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Gold Standard program at RANZCO's 50th congress

01/02/2019By Lewis Williams PhD
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RANZCO celebrated the golden jubilee year of its Annual Scientific Congress in 2018. LEWIS WILLIAMS details some of the groundbreaking research laid out on the day.

RANZCO held its 50th Annual Scientific Congress at Adelaide’s Convention Centre from November 17–21. The congress was well attended and the trade display was well supported by the industry.

The college’s annual graduation awards ceremony and president’s reception was also held as part of the congress. A total of 31 graduated as Fellows of RANZCO, including Australia’s first indigenous ophthalmologist Dr Kristopher Rallah-Baker.

The evening’s guest of honour was surgical oncologist Associate Professor Susan Neuhaus FRACS, CSC who holds appointments in the University of Adelaide’s Department of Surgery and Conflict Medicine. The latter is a direct result of her roles as an army medical officer. She has operational experience with the UN in Cambodia and Bougainville, and most recently served in a NATO hospital in Uruzgan Province, Afghanistan; the location of some of the Australian Army’s most recent overseas activities.

In keeping with past formats, the congress invited keynote speakers drawn from local and overseas sources.

The Cornea Society (USA) and the ANZ Cornea Society held a joint symposium on the final day of congress titled Update on Common Corneal Challenges for the General Ophthalmologist.

The named lectures were presented as follows:

• The Council Lecture: Professor Stephanie Watson (USyd and UNSW)

• The Fred Hollows Lecture: Associate Professor Angus Turner (UWA and Lions Outback Vision)

• The Norman McAlister Gregg Lecture: Professor Robyn Guymer AM (UMelb and CERA)

• The Dame Ida Mann Lecture: Professor Russell van Gelder (UWashington)

Corneal blindness

Professor Stephanie Watson delivered the Council Lecture, titled Fighting Corneal Blindness: Yesterday, Today, and Tomorrow.

Starting with one of her signature topics, stem cells (SCs), she gave the limbal epithelial SC life cycle as being between 7–10 days. Over this time the limbal epithelium is replaced completely. Serious problems arise when the limbal SC population is damaged or destroyed, such as if industrial chemicals access the anterior eye. This is especially critical for young people with much of their life still in front of them.

One approach she uses is to seed and culture a patient’s SCs in autologous serum, with 63% of cases resulting in stable corneal epithelia. When returned to the patient’s eye, around 80% of cases achieve an increase in VA. Unfortunately, the other 37% of cases do not respond favourably to that approach.

If vitronectin is added to the extracellular matrix during SC culturing, there is an increase in the level of vitrine, which has enhanced colony-forming properties.

Although limbal SC failure is uncommon, she reported that dry eye can affect the limbal SC population. Watson and others have investigated topical statins, especially Atorvastatin, as a possible treatment for dry eye. It has already been shown to decrease corneal sodium fluorescein staining.

She then shifted her focus to corneal cross-linking (CXL) for keratoconus (KC). She admitted that when to perform CXL in KC was still an issue, and was just one of many issues addressed in the Save Sight Institute's (SSI) KC Registry.

A suggested criterion for CXL was the observation of corneal changes of the order of 10% per month in a particular patient. In essence, the SSI KC Registry amounts to post-market surveillance with information available to contributors. The SSI now has a CXL brochure available on its website.

While microbial keratitis (MK) is not common, its occurrence in the elderly was singled out because in those cases, up to 10% can lose an eye and up to 40% experience a permanent loss of VA. MK in children can lead to amblyopia if sufficient permanent media changes result, and a corneal scrape was stated to be the only way to identify the organism responsible.

The most common cause of corneal blindness remains herpes simplex keratitis. It’s a major public health problem, with more than 1.5 million people affected by it worldwide and only 54% of cases dosed or treated properly. Another pursuit Watson is involved in is the prevention of blindness from ocular trauma, which is the topic of a PhD research project being undertaken by Ms Annette Hoskin that she is supervising.

Watson and Hoskin are also participants in the International Globe and Adnexa Trauma Epidemiology Study (IGATES). Vitamin A deficiency is still often encountered due to poor diet, and Watson estimates that every year about 2 million people go blind from corneal blindness.

KEYNOTE SPEAKERS

Mark Daniell

Angus Turner

Heather Mack

Stephen Wade

Genevieve Oliver

Corneal biomechanics

American ophthalmologist Professor Bradley Randleman from the University of Southern California’s Roski Institute gave the corneal update lecture, focusing on KC and myopia.

According to him, the prevalence of KC around the world varies greatly, spanning 1:21 in Saudi Arabia and 1:375 in the Netherlands, all the way through to global averages that are generally about 1:2,000. To date, the FDA has only approved one protocol for CXL.

Despite most corneal biomechanics assessments using corneal shape as a proxy, Randleman questioned what the best way to measure ectatic changes is, and suggested that alternatives to corneal shape might be required. He is not an acceptor of the existence of so-called unilateral KC, preferring instead to refer to such cases as highly ‘asymmetric’.

Other evaluations of corneal ectasia are the increasingly accepted Belin/Ambrósio Enhanced Ectasia Display (BAD-D) (pachymetric progression), the Ambrósio Relational Thinnest, the index of height decentration, and pachymetry of the corneal apex. A single, useful post-treatment metric is yet to be identified. However, when a combination of 13 variables is used identification of KC is accurate 100% of the time.

In summarising what we know about the cornea, Randleman offered:

  • There is a depth-dependent difference in corneal stiffness (anterior third is stiffer)

  • KC reduces corneal stiffness

  • There are regional differences in stiffness in KC

  • LASIK decreases corneal stiffness

  • CXL increases corneal stiffness

  • Epi-off CXL has a better outcome than Epi-On

While little is known about corneal biomechanics post-surgically in PRK, LASIK, or SMILE, questions are now being asked about how much corneal weakening is too much.

The unknowns are:

  • Are their focal abnormalities in KC?

  • Where are KC corneal changes first detected?

  • How much CXL is sufficient to arrest corneal progression?

  • What is the significance of the CXL demarcation line?

  • Does repeated CXL increase corneal stiffness?

  • What is the usefulness of CL-assisted CXL?

Although destructive corneal biomechanics testing was described as easy, non-destructive assessments are another matter. Current techniques include:

The OCULUS Corvis ST, which measures the corneal profile’s response to defined air pulses

OCT analysis of respiratory activity on the contours of the cornea and anterior chamber

OCT Corneal Elastography

Brillouin microscopy, a non-contact, 3D corneal imaging using reflected light from a tissue of interest while it is subjected to ultrasonic modulation

The Ocular Response Analyzer, which measures corneal hysteresis.

The corneal biomechanical index (CBI) is similar to BAD-D, but is not regarded as a superior measure.

Current pursuits in the corneal biomechanical field were given as: CXL in post-surgical ectasia (such as after LASIK); the utility of repeated CXL; confirming that KC, regardless of how mild, is actually more prevalent than thought previously; and refining CXL methodology.

Randleman does not believe that eye rubbing causes KC progress, but to date it remains a significant and the only modifiable factor in the disease. Like a few others before him, Randleman now subscribes to the view that KC is inflammatory, a departure from the long-held view.


An alternative to the bionic eye?

Professor Russell van Gelder’s presentation, Progress Toward Pharmacologic Vision Restoration in Outer Retinal Blindness, was the final lecture of the congress.

Although the subject of bionic eyes did feature at the congress, the topic he presented was a novel approach to vision restoration for patients in which the inner retina is accepted to be largely or fully functional, such as retinitis pigmentosa (RP).

Despite the fact that RP is limited to the photoreceptors, substantial retinal ‘rewiring’ is known to occur. For example, this includes neural adaptation, retinal remodelling, and neuron migration. Stem cell replacement, microchip prostheses, photoreceptor molecular gene therapy, and so-called bionic eyes, are some of the current approaches to RP.

The US FDA has already approved a gene therapy for Leber’s Congenital Amaurosis (LCA) in cases with a faulty RPE65 gene. The RPE65 protein is central to the generation of 11-cis retinal, thereby powering phototransduction and the visual cycle. Mutations in RPE65 are known to be capable of causing LCA or RP (type 20). The drug is called Luxturna (voretigene neparvovec-rzyl), and is based on work by Dr T Michael Redmond of the US National Eye Institute.

Luxturna is only FDA approved for LCA and RP20, with other variants of RP currently excluded. The treatment doesn’t restore full or normal vision, however navigation, including in relatively low light levels, has been demonstrated in treated patients.

More recently, research has examined ion-channel opsins, also known as G-protein-coupled receptors (GPCRs). With their co-factor retinal, a vitamin-A-like molecule, GPCRs absorb photons and undergo isomerisation. The latter leads to a conformational change in the attached opsin, initiating transmembrane ion movement or a signalling cascade (Kalanithi and Purger, 2017).

When ion channel opsins are exposed to light at their characteristic wavelength of maximum absorption, a transient peak in photocurrent is produced. That is followed by a lower, stable plateau photocurrent. Research into opsins in the inner retina has shown promising results, with the focus now on the use of small-molecule therapy for reversing blindness, specifically photoswitch compounds such as azobenzene.

Potassium-ion (K+) channels are often used to maintain resting membrane potentials, repolarising, and the hyperpolarising of cell membranes during action potential propagation. A K+ channel blocker is triethylamine.

Enter azobenzene, a compound with a peak sensitivity of 390 nm that can block potassium-ion channels at longer wavelengths, such as 500 nm, or open channels at shorter wavelengths, such as 390 nm. By modulating the incident wavelengths, azobenzene can act as a photoswitch, which van Gelder’s lab has demonstrated can produce light-dependent firing of retinal ganglion cells (RGCs).

His lab’s approach to vision restoration is to use organic photoswitch chemical entities to stimulate the inner retina. To date experiments have been on mice, using 520 nm (off) and 360 nm (on) light, and acrylamide-azobenzene-quaternary ammonium (AAQ) – a small-molecule K+ channel photoswitch. The transform of AAQ blocks K+ channels, whereas the cis form unblocks those same channels.

Mouse experiments used micro-electrode arrays to record the extracellular potentials of RGCs, with AAQ injected as 2 microlitres of a 2 molar solution. One of the early effects is partial restoration of the direct pupil reflex, along with some consensual response in the contralateral eye.

Research has now moved away from the use of differing wavelengths of light to the use of light and dark stimulation instead. Next, a third generation photoswitch, red-DAD (diethylamino-azo-diethylamino), a much more soluble, uncharged compound that specifically targets bipolar cells, was applied in 1–10 millimolar solutions. It proved to be so soluble that it entered the vitreous and the crystalline lens and blocked incident light, subsequently leading to its abandonment.

The next compound used was a synthetic azobenzene called BENAQ, a non-toxic compound even when used in much higher concentrations. Although the initial results are promising, the 100:1 convergence of neural elements in the peripheral retina has been a complication in all such studies.

Research into photoswitches in mice is now using a 4,096 CMOS multi-electrode array to monitor the retina’s activity. Spatial frequencies of 0.04–0.35 cycles/degree are used as test patterns, and early results suggest that vision equivalent to 6/18 in humans might be possible. Van Gelder is hoping that human trials in unseeing eyes might commence in the next 12 months. BENAQ toxicity studies in humans are due to commence ‘soon’.

Paediatric eyecare

Brisbane-based ophthalmologist and academic Professor Glen Gole opened his presentation by stating that there was a pressing need to reduce the workload experienced by him and his sub-specialty colleagues, and by inference, waiting times experienced by paediatric patients. Contributing factors are the increasing number of children in the population and the expanding complexity of ‘the job’.

To at least partially address the problem, Gole proposed that once assessed ophthalmologically, the responsibility for low-risk cases should be passed to suitably trained optometrists. The transfer would occur on the basis that an ophthalmological pathway is created by such a step, the paediatric ophthalmologist has already established a relationship with the patient and their parents or carers, and a reverse flow back to the ophthalmologist, should that become necessary, is along well-understood lines.

Such a system, the Paediatric Optometry Alignment Program (POAP), has already commenced operation in Queensland based on a program run by the Ophthalmology Department of Lady Cilentro Children’s Hospital (LCCH). POAP seeks to impart the knowledge, skills, communication strategies, CPD, and resources to provide ongoing eye care to children.

POAP is evidence-based, runs face-to-face workshops, and has an online portal. Topics covered include paediatric eye care; development of the visual system; conducting paediatric eye examinations and assessments; refractive errors in children; amblyopia; strabismus in childhood; referral and evidence-based, best practice clinical care pathways; and improved, direct lines of communication with the LCCH. POAP also attracts 18 CPD points.

By the end of 2017, more than 97 optometrists had completed the program. Attendees had expressed high levels of satisfaction with their exposure and would recommend the program to their professional colleagues. More than 320 children have been a part of the system, and feedback from 80 participating optometrists has been processed.

Most importantly, more than two-thirds of the patients are happy with the arrangement. Most understood why it was initiated and most hadn’t been to an optometrist before, since many have conditions that would be typically referred to an ophthalmologist or a hospital eye department. The waiting times for ongoing assessments have also been reduced, although according to Gole many remain on hospital waitlists for valid reasons.

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The rational use of ophthalmic manpower is likely to become a bigger issue in the future as the constraints on ophthalmology registrar positions, mostly in the public hospital sector, show few signs of loosening in the foreseeable future.

AMD fluid tolerance

Professor Robyn Guymer AM from CERA revealed some of the results from the first 24 months of the Australian, multi-centre FLUID ‘wet’ AMD trial. The trial, a Phase IV, randomised, controlled study, investigated the efficacy and safety of ranibizumab (Lucentis) used on an ‘inject and extend’ basis. It utilised an intensive retinal fluid retreatment regimen compared to a relaxed retinal fluid retreatment regimen in patients with neovascular AMD.

The criteria that were monitored using OCT included the loss of VA and the appearance of new retinal haemorrhages, IRF (intra-retinal fluid) and SRF (sub-RF).

The study posed the questions: Are IRF and SRF indicative of vascular leakage in choroidal neovascularisation and is a ‘dry’ macula necessary in ongoing AMD therapy? Despite current dogma seeking a ‘dry’ retina, that state is not achieved in all patients, with some never achieving that endpoint with monthly or PRN injections.

Often, VA shows little difference in those in whom a ‘dry’ macula is achieved versus the incomplete responders. The trial set out to demonstrate that there were no VA benefits to eliminating all traces of IRF and SRF using VA at the 2-year mark as the criterion. The initial loading dose was an injection every 28 days for the first 3 months, followed by a ‘treat and extend’ regimen of 2-weekly increments out to a maximum of 12 weeks between injections.

Half the subjects were given ‘intensive’ treatment that sought to completely resolve the presence of IRF and SRF. The other half were treated less rigorously, in that there was resolution of IRF or less than 200 microns of SRF but only at the foveal centre. Ultimately, there were 134 subjects in the rigorous arm and 145 in the relaxed arm of the study.

Regardless of which arm of the study they were in, approximately 80% of subjects had some SRF after 24 months. However, there were no significant differences between groups and, importantly, the relaxed treatment group didn’t have inferior outcomes. The researchers concluded that intensive treatment was only prudent in the very early phase of the disease and that there was ultimately no significant difference in outcomes.

Interestingly, the relaxed subjects did have more SRF, likely because of fewer injections. Guymer’s recommendation was to use disease activity as the treatment criterion. IRF was noted to be less desirable and SRF was thought to be a possible consequence of the failure of the interdigitating photoreceptors and RPE to reconnect tightly, thus leaving a small ‘space’ after the initial problem developed and was therefore not a part of the active disease process itself. Extra treatment was recommended if there were changes in SRF or IRF, but if the volume was stable, extending treatment was suggested.

KEYNOTE SPEAKERS

Russell van Gelder

Rathika Kandasamy

Robyn Guymer

David Andrews

Glaucoma sensors

US ophthalmologist and academic Professor Marlene Moster, of Wills Eye Hospital, delivered a presentation on the future of sensors in the diagnosis and treatment of glaucoma.

Her opening statement was that measuring IOP at 3-month intervals “does not cut it”. Rather, continuous monitoring tells the full story. The first such device was the Swiss-made Sensimed Triggerfish CL, a tool that actually measured continuously, changes in ocular volume.

Well tolerated but expensive, unfortunately Triggerfish assessments of ocular biomechanics and volume are not IOP measures. Complicating matters, specific types of glaucoma, such as NTG, have greater fluctuations in IOP than ‘normal’ glaucoma. For that reason, among others, 24-hour recordings are regarded as better.

However, during sleep there are artefacts and unexplained variations as well. An intraocular sensor is regarded as a better idea because it allows for 24/7 IOP monitoring of the disease and an element of personal involvement on the patient’s part.

An experimental RFID-based intraocular permanent device now exists, the Wireless IOP Transducer (WIT), which is implanted during cataract surgery. The WIT’s data reader needs to be within 50 mm of the eye and requires a 5.5 mm incision for insertion. It’s put in front of the IOL but behind the iris, so technically, it is a posterior chamber device.

All 6 initial cases resulted in corectopia (pupil displacement), some inflammation, and pigment dispersion. Worse, the WIT’s IOP didn’t match Goldmann IOP measurements. Improvements and miniaturisation have subsequently seen the incision size reduced to 3.2 mm and the side-effects reduced to such a level that the European CE mark has already been granted, following the ARGOS-02 trial in Germany in 22 POAG cases followed out to 12 months.

That trial revealed no serious adverse events and IOPs slightly higher than the Goldmann tonometer equivalent. The optimum location for such a device remains unknown, but because to date they have been powered inductively, a location closer to an accessible surface of the eye is probably desirable. However, as power requirements for complex electronics decreases with each new development, often along with further miniaturisation, the concepts involved cannot be dismissed.

An IOL with an embedded sensor has also been suggested, adding yet another consideration to the deliberations of cataract surgeons. Micro-Electro-Mechanical Systems (MEMS) and capacitance-based pressure sensors combined with an application-specific integrated circuit are also under active investigation. Initial devices have proved to be patient and battery friendly, requiring just 20 minutes per day to recharge. During that time, the data is also downloaded.

MEMS-based micropumps for drug delivery, such as Innovative Micro Technology’s 100 nm device, are also being investigated as a way of lowering detected IOP spikes interactively. Ultimately, Moster’s hope is to be able to deliver a sensor intraocularly via a syringe and needle. Given the advances in electronics made to date, her hopes seem plausible.

Bevacizumab vs. Triamcinolone

Ophthalmology registrar and CERA researcher Dr Rathika Kandasamy gave the 6-month results from the DiMECAT trial that studied patients exhibiting diabetic macula oedema (DMO) who also underwent cataract surgery.

The trial was a prospective, masked, randomised, controlled study. As DMO and cataracts often coexist and cataract surgery in diabetics can have worse outcomes, including increased DMO post-surgically, the question arises as to what is the optimum treatment.

To be eligible for the study, the subjects needed to have DMO requiring treatment within the 24 months before cataract surgery. They were then assessed at 1 month, 6 months, and 12 months post-surgery.

Central macular thickness (CMT) was measured in 61 eyes of 58 subjects. Triamcinolone was found to reduce CMT while bevacizumab increased it.

Overall, VA improved over time with triamcinolone giving slightly better VA, but not statistically significantly so. Importantly, triamcinolone required fewer retreatments, sometimes with intervals out to 6 months.

The study concluded that intravitreal triamcinolone was best for those subjects with pre-existing DMO, and often a single-dose was all that was required. No difference in VA was found between the groups. If a patient proved to be unresponsive to anti-VEGF therapy, the addition of, or switching to, triamcinolone was suggested, especially in view of the latter’s lower treatment burden. Only triamcinolone maintained and sustained anatomical benefits that lasted up to 6 months.

However, Kandasamy noted that anatomical improvements did not necessarily equate to visual functional improvements.

Paediatric eye injuries

Research Fellow at Perth’s Lions Eye Institute Ms Annette Hoskin gave a brief presentation on paediatric eye injuries, a topic of her PhD research being supervised by SSI’s Professor Stephanie Watson.

Because of compulsory seatbelt usage, the incorporation of safety glass in motor vehicles, and Australia being a mostly peaceful country, much of the ocular trauma in this country relates to occupations and sport. Some examples include bats, balls, ice hockey, pens, pencils, cleaners, and detergents. Other sources include pets such as cats and dogs, insects and birds, in particular magpies. Falls, especially in children under 5 years of age involving tables, furniture, corners of house features and furniture, are also sources.

In a sporting context, small balls are not the only threat, because blunt trauma received from basketballs and footballs and elbows in contact sports is also taking its toll. By way of contrast, most adult problems outside the workplace or sporting arena are due to falls, especially in those over 50 years of age.


AI’s impact

RANZCO CEO Dr David Andrews gave an overview of how the future might affect ophthalmology, optometry, and ophthalmic practice. He noted the advances already made in diagnostic imaging and equipment, with further evolution expected.

Robotic surgery has made some headway in general surgery where less finesse is required, but so far, little impact has been felt in ophthalmology. However, advances in robotic ophthalmic surgery are being made, and it is probably only a matter of time before they enter regular usage.

Already, FLACS has advanced along the robotic path. Central to greater levels of automation will be referral pathways, but decisions about who gets paid and who will own the machines are matters yet to be sorted. It may mean a rise in corporate involvement once the investment exceeds the ability of a solo or small group practice ‘to pay’.

Importantly, what vital skills might be lost to increasing automation and the rise of AI? Does that matter? Will the advances force greater sub-specialisation? What are the public health and private health insurance implications for the coming changes?

Already VR devices such as Microsoft’s Hololens are being incorporated into medical training. Such technology can incorporate the latest knowledge in detailed anatomy to an extent that can affect training programs and the examinations that follow. VR surgical simulators are already in use in some institutions, and their use in relation to surgical procedures before ‘going live’ has been shown to improve surgical outcomes. Naturally, such technology is expensive so numbers, access, and the ability to acquire such hardware might be, at least initially, limited.

The rise of AI is also likely to decrease demand for optometrists, a possibility already canvassed in OA’s Optometry 2040 document. With initiatives such as Specsavers ANZ’s roll-out of OCTs to practices, the growing cost of high-tech equipment could mean that eye care will be carried out in eye super centres, because the total investment required would be beyond smaller players.

Following Andrews’ lecture was Melbourne ophthalmologist and academic Dr Peter van Wijngaarden, who delivered a presentation on AI in the eye care workplace. He posed the question: Do we need to be afraid?

He expects that AI’s ingress into diagnosis and treatment decisions will make some parts of eye care practice redundant. He also foresees the likelihood of health information being used against the subject of that information, such as health insurance companies declining to issue policies to those with known issues.

AI will also probably level the practitioner playing field to some extent by enhancing the ability of lesser players to compete with the discipline’s ‘stars’. Despite discussion about who owns the volumes of information generated, AI is likely to assist the rise of personalised medicine in which optimum treatment is tailored to the needs of individuals based on their personal medical information.

More cost-effective healthcare is also expected to result from the rise of AI. However, it’s difficult to see how some roles, such as those of top surgeons in most fields, will be supplanted by AI, robotic surgery, or a combination of the two. Van Wijngaarden believes that the current annual increases in healthcare costs are unsustainable.

Switching to the widely-reported diabetic retinopathy (DR) AI deep learning diagnostic system created by Google and a panel of MDs, he reported that the US FDA had authorised the use of the system for the diagnosis of DR and DMO autonomously.

He also referenced a Moorfields Eye Hospital study that involved 14,884 OCT images of 50 common retinal conditions being analysed by staff ophthalmologists, some trained in-house optometrists, and an AI ‘machine’. The latter outperformed all humans except one, who only equalled the machine’s performance. Regardless, AI is still regarded as ‘narrow’ and even Google estimates that it will probably not be mainstream until 2030-2035.

The questions the technology raises include: Are consumers ready? What are the eye care workforce implications? What is the scope of innovation in an AI world? Who will provide the ‘input’ for future systems? What is acceptable machine error? How will regulations cope with AI?


Training processes

NZ ophthalmologist and RANZCO’s Censor-in-Chief Dr Justin Mora gave a brief overview of current thinking about the evolution of the RANZCO selection and training process, with a specific focus on indigenous trainees. His presentation was not NZ-centric but reflected RANZCO thinking generally.

Starting in February 2020 in Australia, and 2 months earlier in NZ, a RANZCO selection board and RANZCO selection panels will be formed to ensure a standardised, anonymous selection process is carried out according to RANZCO criteria. Stakeholder representation on such panels will be increased. Referee numbers will be increased from 5 to 7 and following graduation from medical school, work histories will also be sought.

The aim is to select the most suitable candidates with the best professional attributes via a central system. Additional weight is added for being of Indigenous descent, having worked in a rural setting, or having a particularly scholarly background. RANZCO is also seeking to achieve earlier entry to its scheme, meaning registrars will graduate at an earlier age than is common now.

Attributes such as learned publications, higher degrees, and particular CV attributes are also to be considered. While references are still requested, their value is questioned. RANZCO sought and received expert advice from Monash University when making changes to their selection process.

Surprisingly, flexible and part-time training possibilities are also being considered. It’s proposed that a regional training network of up to 12 trainees being cycled through up to 8 centres form the basis of the new system once training commences.

The program has received 135 applicants for just 35 places, highlighting its popularity.

RANZCO’s 51st Annual Scientific Congress will be held in Sydney from November 7–12 November 2019 at Sydney’s International Convention Centre.

RANZCO’s 51st Annual Scientific Congress Gallery








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