancer later. Her research was assisted by the use of IBM’s Watson Discovery AI platform, which she described as the world’s most powerful search engine.

Wood postulated that burns have stress and inflammation components, and those contribute to problems later in life. Her advice was to learn from the suffering of others and yourself, noting that you learn more on a ‘hard’ day than on one that flows smoothly. For her parting advice, she repeated her earlier statement to “get up each day and be the best you can be.”


Visiting Fellow from ANU’s College of Science, Professor Ian Morgan added to the expanding body of knowledge on myopia with his presentation ‘Epidemiology of myopia, risk factors, preventative treatments’. He attributed only 1–2% of myopia to genetic factors alone, blaming single nucleotide polymorphisms (SNPs) and chromosomal rearrangements for those cases.

In passing, Morgan noted that syndromic myopia, e.g. associated with Marfan’s or Stickler Syndromes, static congenital myopia, etc. was also an issue, but not part of the current myopia problem as their characteristics have remained largely unchanged over time. He attributed high myopia, defined as ≥–5, as being a natural progression of so-called ‘school myopia’. If prevention is to be successful, he believes that research needs to concentrate on the 6–10 years of age bracket.

Morgan listed the education system, the amount of near work, time spent outdoors, and parental myopia (presence/absence, one or both, and magnitude) as factors that contribute to myopia. Describing it as a serious problem, especially in East Asia, he covered the genetic aspect further by revisiting the parental myopia issue and posed the question: Is it genetic or have the parents created a myopigenic environment for their children instead?

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Environmental factors are supported by a 1993 study of male orthodox Jews in Israel – the study’s subjects showed significant myopia while their sisters had little or no myopia. Schooling of orthodox males is characterised by sustained near vision, and frequent and significant changes in accommodation.

The importance of time outdoors, a principal finding of the Sydney Myopia Study (Morgan was a researcher in, and co-author of, the landmark paper that resulted [Rose et al., 2008]), is still the subject of significant research around the world, especially in East Asia. The beneficial effect of time spent outdoors in a child’s formative years has been attributed to the light-dopamine pathway, because dopamine has been shown to decrease axial elongation of the eye.

As a result, several practical trials are underway in Asia, and Taiwan has shown long-term benefits from two hours per day of outdoor exposure on school days. Other measures shown to be effective in varying amounts include Ortho-K CLs, anti-myopia CLs, anti-myopia spectacles, and low-dose atropine. However, while 0.01% atropine is now preferred, children with collagen problems that lead to weak scleras do not respond favourably and the number of resistant cases could be as high as 10%.

Ian Morgan
Ian Morgan

Quoting the managing director of Lions Eye Institute (LEI), Professor David Mackey, Morgan rated genetics as number 18 among the bases of myopia whereas, by way of contrast, genetics was rated third in the aetiology of glaucoma. To date some 20 genetic loci have been identified as myopia-related.

Tellingly, data gleaned from the simple question of “Do you wear glasses?” on commercial DNA genetic testing and analysis service, 23 and Me, overlaps LEI’s rigorous data almost perfectly. The privately held personal genomics and biotechnology company is also a member of the Consortium for Refractive Error and Myopia (CREAM).

When all data is combined there are some 104 DNA regions involved in myopia, 70 of which are new, including a dopamine-related locus. Regardless, genetics cannot explain most myopia observations because the majority of the current problem is post-1970 and genetic factors do not change at a rate that might explain, even partially, the prevalence of modern myopia.

A possible myopia pathway is the poorly understood retina-to-sclera signalling cascade. However, a lack of a significant number of suitable cases in WA has so far thwarted the LEI’s research efforts into high-myopia.

Morgan also noted that high myopia was associated strongly with systemic and other ocular problems and just 8% had ‘simple’ (uncomplicated) myopia. Stickler Syndrome, a collagen disease, was the most common associated condition.

The problem in East Asia has reached the stage that some Chinese children younger than six-years-old have myopia greater than –6 D, but many such cases have now been attributed to the BSG gene, a recent but uncommon mutation. Myopic parents are not a pre-requisite.

To illustrate the change in prevalence, data from the National University of Singapore shows: 1970 – 26%, 1980 – 43%, mid 1990s – 66%, late 1990s – 83%. Pathological myopia prevalence is about 5%. Meta-PM (pathological myopia) is rated by clinical findings: 1 = tesselated fundus, 2 = diffuse atrophy, 3 = patchy atrophy, 4 = macular atrophy. An additional fundal feature that might be seen and appended to a rating is ‘lacquer cracks’.

Morgan reported that the posterior staphylomas that can appear in PM can be one of 10 types. High myopia is neither static, nor a simple condition, and is a leading cause of vision impairment and blindness. Unsurprisingly, the risk of myopic macular degeneration increases with age. Fundal changes in high myopia appear as a nasal extension of the optic disc/nasal peripapillary lesion and choroidal thickening, followed possibly by PM.

In a longitudinal study, the Singapore Epidemiology of Eye Diseases (SEED) project is following 1,200 adult high myopes in a bid to quantify the changes experienced and to gain a better understanding of what they are dealing with.

He added that Specsavers were looking for local education from local ophthalmologists and hoped to be able to lodge entries in the Save Sight Institute (SSI) Glaucoma Registry Database.

To that end, he reminded the audience that RANZCO was still seeking local fellows interested in the education of their Specsaver optometrists as well as local GPs. Professor Robyn Guymer (CERA, Victoria) and Dr John Downie (private practice, NSW) were reported to be working on other guidelines to augment those already available and agreed to.

Updating keratoconus

US ophthalmologist and regular RANZCO congress presenter, Professor Michael Belin, gave an update on the ‘ABCD’ classification system he and colleagues developed to better describe and grade keratoconus (KC). His group is now seeking global consensus on their system, while he also described the existing Amsler-Krumeich Classification for Grading KC as useless because it ignores posterior-cornea factors.

Optical pachymetry also has its limitations, especially if only measured at the apex of the ectasia. A major driving force behind his team’s latest endeavours is the failure of current systems to recognise early disease and their poor utility in relation to corneal cross-linking (CXL). The team’s aim was to create a simple, instrument-agnostic grading system that took into account anterior and posterior corneal radii, and corneal thickness.

The system is based exclusively on a three millimetre-diameter zone, centred on the cornea’s thinnest point. Belin based the system on curvature radii and not on the surface powers, as the former is what keratometers and topographers actually determine – powers are based on assumptions of refractive index/indices.

The four main grades are A–D with five stages, Stage Zero is reserved for a completely normal cornea, Stage Four for the most advanced grades. The absence, presence, and magnitude of any corneal scarring is added as a rider to the Stage/Grade.

A one-sided Confidence Interval approach is taken to determine true KC progression, as practitioners are only interested in corneal thinning, not thickening as well (i.e. a two-sided approach is not regarded as relevant). Belin questioned the existence of true unilateral KC and he recommended that CXL intervention be instigated before any decrease in VA occurs.

The future of CXL

Gerard Sutton
Gerard Sutton

Foundation chair of Cornea and Refractive Surgery at USyd., Professor Gerard Sutton, posed the question of where CXL was leading anterior segment surgeons, including the possibility that CXL might render most penetrating kertoplasties redundant.

Sutton described CXL as an effective procedure that flattened the cornea, improved VA, enhanced the quality of life (QofL), and reduced anxiety. However, while reduced average K equates to better Kmax, a paper by the University of Auckland’s Professor Charles McGhee found that the cornea can flatten progressively in the long-term in some cases.

While still a surgical procedure, Sutton regarded it as being safe with a good safety profile. Regardless, he does not regard CXL as a procedure for all, rather it should be reserved for those that demonstrate progression clearly. However, if there was evidence that progression was likely, he advised that CXL be performed early in anticipation.

Additionally, if the patient also has an atopic condition, he advised that the atopy be treated before any CXL to prevent problems arising from eye rubbing post-CXL. Overall, Sutton recommended that the patient be examined at one, three, and six months before any possible CXL procedure is undertaken. He also warned that KC can progress later and CXL does not necessarily stall that possibility.

CXL is not regarded as a repeatable treatment
CXL is not regarded as a repeatable treatment

Further episodes of CXL treatment do not result in additional improvements, i.e. CXL is not regarded as a repeatable treatment. While accepting that children as young as eight years can be treated and generally, the results are comparable to that of adults, he noted that some children can still progress later.

In a comparison of epi-on CXL and the less desirable but standard epi-off alternative, Sutton noted that epi-off was less efficacious and resulted in greater curvature differences post-treatment. Although some surgeons view 400-micron corneal thickness as the minimum thickness that can be CXL’d, his view is that 330 microns is an acceptable minimum.

Because the original, so-called Dresden technique of CXL uses a 30-minute UV exposure time, many attempts have been made to accelerate the process, such as different concentrations of riboflavin, different vehicles, different irradiation intensities, etc. To date, most such attempts have resulted in inferior outcomes but research is ongoing.

Other methods of delivering riboflavin into the cornea, such as iontophoresis or assistance from vitamin E as a permeability enhancer, are under investigation. Likewise, topography-guided CXL is also being pursued in an attempt to dose only those parts of the cornea requiring treatment, rather than the routine dosing of the whole cornea.

To help refine the profession’s knowledge base on KC and CXL, Sutton recommended the use of at least one of the two ANZ KC registries.

The next RANZCO Annual Scientific Congress, the 50th, is scheduled to commence in Adelaide on November 17.

RANZCO’s Annual Scientific Congress Gallery



Ruth Ferraro
Ruth Ferraro
Bonnie An Henderson
Bonnie An Henderson

David Andrews
David Andrews
Ian Morgan
Ian Morgan

Gerard Sutton
Gerard Sutton
Fiona Wood AM
Fiona Wood AM

Michael Belin
Michael Belin
Geoffrey Cohn OAM
Geoffrey Cohn OAM

Noel Alpins
Noel Alpins
Jonathan Crowston
Jonathan Crowston

Trevor Sherwin
Trevor Sherwin
CXL is not regarded as a repeatable treatment
CXL is not regarded as a repeatable treatment

 

 


More reading: Special Report Part 1: RANZCO maintains high momentum at 49th Annual Scientific Congress

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