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Report

Collaboration the focus of RANZCO 2016

30/10/2017By Lewis Williams PhD
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With the deadline looming over glaucoma care between opthalmologists and optometrists and RANZCO’s MOU with Specsavers, the 48th RANZCO Conference had plenty on the agenda. LEWIS WILLIAMS reports on the key lectures and the challenges ahead.

RANZCO CEO, Dr David Andrews, opened the organisation’s 48th Annual Scientific Conference by summarising the college’s goals, which included being: the leader in collaborative eye care; the source of evidence-based training, practice, accreditation, and education; and engaging more effectively with college members.

Ms Emma Carr, RANZCO general manager of communications, expressed her desire to engage Australian and New Zealand GPs and optometrical organisations in, two-way explorations to find common ground in achieving the desired outcomes of all parties.

To that end, Carr called on RANZCO members to help build relationships with the media, policy makers, governments, patient bodies, and social media. Her aim is to reinforce the existing RANZCO position of being the trusted source of authoritative, clear, reliable, evidence-based ophthalmic information and to enhance stronger and more open communications with optometry to reflect leadership and collaborative health and eye care.

Dr Brad Horsburgh, RANZCO’s outgoing president, summarised 2016’s achievements as the memorandum of understanding (MOU) signed with Specsavers in March, the release of the glaucoma care guidelines and referral pathway in August, and the diabetic retinopathy (DR) and AMD guidelines and pathways in November.



"My wish is for RANZCO’s guidelines to become the lingua franca or the Rosetta Stone for eye care."
Dr Brad Horsburgh, RANZCO’s outgoing president

Horsburgh’s wish is for RANZCO’s guidelines to become the lingua franca or the Rosetta Stone for eye care. The underlying principles of the guidelines should be available to all GPs and optometrists and all relevant education should be available to all eye care practitioners.

He described collaborative eye care as an idea whose time has come. The glaucoma guidelines derived from work by Associate Professor Ivan Goldberg and Dr Andrew White and vetted by Professor Stuart Graham are a result of the conflict between ophthalmology and the Optometry Board of Australia two years ago. The DR guidelines incorporate the NH&MRC guidelines released earlier, and regard fundus photography as an integral and essential part of collaborative care.

Guidelines for paediatric care are the next scheduled for release – unlike the others released previously, the paediatric guidelines are likely to create some waves if the recent fallout in Queensland over the denial of participation by some behavioural optometrists in an ophthalmological paediatric course is anything to go by.

Referring to the $600,000 ‘burned’ collectively by ophthalmology and optometry in legal jousting at the High Court level over glaucoma care, Horsburgh stated that good relations between ophthalmology/medicine and optometry needed formalising, using the “remarkable and positive” turnaround that followed the dispute’s resolution.

Horsburgh noted that governments were keen on the savings that such collaboration can generate over time and he also raised the recent UK manslaughter case against an optometrist as evidence that a medico-legal, risk-mitigating strategy was required by both professions.

Furthermore, any such development had to occur by 17 December 2017 because several earlier undertakings (guidelines) expire the following day.

Admitting that many within optometry were unhappy over RANZCO’s MOU with Specsavers, Horsburgh suggested a project officer was needed to “smooth the wrinkles” if wider acceptance was to be achieved.

New RANZCO president, Associate Professor Mark Daniell spoke about the governance of the college’s branches noting that the relevant bylaws were “antiquated”, branch stacking was known to occur, and questions without notice were too common.

Some tidying-up was required along with an audit to clarify a number of issues and, unless changes are made, special interest groups and their directors may be liable for any administrative failures or shortcomings.

Following the opening addresses, a series of presenters delivered reports on their fully, or partially funded research by ORIA.

Topics covered included gene therapy (RPE cells have been grown, cultured, and transplanted into diseased eyes with mixed success), the nascent technology of gene editing (which is not gene therapy) using CRISPR/Cas9 technology, the role played by SD-OCT in visualising neovascular AMD, research into induced pluripotent stem cells (iPSCs)(the creation of a human retina is estimated to be just five years away), and the optometric use of telemedicine in rural WA (see later in this report).

The council lecture

Professor Gerard Sutton, Sydney University’s foundation chair of cornea and refractive surgery delivered the Council Lecture. Titled Synergy and Serendipity: Essential Ingredients in Innovative Corneal Therapy Sutton used 20th century examples to illustrate serendipity in medical discoveries starting with Alexander Fleming and penicillin, then Barry Marshall and stomach ulcers attributable to Helicobacter pylori, and ending with Viagra.

The RANZCO exhibition hall was well-attended all day, every day
The RANZCO exhibition hall was well-attended all day, every day

Moving on to surgical intervention in keratoconus (KC), a topic central to Sutton’s work, he noted that Australia has a penetrating keratoplasty (PK, first performed by Zirm in 1905) rate of around 31% whereas NZ has more than 41%, the latter possibly representing severity of cases rather than differences in practitioner behaviour.

Also lowering the PK rate is the increasing use of corneal cross-linking (CXL) although Sutton nominated neoplasia, corneal haze, and a reduced ocular healing rate as possible downsides to the procedure.

Depending on a number of factors including ethnicity, environment, and diagnostic definitions, the genetic links with the disease range from 6 to 23.5% of cases. Confounding the issue is the large number of genetic loci that have already been identified in KC. Despite all the research, the aetiology of KC is still poorly understood.

In KC, early corneal epithelial cell elongation has been demonstrated, genetic predisposition, if not the aetiology, is suspected, and there is little doubt that secondary behaviour such as vigorous eye rubbing or knuckle rubbing (probably a response to symptoms of KC or other underlying, predisposing conditions such as atopy) are implicated.

One avenue that has involved Sutton and colleagues for several years now is the possible role of the Wnt Signalling Pathway in KC’s aetiology, especially its secreted frizzled-related proteins in tears and cornea that are up-regulated in the condition.

Moving further back in the cornea to the endothelium, Sutton gave current estimates of endothelial cell density loss annually as 0.6%. In endothelial diseases such as Fuch’s Dystophy, some success with Rho/Rho-kinase inhibitors have been reported by inhibiting apoptosis of endothelial cells thereby preserving the layer’s function.

In primate experiments, seeding the anterior chamber with cultured endothelial cells has seen as many as 40% take-up normal cell positions on the posterior cornea. As a result, he believes that a shift from surgical to cell-based therapy might eventuate for such endothelial diseases.

Acknowledging the work of colleagues in Auckland, particularly Professor Charles McGhee and Associate Professor Dipika Patel, Sutton noted their early success using acellular, stromal, bioengineered, corneal ‘scaffolds’ with ex vivo colonization of host endothelial cells, keratocytes, and epithelium.

A contributing factor to his interest in eye banks is the evolving role such repositories have in preparing pre-cut corneal tissue that saves time and stress during penetrating (eg, penetrating keratoplasty) or lamellar (eg, DSAEK) corneal procedures – a process he described as “value-adding”. From the developments completed or being undertaken currently, it would seem that KC patients have a brighter outlook for their future care.

KEYNOTE SPEAKERS

David Andrews

Emma Carr

Brad Horsburgh

Gerard Sutton

The risk of making cataract patients wait

Falls by older Australians often lead to significant, adverse long-term outcomes including death, an issue addressed in the paper by Ms Anna Palagyi, Research Fellow at the University of Sydney-affiliated George Institute for Global Health.

Her presentation was based on a recent publication (Palagyi et al., 2016) by authors from various hospitals and research centres around Australia. About 30% of those waiting for cataract surgery experience falls before undergoing cataract surgery and the delay, even in high-income countries, can be quite lengthy.

While it has always been known that vision impairment (VI) increases the risk of falls, the Blue Mountains Study showed that the presence of cataracts doubled, and in some cases, tripled the risk of falls. Ironically, the first cataract surgery increases the risk of falls while hospitalised but surgery resulted in a 33% reduction in falls ultimately.

Palagyi is the project manager of the FOCUS study that is examining the relationship between falls risk and cataracts in a longitudinal study of older people (329 bilateral cataract cases, ≥65 years of age, mean age 75.7 years). Eight public hospitals in Sydney, Melbourne, and Perth are involved and each case is studied in the pre-first surgery period and after surgery.

Participant’s vision (VA, stereopsis, Rx, a cataract questionnaire, visual disability), health status, physical function including the use of walking aids, and Quality of Life (QofL) were analysed.

A total of 267 falls were reported by 101 (30.7% of the 329 cohort) participants during the waiting period (mean 176 days), an incidence of 1.2 falls per person-year. Although the number of falls is similar for people of similar ages who are not waiting for cataract surgery, the per person fall rate is somewhat higher than reported in one US study of those aged ≥65 years (0.4 to 0.6).

Factors associated with falls, 51.7% of which were injurious, included greater walking activity, poorer health-related QofL, and a fall reported in the previous 12 months. No visual measure (vision/VA, Rx, contrast sensitivity, anisometropia, and spectacle wear) predicted fall risk independently.

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The study’s recommendations included reducing surgery waiting times, taking extra care when spectacle Rxs or correction forms are changed, and further studies on the relationship between greater physical activity and falls.

Glaucoma update

Professor Keith Martin from the University of Cambridge gave the glaucoma update lecture, which focused on the neuroprotection of retinal ganglion cells (RGCs), the degeneration of which he described as the leading cause of reduced vision and blindness.

Although IOP lowering is still the only modifiable factor in glaucoma, he believes the current means of achieving a lower IOP need to be better and more convenient. Glaucoma progression remains an issue for at least 12- 14% of cases.

The paths possible are neuro-regeneration and neuro-protection. The neuro-protection approaches are to slow the RGC death rate (apoptosis) and preservation of the structure and function of the RGCs. Already, a trial using memantine (a glutamate blocker used in Alzheimer’s disease), has failed as a neuro-protective agent.

In a low-pressure glaucoma study comparing brimonidine tartrate (α2- adrenergic agonist) and timolol maleate (β-adrenergic antagonist), it was concluded that brimonidine preserved the visual field in such glaucoma cases. Prof Martin concluded that the combination of a β-blocker with normal-tension glaucoma made the situation worse.

On the stem cell (SC)/gene therapy front, Prof Martin noted that mesenchymal SCs (MSCs) are neuro-protective, in rats at least. Another neuro-protective agent is platelet-derived growth factor (PDGF, specifically PDGF-AA), which Martin described as being powerfully protective. However, its use in humans has been questioned, one reason being that GFs are known to induce gliosis.

MSCs were described as being even more powerful neuro-protectors but a study (Stem Cell Ophthalmology Treatment Study – SCOTS) involving 10 blind eyes (AMD, MMD, RP, Stargardt’s disease, glaucoma, optic atrophy, LHON [Leber’s Hereditary Optic Neuropathy], and several others) has yet to report any results. Neuro-protective gene therapy research in LHON is also underway but again no results have been reported yet.

Researchers are encouraged by the knowledge that RGC regeneration has been demonstrated as far back as 1987. Regeneration of the CNS is also possible but generally, its environment is inhibitory according to Martin. Interestingly, crystalline lens damage is known to stimulate optic nerve axon regrowth. Noting that, so far, all restorations have been sub-cortical his parting question was “Can cortical vision be restored?”

Pressure spikes in IOP

Medical student Ms Sascha Spencer reported the results of a brief study into various provocative tests in glaucoma suspects. Noting that a waterdrinking test is unacceptable in some renal cases or those who might suffer a cardiac arrest as a result, she investigated the alternative of monitoring the IOP while supine.

IOP measurements were taken in 21 patients at time 0, 20, and 40 minutes. The measurements were made using a slit-lamp-mounted Goldmann applanation tonometer, which necessitated sitting-up briefly. A Perkins or similar hand-held applanation tonometer was suggested by a questioner at the end of her presentation, as a means of avoiding the disturbance caused by the need to sit-up for IOP determinations.

The IOPs at both the 20 and 40-minute assessments were elevated significantly compared with the baseline value and while the peak seemed to occur at about 20 minutes, the 40-minute reading was slightly higher in some cases.

Spencer believes that a similar physiological pathway is behind both provocative tests. Quoting NZ-based Professor Helen Danesh-Meyer, the supine position is a simple and often overlooked alternative that is comfortable, easier, and safer. She concluded that a larger study was warranted to confirm her study’s finding.

Corneal deformation dynamics

Dr Farshad Abedi from the ophthalmology department of the Flinders Medical Centre investigated the association between corneal deformation dynamics and retinal nerve fibre layer (RNFL) loss in glaucoma suspects and early manifest glaucoma patients.

Using the OCULUS Corvis ST device to visualise and record a cornea’s deformation response to calibrated pulses of air recorded at 4300 frames per second (140 images in <33 milliseconds). The device applanates the cornea twice during each pulse cycle - the cornea is indented to a shape akin to an inverted sombrero and the cornea is flattened on the leading edge of the cycle and during the returning/recovering phase.

Some 200 consecutive patients from the Flinders study of glaucoma suspects and early glaucoma patients were assessed. Their RNFLs were examined by OCT every six months over a three-year period to determine any progressive RNFL loss. The OCT-guided progression analysis (GPA) function was used to track any losses and the hysteresis and rigidity data generated by the Corvis instrument and its two applanation positions, were compared.

An initial analysis of Corvis’ SP-A1 data (Stiffness Parameter A1) suggests that stiffer corneas were associated with greater progression of RNFL loss but Abedi did not conclude that a cause and effect relationship existed between them at this early stage.

However, he did raise the possibility that, in the future, corneal deformation dynamics might be used as a marker for personalised glaucoma management and treatment.

KEYNOTE SPEAKERS

Keith Martin

Sascha Spencer

Farshad Abedi

Boris Malyugin

Telehealth, WA Style

WA ophthalmologist and a director at UWA’s Lions Eye Institute, Associate Professor Angus Turner, reported on the early experiences (first year) with the optometry-facilitated videoconference and telehealth system in WA.

There is now special Medicare item numbers applicable to consultations using the system. To test the system properly, Turner admitted to avoiding the “low-hanging fruit” deliberately. He reported that 94% of optometrists operating in 79% of the practices in the catchment areas are on board with the project.

Early data suggests the system is successful and has met with high patient acceptance. The non-attendance rate is low at 4.6% and about 49% of attendees are booked appropriately for a procedure that might include cataract (40%), glaucoma (11%), and AMD (4%).

Previously, a much lower ‘efficiency’ was the norm in that only 10-20% of procedures booked, actually required an ophthalmologist’s attention. The new figure of 49% leads to much greater use of resources, manpower, and time.

On average, some 17% of patients still need to attend an outreach clinic but the ‘filtering’ by affiliated optometrists and/or a telehealth call between the patient and a Perth-based ophthalmologist from an optometric practice or a remote eye health centre, focuses the attention and resources where they are needed most. The cost savings far outweigh the alternatives that include an ophthalmologist visiting outreach centres more often.

OCT Screening for DR in WA

Medical student and new Rhodes Scholar, Mr Richard O’Halloran reported on the impact of OCT as a screening tool for diabetic retinopathy (DR) in indigenous Australians. As DR is a growing problem and telehealth is gaining in importance as a way of dealing with remote populations, he believes that OCT is the answer.

Based on retrospective cases from Perth and Port Hedland from 2014, a total of 222 cases were analysed, 80 control cases and 142 intervention cases.

An OCT instrument was introduced to the scheme 12 months after its commencement. Because of inexperience, presence of other ocular pathologies, and other issues, not all OCT images were useable and the conservative approach of referring all imaging failures for further investigation was undertaken.

Generally, an aboriginal health care co-ordinator takes the OCT images that are then reviewed by an ophthalmologist in Perth who decides if a follow-up is required. Probably because of the complexity and volume of the data created, O’Halloran does not believe that OCT imaging is a suitable, broadly applicable screening tool.

Lord of the malyugin ring

Russian ophthalmologist and surgical tools inventor, Dr Boris Malyugin of Malyugin Ring fame, gave several papers at RANZCO 2016. One was on descemetorhexis (removal of the endothelium-Descemet’s membrane complex from the overlying stroma) without endothelial cell transplantation versus DMEK (Descemet’s Membrane Endothelial Keratoplasty – a lamellar corneal transplant procedure).

He focused on Fuch’s Dystrophy in which the more abnormal central endothelium is removed so that the more peripheral, less abnormal endothelium can spread to replace the removed tissue, albeit with what is almost certainly an abnormal but functional matrix of endothelial cells.

Alternative therapies are DSEK/DSAEK (Descemet’s stripping automated endothelial keratoplasty), DMEK, or DMET (Descemet’s membrane endothelial transfer) all of which involve the transplantation of cells derived from others (culturing of the patient’s own endothelial cell is a possibility).

According to Malyugin, Descemetorhexis without transplanting endothelial cells is successful in about 75% of cases, meaning the cornea clears over time thereby restoring vision to an acceptable level. The advantages of a Desmetorhexis are a lower risk of rejection and no need for chronic medication. Vision restoration can take from three to nine months but progress is usually apparent in a matter of weeks.

* The next RANZCO Annual Scientific Congress will be held in Perth from 28 October to 1 November 2017. 


References
Palagyi A et al., 2016. While We Waited: Incidence and Predictors of Falls in Older Adults With Cataract. IOVS. 57: 6003 – 6010.
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