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Report

Super Sunday 2019

02/05/2019By Lewis Williams PhD
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Optometry Australia NSW/ACT held its annual Super Sunday 2019 education event at Sydney’s Luna Park Big Top on 10 March. In part one of a series, LEWIS WILLIAMS details some of the topics covered at the event.

A wide range of topics were featured at Optometry Australia’s (OA’s) Super Sunday event for 2019, with presenters drawn from across Australia and New Zealand. For the first time, OA NSW/ACT also ran a parallel Practice Staff Program. During the program, both the H Barry Collin Research Medal and the Josef Lederer Award for excellence were presented. Super Sunday’s popularity also continued to increase, with this year’s event attracting some 460 delegates.

Beyond the eyeballs

Dr Kate Kalloniatis and Dr Chris Gilbert opened the formal part of the program with a presentation titled: What else is going on? Looking beyond the eyeballs. The thrust of the presentation related to communications between optometrists and GPs relating to the patients consulting them, using guidelines by the Royal Australian College of General Practitioners (RACGP).

The key issues related to vascular disease are: age, sex, smoking status, cholesterol (total and HD lipoprotein), systolic blood pressure, diabetic status, and left ventricular hypertrophy. It is possible for an optometrist to make an Absolute Cardiovascular Risk Assessment of a patient for the next five years, based on statistical data backing the RACGP Guidelines’ cardiovascular disease charts.

A GP’s interest is in prevention, and their heightened interest in cardiovascular disease kicks in at 45 years of age for the general Australian population. However, it starts a decade earlier for indigenous people. Current thinking on acceptable blood pressures (BP) is ≤140/90 mm Hg for adults and ≤130/80 for adults with chronic disease, measured on at least two occasions before a diagnosis of hypertension is made.

Decisions on BP significance are based on risk, lifestyle, family history, measured BP, and ethnicity. A hypertensive crisis is defined as BP of ≥180/120 and the patient being unwell as judged by at least one body system. Relevant issues include breathing difficulties, substance abuse, and pregnancy-related conditions, such as pre-eclampsia at ≥20 weeks gestation. Also of concern are: fresh, flame-shaped haemorrhages, exudates, and papilloedema. If necessary, repeat BP assessments 10 to 20 minutes apart were suggested. If the patient seems well, optometrists are advised to refer the patient to their GP within 24 hours. If they are unwell, an ambulance ride to an emergency department was suggested.

Screening for diabetes at least every two years was suggested in all those over 40 years of age or over 18 years of age if the patient is indigenous. A diabetic assessment was recommended every three years, or more frequently when there is a relevant history. The use of the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK) was recommended. Because symptoms do not become apparent until relatively late in the disease and progression can be rapid, screening was recommended strongly. Key risk factors are: the level of glycaemic control, type of diabetes (1 or 2), hypertension, smoking, dyslipidaemia, nephropathy, and pregnancy.

Smoking should barely rate a mention since its problems and sequelae are so widely known, but smoking rates remain at significant levels despite punitive pricing, deterring packaging, and public anti-smoking campaigns. Importantly, if smoking has been avoided for 12 months an ex-smoker’s risk of heart disease is halved. Ocular diseases linked to smoking include: AMD, cataract, inflammation, thyroid, retinal artery emboli, and strabismus if a patient’s mother smoked during pregnancy.

When dealing with a smoker, the 5AS framework for practitioners was recommended: Ask, Assess, Advise/agree to targets, Assist, and Arrange. A pharmacotherapy approach to quitting smoking was stated to be a rational consideration and most products are available over the counter, with the exception of nicotine patches.

Should an optometrist find papilloedema, the cause, usually raised intracranial pressure or benign intracranial hypertension (BIH), will not be immediately apparent. If the former is likely, an ambulance to an emergency department might be prudent. If BIH, the patient should be promptly seen by a neurologist, neurosurgeon, ophthalmologist, or at the very least their GP.

If Graves’ Disease/thyroid eye disease is detected, a GP referral is necessary to get suitable investigations underway. Those investigations can involve an ophthalmologist or an endocrinologist, and the referring optometrist can play a monitoring role.

The presenters gave the role of a GP as preventative health and chronic disease management, and requested that optometrists copy the patient’s GP on any action taken or relevant findings uncovered. This is because patients assume incorrectly that all health professionals communicate with one another. Having patients carry their information from the referring optometrist to their GP is acceptable. Patients who consult optometrists on their own initiative were identified as potential barriers to communication because of the lack of a referring ‘authority’.

KEYNOTE SPEAKERS

Chris Gilbert

Kate Kalloniatis

Nicola Anstice

The dry eye invasion

Associate Professor Jennifer Craig from the Department of Ophthalmology at the University of Auckland, NZ gave a lecture on dry eye (DE) and its treatment. Craig is a senior member of the Tear Film & Ocular Surface Society (TFOS) and filled the role of first author on the Definition and Classification Report in DEWS II.

After presenting the updated definition of DE, she emphasised that the new definition embraced signs and symptoms despite, or perhaps because of, the accepted disconnect between those two factors. Confusingly, the prevalence figures span the range 5% to 50% depending on definition, assessment technique, age, sex, co-morbidities, and ethnicity. She estimated that about 10% of all optometric patients exhibit signs of aqueous deficiency (ADDE) and 15% show signs of anterior blepharitis. Surprisingly, she estimated that 35% of all patients exhibit signs of MGD.

After providing an overview of DE subtypes and the ‘vicious circle’ of DE included in the DEWS II report, she condensed the DE cycle into a bidirectional continuum of tear hyperosmolarity, inflammation, ocular surface cell damage, and tear film instability. She simplified the practitioner’s task as one of ‘breaking the cycle’.

Craig’s first line therapies include eyedrops and warm compresses, supplemented with lid hygiene procedures in cases of moderate to severe DE. TFOS, via its DEWS II Report, recommends a 4-step, staged management of DE, each stage tackling greater severity. Should a Demodex spp. infestation be found, tea tree oil remains the main treatment.

Introducing her concept of ‘big guns’, Craig proceeded with cases showing little evidence of Meibomian gland dysfunction (MGD). She suggested methylprednisolone (1%, preservative-free, 4 times daily, tapering after 3 weeks), azithromycin (300 mg daily for 3 days), and regular use of ocular lubricants (Bion Tears, Theratears). As a result of some of her own clinical studies, she added that IPL therapy might also be helpful.

Confounding the ‘vicious cycle’ are additional factors such as: Sjögren’s Syndrome and other autoimmune diseases, systemic prescribed drugs, ocular surgery including refractive surgery, neurotrophic conditions, viral/bacterial conjunctivitis, environmental factors such relative humidity, CL wear, allergy, use of unrelated topical ocular medications, chalasis or lid margin irregularities, blepharitis or MGD, and sex steroid hormone imbalance.

Anti-inflammatory therapy includes: topical corticosteroids, non-steroidal immunomodulators, inflammatory modulation with systemic and topical antibiotics, and macrolide treatments using azithromycin.

Managing inflammation requires its origin to be ascertained. For example, determining whether is it intrinsic or secondary to lid disease. Inflammation assessment can be done either subjectively using a rating scale or objectively using an instrument such as the Oculus K5M or the RPS InflammaDry Detector.

For ADDE, Craig suggested that the use of ‘big guns’ was justified, starting with topical corticosteroids. However, numerous and serious side-effects are known, such as cataract, ocular hypertension, and increased susceptibility to microbial infection. As a result, only short-term use is recommended to break the DE cycle and even then, the use of non-penetrating steroids is recommended.

Where a longer-term course of treatment is indicated, steroid alternatives were suggested. For ADDE, punctal plugs, cyclosporine, tacrolimus, lifitegrast (when available), nasal neurostimulation, and secretagogues were suggested. For evaporative DE (EDE), lid margin debridement with topical antibiotics, doxycycline, azithromycin, intense pulsed light (IPL) treatment, or thermal pulsation were suggested.

For blepharitis, a topical antibiotic such as fusidic acid 1% was recommended, with an alternative therapy such as medical-grade Manuka honey worth considering. Systemic antibiotics such as the tetracyclines, at less than bactericidal dosage, are useful due to their antibacterial and anti-inflammatory properties. However, its use is contraindicated in pregnancy and children.

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IPL using a broadband light source is widely used in the cosmetic industry for hair removal and facial melisma, and in medicine as a treatment for acne rosacea. More recently, ocular rosacea has also been an IPL target. Usually, a course of three treatments is undertaken without Meibomian gland expression, and the benefits last up to nine months. Thermal pulsation heats the whole eyelid and expresses the Meibomian glands simultaneously in a single treatment. Its efficacy is aided by the achievement of higher temperatures (>40 °C) resulting in lower meibum viscosity and, theoretically at least, easier and more complete expression. Benefits can last up to 12 months.

However, according to Craig, thermal pulsation is no more effective than warm compresses applied consistently, along with regular gland expression. In view of the very significant cost of thermal pulsation, that claim is of great significance to many DE patients.

Ocular surface repair has less relevance, with the exception of scleral and miniscleral CLs because amniotic membranes, tarsorrhaphy, autologous blood serum, and keratoprostheses are outside the current scope of optometrical practice.

Digital devices and children's vision: Curse or Cure?

Second generation optometrist and current Head of Optometry, University of Canberra, Dr Nicola Anstice raised the possibility of using children’s favourite devices, such as smartphones, tablets, and computers, as a means to assess vision. However, the reverse side of that same ‘coin’ is the range of visual problems related to use, and possible overuse, of those same devices.

According to a European study, 68% of children use a ‘computer’ regularly by 3 years of age, pre-schoolers spend up to 2.4 hours per day watching screen-based devices, and 80% of teenagers experience asthenopia associated with electronic displays. Anstice gave visual acuity (VA) measurement, fundus examination, and smartphone adapters for autorefraction as possible uses for digital devices for children’s vision assessments. Those same devices can be used for amblyopia therapy and as visual aids for children with vision impairment or low vision. On the downside, those same devices can contribute to digital eyestrain and alter, or cause problems with, binocular vision.

Even the apparently simple task of taking VA in children is not necessarily straight forward. Aside from the well-researched issues of optotype legibility, scoring, and the decision on when to terminate a VA test, children’s VA assessments are more variable because cognitive function, the assessor, distractions in the environment, and how the test results are recorded, are additional considerations. In an attempt to address some of these issues, she and colleagues developed The Auckland Optotype (TAO) set of pictograms based on just four symbols.

The concurrent exposure to a YouTube clip while a child is undergoing a fundus examination has been shown to be quicker and more successful in achieving what needs to be seen. Ideally, the video clip should be selected by, or be relevant to, the particular child.

A smartphone attachment such as the D-EYE, marketed as the digital direct ophthalmoscope for smartphones, has been found to be useful for viewing the posterior pole but unsurprisingly, the image quality in the fundus periphery is inadequate. Studies using the GoCheck Kids vision screener, a ret reflex photorefractor attachment and app targeting anisometropia-based amblyopia, showed a sensitivity of 76% and a specificity of 67%.

There are more than 40 smartphone apps targeting amblyopia therapy but relatively few have had eyecare professionals involved in their development. Almost half play binocularly, while some use anaglyphic separation. Others use the more expensive, albeit more advanced technically, VR headset approach. Quality assurance related to just what is being attempted, remains largely unknown.

There are some emerging amblyopia therapies, including the dichoptic contrast balancing technique demonstrated by Australian expatriate Professor Robert Hess and colleagues at Canada’s McGill University over the last 6 years. One incarnation is based on a game of Tetris, an approach more likely to maintain interest than traditional methods. Unfortunately, larger RCTs delivered less promising results. More recently, binocular video games have been trialled successfully on older children, teenagers, and adult amblyopes.

Digital eyestrain (DES), defined as a range of transient ocular and visual symptoms associated with digital device use, results in tired eyes, DE, ocular burning/itching, blurred vision, headaches, light sensitivity, and general ocular discomfort. DES can be measured subjectively or objectively. Tests that should be included when assessing children using digital devices are: refraction, especially noting small amounts of uncorrected astigmatism, amplitude of accommodation (subjectively), accommodative lag/lead, accommodative facility, relative accommodation, NPC, distance and near phorias at the distances required, presence of A or V- patterns, associated phorias, vergence facility, and base-in and base-out vergence ranges.

Serious problems in children using smartphones excessively (at least 4 hours per day) include acquired comitant esotropia (15-45 prism dioptres) and DE. Refraining from smartphone use reduced the esophoria, but 5 of the 12 cases in one study still eventually required strabismus surgery. Unsurprisingly, there was little data supporting the use of blue-blocking spectacle lenses for any reason including circadian rhythm resetting.

The H Barry Collin Research Medal

Until recently, Professor Fiona Stapleton was Head of School, School of Optometry and Vision Science (SOVS), UNSW. Now she is the Scientia Professor at SOVS as well as the Associate Dean, Enterprise within the Faculty of Science, UNSW. The H Barry Collin Research Medal is awarded occasionally by Optometry Australia for outstanding contributions to the advancement of knowledge in optics, vision science, or clinical optometry. The recipient is expected to submit a paper to Clinical and Experimental Optometry and also receives a monetary prize.

Before being awarded the medal, Stapleton delivered the conference’s keynote lecture titled Why does corneal infection remain a problem for CL wearers? She revealed that microbial keratitis (MK) is still an issue in Australia, and is often CL-related. The disease’s severity depends on the causative organisms, the patient’s genetic susceptibility, compliance level age, and the time to diagnosis. Compared with non-CL-related MK, CL-related cases are more numerous, generally less severe, have a better visual outcome, are often caused by micro-organisms present in the environment, and usually affect a younger demographic.

Professor Fiona Stapleton
Professor Fiona Stapleton

The most common therapy is monotherapy and, fortunately, resistance to the antibiotics used currently is uncommon. Disappointingly, the advent of SiHy CLs has not seen a reduction in MK, especially when overnight (O/N) CL wear is the preferred mode. In fact, clinical data suggests that the incidence of MK is marginally worse in O/N SiHy CL wear, although the difference might not reach statistical significance. Overall, the rate of disease and the eventual vision loss, if any, has remained stable over time.

Modifiable risk factors in severe MK are: isolation of an environmental organism (no tap water), delays in treatment (especially if greater than 12 hours) and remoteness to treatment availability. Pseudomonas aeruginosa remains the biggest (56%) single cause of MK, followed by Gram-negative bacteria (25%), then Gram-positive bacteria (9%). The potentially devastating causes, Acanthamoeba spp. and fungi, both difficult to treat, are the least common (5% each).

Quoting a Moorfields Eye Hospital (UK) study, Stapleton revealed that 94% of Acanthamoeba keratitis was CL-related and 90% of those cases were SCL wearers. In US and UK studies, risk was heightened by home-made saline, swimming in CLs, tank-fed domestic water systems (UK), poor reticulated water disinfection (US), storing CLs in tap water, and ‘topping-up’ the solution in CL storage cases. Storage case contamination has been shown to be a significant issue in MK cases, and often the causative organism can be cultured from the CL case in use at the time.

The ability of many relevant micro-organisms to form a protective biofilm inside a CL storage case is a known problem. Regular case replacement and biofilm disruption have been recommended for quite some time. The attraction and added safety of daily disposable (DD) CLs is obvious. However, the DD CLs have to be handled during insertion, so switching to DD CLs is not a guarantee of trouble-free wear. This is especially true if the CLs are reused or worn overnight. Furthermore, causative organisms often differ from those involved in non-DD cases of MK. Some cannot even be cultured, fewer environmental organisms are involved, and generally, the disease is less severe. Antimicrobial CL cases based on silver impregnation are also available.

She also pointed out that water contact with CLs was common, such as showering, swimming and CL handling with wet hands. Susceptibility to disease is an emerging issue and can affect ocular surface defences, can have effects on the epithelium (especially, but not only, the corneal epithelium), and can induce a subclinical immune cell response. There is evidence of individual differences in any immune response triggered.

Although there are still CL wearers who did little correctly or safely yet seem to sail through unscathed. Stapleton admitted that we are unlikely to eliminate ocular disease entirely. Modifying risks and risky behaviour is probably all that can be done.

Her parting advice was: DD CLs, don’t delay seeking attention for problems as soon as they arise, address the storage case issues, and avoid contact with tap water. She noted that the unregulated supply of decorative CLs in Australia and Asia is an emerging challenge because the ‘wearers’ have little or no idea of what risks they are exposing themselves to.

The H Barry Collin Research Medal was presented to Stapleton by Emeritus Professor Collin at the completion of her keynote address.

 

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