International

Bigger than ever, SCC5 continues the tradition

The fifth Specsavers Clinical Conference (SCC5) saw 350 delegates converge on the Brisbane Convention and Exhibition Centre on Saturday 10 Septber for half a day of clinical education sessions. An additional 200 delegates arrived for the full-day conference on Sunday 11 Septber, with a total of 80 optometrists not associated directly with the organisation attending across both days.The Saturday program hosted two concurrent optometry-focused streams – pathology managent and paediatrics – while the Sunday program consisted of seven sequential lectures delivered by an all-ophthalmological faculty.ASSESSMENT AND DIAGNOSIS OF GLAUCOMADr Michael Yapp, chief staff optometrist at the UNSW-based Centre for Eye Health (CEH), opened the Saturday pathology managent program with a fast-paced and comprehensive overview of glaucoma, the evidence base for its assessment, and the clinical tools available to assist in the decision-making process.A key tool is a guideline or a care and treatment pathway for glaucoma and many are available, including the National Health and Medical Research Council’s (NH&MRC) 2016 Guidelines for the Screening, Prognosis, Diagnosis, Managent and Prevention of Glaucoma, the Optometry Board of Australia’s Guidelines for use of scheduled medicines, and the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Referral Pathway for Glaucoma Managent in Australia; as well as the International Council of Ophthalmology’s Guidelines for Glaucoma Eye Care, the Canadian Ophthalmological Society’s evidence-based clinical practice guidelines for glaucoma managent, the South East Asia Glaucoma Interest Group’s Glaucoma Guidelines, and the UK National Institute for Health and Care Excellence’s glaucoma pathway. These guidelines were also referenced by other speakers during Sunday’s program, including Dr Russell Bach.Illustrated with ambiguous examples, Dr Yapp pointed out that the cup/disc ratio was not a reliable sign of glaucoma, especially in the presence of sloping disc anatomy. He lamented the lack of standards in relation to the equipment and methods of visual fields assessment. He also noted that despite the existence of normotensive glaucoma, the only proven modifiable risk factor in glaucoma was IOP.Regardless of the foregoing, and the evolution of OCT evaluation of the posterior segment, the cornerstones of glaucoma assessment rain assessments of the optic disc (OCT, binocular indirect ophthalmoscope, fundus lens and slit-lamp, fundus camera, etc) and visual fields – the “gold standards”, as he called th. Importantly, effort should be made to correlate structure and function – ie, is there a logical relationship between an area affected and the performance of that area?If a patient is categorised as a glaucoma suspect, extra diligence is required subsequently, to ascertain if, and when, glaucoma might become manifest. Progression monitoring requires the maintenance of comparable data and/or images to allow valid subsequent comparisons. Criteria include progression in three repeatable visual fields and generalised or localised thinning of the neuroretinal rim (NRR).The latter is best assessed using stereo comparative images. Red-free disc imaging was recommended for retinal nerve fibre layer defect detection, and if necessary, a side-by-side or better still, a superimposed, alternating viewing (flicker) comparison of earlier and current images are most likely to disclose any changes including the appearance of, or changes in, Drance haorrhages. Interestingly, despite being relevant to tonometry, corneal thickness varies little over time in glaucoma and only an initial measurent is usually required. Dr Yapp noted that increasingly common high myopia cases should be regarded as ‘special’.Visual field defects tend to get ‘deeper’ and numerical data or field plots will usually reveal the extent of any progression. A good understanding of how instruments work is required if their outputs are to be interpreted optimally. Dr Yapp asserted that raw data should be relied on more than the automated outputs. He also reviewed the ISNT rule of NRR thickness (thickest to thinnest).Based on his experience at the CEH, Dr Yapp reiterated that patient follow-up was the responsibility of the referrer to ensure that care, after-care, treatment, further assessments, etc. happened. All attpts at follow-up should be documented because, although many are deliberate decisions to opt out, it is not unknown for changes of mind to later result in claims and counterclaims of failure on the part of ‘others’. 

PRESENTERS

Michael YapAlex GentleRichard JohnsonPeter LarsenRussell BachNathan Walker

OCULAR ALLERGYProf Alex Gentle, associate head of school (teaching and learning) at the School of Medicine, Deakin University, delivered an update on the best practice in ocular allergy, its diagnosis, and managent. Using the International Statistical Classification of Diseases and Related Health Probls 10th Revision (ICD-10) for naming, he started with H10.1: Acute atopic conjunctivitis, a distinct symptom complex.In passing, he noted that most ocular allergies have comorbidities. Allergic rhinitis (J30.4) affects about 10% of six- to seven-year-old children in the UK, New Zealand, and Australia but can affect up to 40% of adults in the same populations. Its prevalence is a function of age and geography. However, about 50% of allergic rhinitis sufferers also have an allergic conjunctivitis (H10.1) and from a public health point of view, its increasing prevalence is estimated to cost Australia about $8 billion per annum, although it has been estimated that 70% of that cost is the result of presenteeism not absenteeism.Because treatment of the ocular component of such complexes is within the scope of therapeutically-endorsed optometrists, Prof Gentle described the public health benefit of optometrists as ‘massive’ by virtue of their ability to get workers to their jobs promptly, symptom-free, and with less time off. As systatic managent may also be required, other health professionals may need to be involved in patient care.Although a scientific definition of allergy suggests immunoglobulin E (IgE), mast cell, and histamine involvent, some allergies do not involve IgE primarily. While some hypersensitivities have a rapid onset, some can be delayed up to 48 hours and are not an allergic reaction per se. Cases with delayed onset hypersensitivity need steroids.Allergy risk factors include:

  • Seasonal fluctuations such as grass, weeds, trees, pollens, dust mites, and moulds
  • Genetics
  • Air pollution and urban living
  • Domestic pets, especially if kept indoors
  • Hygiene (lack of early exposure to antigens may exacerbate)
  • Biota of digestive syst such as parasitic worms, and gut bacteria.

If the mechanism or cause is not recognised or determined, treatment selection becomes difficult as its target rains unknown.Treatment can be non-pharmaceutical, such as face washing, cold compresses, and simple allergen avoidance – all of which are only tporary. Ocular lubricants offer symptomatic relief and decrease exposure to allergens by dilution but again are only tporary. Vasoconstrictors decrease apparent ocular redness, provide some symptom relief, and decrease the access inflammatory mediators have to the ocular surface via vascular constriction. Dual-action products (combination antihistamine and mast cell stabiliser) relieve itching, reduce ocular redness, and provide some symptom relief by decreasing H1 histamine-related inflammatory activity on the ocular surface.Non-steroidal anti-inflammatory drugs (NSAIDs) decrease the itch, reduce redness, and provide symptom relief by altering the prostaglandin component of the reaction pathway. Prof Gentle’s advice was to use NSAIDs as a corticosteroid replacent. Corticosteroids decrease itching, redness, and provide symptom relief, albeit with significant side effects. The most effective pharmaceutical, loteprednol, is not readily available in Australia currently, despite being approved by the Therapeutic Goods Administration.In 2014. Other products not readily available in Australia, especially to endorsed optometrists, include the immunomodulators cyclosporin and tacrolimus.Treatment of ocular allergies in children is problatic because there are few randomised, controlled trials of under-three-year-olds to offer supporting data. Dual-action products are safe when the child is older than three years and decongestants can be used when they are older than six years. Similarly, NSAIDs can be applied to children over three years and steroids when over two years. When children are over three years old, ‘medication holidays’ (breaks from medicine use) are a good idea in their ‘off season’.UVEITISMr Richard Johnson, principal optometrist at Greenlane Clinical Centre in Auckland, New Zealand, delivered a presentation on uveitis and its diagnosis and managent. Most uveitis cases are anterior uveitis – an inflammation of the anterior uvea consisting of the iris, ciliary body, and the anterior angle.Uveitis lasting for less than three months is considered to be acute and chronic if the duration exceeds three months. The incidence was given as varying between 17 and 52 cases per 100,000 people. It is relatively uncommon before 10 years of age or after 70 years of age. Some 7.1% of attendances to Auckland’s ergency Eye Clinic are for uveitis. Symptoms include brow ache, photophobia, ocular hyperaia, watering eyes, and blurred vision.The signs are a function of the severity of the condition and can include: white blood cells in the anterior chamber (AC, aqueous flare), synechiae, the presence of fibrin and keratic precipitates (KPs), conjunctival injection, vitritis, plasmoid aqueous, and hypopyon. A simple rating syst ranges from none to mild, moderate, or severe.

RATING

CELL COUNT

FLARE

0<1None
0.51–5None
16–15Faint
216–25Moderate
326–50Marked (iris and crystalline lens appear hazy)
4>50Intense
Table 1. Uveitis severity rating syst

Mr Johnson offered a more detailed rating syst based on a 1 mm X 1 mm square slit-lamp beam as detailed in table 1. His recommended slit-lamp technique was to dilate the pupil and start with a larger beam, then narrow it to a 1 mm square using a 45 ° separation of the illumination and microscope systs.He likened the cells to be dust-like while the flare caused by aqueous protein content was smoke-like. Features to look for include: posterior synechiae; the presence of fibrin that can contract and form scars including posterior synechiae subsequently or form ‘clouds’ in the AC; KP appearing as a fine dust or clumps of cells on the posterior endothelium; conjunctival injection; and hypopyon. Pigmented KPs are suggestive of a longer-term condition.Steps are needed to rule out a uveitis involving the posterior chamber and/or posterior vitritis – instrument lighting appears like fog lights in a haze and OCT will confirm such a finding. Such disturbances to the intraocular structures can result in an increase in IOP secondary to blockage of the trabecular meshwork, synechiae, or trabeculitis. An aqueous suppressant may be called for.However, if the ciliary body is involved, the inflammatory reaction can suppress aqueous production, leading to an IOP decrease. Significant numbers of KPs can affect the endothelial pump adversely and corneal oeda can ensue. Corneal oeda and/or the presence of fibrin can decrease the patient’s VA.Chronic anterior uveitis is accompanied by a reduction in VA, less severe inflammation, and white blood cells in the anterior chamber. Complications can include cataract, glaucoma, and cystoid macular oeda.Secondary uveitis can be due to a foreign body raining in the eye for days. If the latter results in an epithelial defect, it is important to avoid the use of steroids. Light sensitivity may be reported and some symptomatic relief may be given by the use of a cycloplegic. Sunglasses are recommended to overcome the light sensitivity and the effects of any mydriasis secondary to cycloplegia.Iatrogenic anterior uveitis (IAU) secondary to cataract surgery, for example, can be treated with prednisolone (eg, Pred Forte) 1% q.i.d for one month. IAU can also follow the use of bisphosphonates for osteoporosis.Therapy for anterior uveitis where there are posterior synechiae starts with up to three or four applications of a mydriatic or a cycloplegic to break the bonds. Pharmacological treatment usually involves the use of a corticosteroid such as a prednisolone, however there is a ‘pecking order’ of efficacies of its various forms; for example, the acetate variant is more effective than the alcohol form, which is more effective than the phosphate form.Application is hourly initially. A cycloplegic such as cyclopentolate (1%) closes gaps in the vascular endothelial cells thereby creating a blood-aqueous barrier. A t.d.s. (eight-hour cycle) application was recommended. The condition should be no worse after one to two days. If it is, the regimen should be extended for a further three days. If the condition still does not respond, an infectious aetiology should be suspected.Although there is little supporting evidence, therapy should be tapered once AC cells disappear or their appearance plateaus (in some cases they never disappear completely). If they fail to disappear, plateau, or if they actually increase, treatment with the maximum dose must be resumed. Should treatment se to be effective but a red eye is experienced some time later, an eye professional (not a GP) must be consulted.Although corticosteroids cause cataract in the long-term, failure to address the issues cause much bigger probls (eg, a ciliary body shut down can result in a phthisis bulbi). Red flags in uveitis include coughs, fevers, rashes, shortness of breath, and bowel, joint, or gastro-urinary symptoms. Blood tests to ascertain HLA B27 status may also be relevant, especially if uveitis is clustered with other HLA B27-related conditions such as ulcerative colitis, psoriatic arthritis, ankylosing spondylitis, or reactive arthritis.COLLABORATIVE EYE CAREThe main Sunday program was opened by Specsavers director of optometry Mr Peter Larsen, who also acted as the MC for the day. In highlighting the need for collaborative eye care, he gave the following statistics:

  • 7–30% of referrals are over-referrals
  • At least 15% of those referred fail to attend their appointments
  • Up to 50% of glaucoma cases rain undiagnosed
  • Even if diagnosed, up to 40% of those glaucoma patients are non-compliant in some way.

He summarised an August 2016 survey of 1,000 Melbourne Specsavers patients as follows: 19 glaucomas, 13 cataracts, six neuro-ophthalmology cases, five AMDs, three retinal detachments, three requiring corneal collagen cross-linking, two ‘wet’ AMDs, and two papilloedas. He also referred to the RANZCO-Specsavers morandum of understanding and detailed how the Oculo communications, audit, and referral portal could play a role in collaborative eye care.DIABETES – CARE AND REFERRALDuring his lecture, Dr Bach, the Princess Alexandria Hospital’s senior medical officer in ophthalmology, said that as far as clinical practice was concerned, the unprecedented capacity to store data, information overload, and increasing complexity of our knowledge of conditions were huge challenges. He also believed multidisciplinary teamwork was one answer to those challenges that would benefit patient outcomes.According to Dr Bach, ethical guidelines for new procedures in medicine is a concept just over a century old and in their latest incarnation are likely to be the result of a systatic review of the evidence. Although turf battles, conflicts of interest, and the need for methodological rigour can often thwart implentation of guidelines among the professionals involved, there comes a time when it becomes unacceptable to ‘sit on one’s hands’ any longer.That situation has been reached with diabetes, a condition estimated to affect more than one million Australians, many of whom are asymptomatic, 300,000 of whom have diabetic retinopathy (DR), and 75,000 of whom have reached a vision-threatening stage of the disease.Risk factors for diabetic eye disease include high blood-sugar levels, hypertension, and inappropriate cholesterol and lipid profiles. Diabetic macular oeda can occur at any stage of the disease and is the major reason for vision loss in type 2 diabetes. Foci while taking a medical history should include: obesity, renal disease, hypertension, lipid profile, pregnancy, and any neuropathy. Red flags during a posterior pole examination include: macular oeda, severe non-proliferative DR (NPDR), new vessels on the optic disc, new vessels elsewhere, vitreous or preretinal haorrhages, and decreased VA, especially when a pinhole aperture does not improve VA.Dr Bach recommended referral when VA was worse than 6/9 and referred the audience to the Diabetic Retinopathy Disease Severity Scale and the International Clinical Diabetic Retinopathy Disease Severity Scale as suitable guides when referring diabetics. While he supported the use of OCT for any vision-threatening condition, he does not regard OCT as essential for screening DR. He recommended urgent (<24 hours) referral in cases of sudden severe vision loss or any signs of retinal detachment.VITREORETINAL SURGERY IN 2016Gold Coast vitreoretinal (VR) surgeon and one-time optometrist Dr Nathan Walker presented an update on the state of the art in his subspecialty.For the purposes of minimising the invasive nature of VR surgery, vitrectomies using 27 gauge (OD: 0.4 mm) tools are now possible. Despite the rise in the use of robotic surgery in other parts of the body, the finesse required for ocular surgery has slowed its adoption in the eye field.{{image8-a:l-w:400}}However, epiretinal mbrane (ERM) peeling, a process that is quite danding, has been performed successfully by a robot where the lack of natural hand trors proved useful. Regardless of the techniques ployed, an ERM peel results in a slow improvent in vision, although Dr Walker admitted that the vision may actually get worse in the first month or so before it gets better, eventually returning to normal usually.Full-thickness macular holes are usually secondary to posterior vitreous detachments (PVDs) and are the result of traction between the vitreous and the fovea. Pseudomacular holes and lamellar macular holes are not PVD-related and are idiopathic mostly.Full-thickness holes occur in about 1:3,000 people, with the majority occurring in fales over 65 years of age. Their prognosis is better if they are of less than six months duration. About 90% of macular holes are ‘closed’, 70% eventually experience improved vision, 50% get 6/12 or better VA, and 15% constitute a risk to the fellow eye.A retinal detachment (RD) can be a disorder of a PVD. Symptoms can include flashes of light (photopsia), often in the tporal field (can be due to traction between the vitreous and the optic disc [vitreopapillary traction]).New floaters can be another warning sign. RD occurs in one in 10,000 people with a 10% risk to the fellow eye. As is now well established, myopia increases the risk, especially in high myopia (≥5 D). Surgery for RD is usually 90% successful after the first operation and 99% eventually.RD is an ocular ergency. The gas bubbles introduced to hold the detached retina in apposition to its support syst can take two to three weeks to absorb. The visual outcome is usually dependent on what happened to the macula during the episode.If the macula is ‘off’, vision will be distorted and can be variable. If a detachment repair can be effected within seven to 10 days, the vision will usually improve slowly. If 10 to 30 days are allowed to elapse, the prognosis is much poorer. Beyond one month, the prognosis is increasingly poor.On the topic of DR, Dr Walker noted that the advent of insulin treatment meant that life was prolonged sufficiently for microvascular changes and other probls to manifest thselves (eg, microaneurysms, the result of loosened junctions between capillary vascular endothelial cells).Intraretinal microvascular abnormalities can be new shunt vessels between existing capillaries or arterioles and venules. In proliferative DR, a vitrectomy may be required for haorrhages into the vitreous body in the late stage of the disease as a secondary complication of the underlying microvascular disease. Unfortunately, the outcomes are often disappointing.Referral was recommended in cases of macular oeda, moderate or worse NPDR, related decreases in vision, or if a second opinion was thought to be prudent.EYE CANCERS – THE GOOD, THE BAD AND THE UGLYArguably the best lecture of the day was delivered by Dr Sunil Warrier, a Queensland ophthalmologist who is also the director of training for RANZCO’s Queensland theatre of operation. He set out to convey a finite topic (a subset of the much bigger topic, ocular oncology) and then proceeded to deliver a measured, entertaining, and lucid exposé of the topic of what optometrists might encounter.{{quote-A:R-W:450-I:9-Q:"Although a lesion overlaid with drusen suggests a long-established situation, changes in the underlying lesion can still occur."-WHO:Dr Sunil Warrier, Ophthalmologist in Queensland and training director for RANZCO’s Queensland theatre of operation}}<>The good – Iris lesions mostly require careful monitoring noting any change in shape or size and the pace of any changes. Although changes in height or width are important, growth into the anterior chamber angle is more important, especially if pigmented. Furthermore, tumours close to the pupil are less concerning than those closer to the angle.Changes in IOP are also important as they can indicate that the changes that are occurring are more significant than those apparent or that deeper structures are involved. The possible involvent of the ciliary body must be ruled out but that requires specialised imaging using ultrasound biomicroscopy, for example, or at the very least, simple transillumination with a dilated pupil.If a tumour could be a melanoma, extra caution is required lest any interference results in a spreading of the tumour by fragments seeding new tumours at rote sites. Iris pigment epithelium adenomas warrant close observation, and if treatment is required, a decision on how ensues.Possibilities are excision (iridectomy or iridocyclectomy) or a radiation plaque, which is usually successful but can lead to a cataract in under two years. A key issue to be monitored in iris tumours is iris/pupil distortion.Reviews at three- to four-monthly intervals were recommended because, with the notable exception of retinoblastoma, many ocular tumours are relatively safe. An artificial iris segment can be used to replace excised iris tissue to restore the pupil’s optical function and improve cosmesis.<>The bad – Choroidal lesions can be primary (a choroidal source) or secondary (to a tumour located elsewhere). A choroidal melanoma is fatal in more than 50% of cases. Other concerning choroidal lesions are haangiomas, melanocytomas, and naevi. Most melanomas are treated locally using a laser and/or a radiation plaque (often iodine125 but a ruthenium106 plaque is thinner).{{image10-a:l-w:300}}There is always an attendant risk of a metastasis and enucleation may become necessary. The SPOTS syst (symptoms, position, orange pigment, thickness, subretinal fluid) can be used to identify the nature of a tumour. The use of ultrasound will disclose whether a lesion is solid or hollow and fluid filled.Although a lesion overlaid with drusen suggests a long-established situation, changes in the underlying lesion can still occur. Dr Warrier stated that he performed Optos wide-field imaging on all his patients. Fewer than 2% of those with an ocular melanoma have a tumour detectable elsewhere.When radiation is used to treat a tumour, the treatment can extend up to nine months and the area affected can mimic DR or a haorrhage in appearance. Adjunctive therapy can be laser, anti-VEGF, or two to six steroid injections. Melanocytomas have a 1% risk of converting into a melanoma, which ultrasonically has a high reflectance.A history of sun, breast, bowel, or prostate cancers often offer supporting evidence of the likelihood of a metastatic tumour rather than a primary one.Laser alone or photodynamic therapy can be very selective and have little effect on the surrounding tissue. Choroidal haangiomas require indirect ophthalmoscopy to see well and ultrasound images vessels well. Dr Warrier’s advice was to do nothing as long as there is no leakage detected and no decrease in vision.<>The ugly – Conjunctival lesions require a more serious approach and are not a lesion that should be watched for very long. They are more common in countries like Australia where actinic exposure is greater.{{image11-a:r-w:300}}Obvious anterior eye tumours such as leukoplakia (white gelatinous lesion with servicing blood vessels) require prompt specialist attention. While recurrence is <5%, the condition is fatal in up to 20% of cases, so it is prudent that a biopsy be taken sooner rather than later (beyond three to four months). Generally, pigment in any lesion of the anterior eye in a fair-skinned patient should be viewed with suspicion. Leukoplakia is easy to treat – by incision, local cryotherapy, and after the area settles, topical chotherapy drops.Conjunctival melanomas can metastasise to the liver or other eye locations and cannot be diagnosed by observation only – a biopsy is required. Despite its rarity, the highly aggressive conjunctival mucoepidermoid carcinoma is important to an Australian audience because its appearance is similar to that of a pterygium. Left untreated, enucleation or orbital exenteration become possibilities.SCC5 continued the tradition and standards set by Specsavers’ previous conferences. SCC6 will take place from 9–10 Septber 2017 and while it has not yet been locked in, Specsavers’ plans to potentially move the event to Melbourne implies the next conference will almost certainly be bigger and at least as good as – if not better than – SCC5.<>* Lewis Williams attended SCC5 courtesy of Specsavers.

‘GRAMMING’ AT SCC5{{image12-a:l-w:300}}The presence of early-career optometrists was highlighted throughout the fifth Specsavers Clinical Conference (SCC5), not only via a Young Optometrists (YO) exhibition stand but also through the hosting of an Instagram competition.All optometrists attending the conference aged 30 or under were encouraged to take images of the event and share th with their peers on Instagram. The competition was met with enthusiasm and a total of 78 entries were submitted.On the second day of SCC5, Ms Nisha Sharma, an optometrist from Specsavers Tea Tree Plaza in Adelaide, was announced as the winner of the major prize – an all-expenses-paid trip to the Himalayas with Eyes4Everest, an organisation dedicated to providing primary eye care in the Sagarmãthã (Mt Everest) National Park of Nepal. Several state-based prizes were also awarded, with all prizes sponsored by Specsavers.YO NSW/ACT chair Ms Carina Trinh said she was delighted to have Specsavers’ support in running the Instagram competition alongside other early-career optometry groups, including YO Victoria, YO South Australia, and the Optometry Western Australian Graduate Group.{{image13-a:r-w:300}}“We re