In addition to cutting-edge clinical lectures, the CCLSA embraced all things Pink Floyd for the 17th International Cornea & Contact Lens Congress. In part one of his report, LEWIS WILLIAMS details several lectures and awards presented during the event.
The Cornea and Contact Lens Society of Australia (CCLSA) held its 17th International Cornea & Contact Lens Congress (ICCLC) in the Macquarie Conference Centre, part of the Peppers Noosa conference complex, at Noosa Heads, Queensland from 11-13 October.
This year’s ICCLC was unlike any previous event because of its thematic approach and celebration of all things Pink Floyd, particularly the rare 1970 album Picnic – A Breath of Fresh Air. The novelty was the result of efforts by Ms Margaret Lam, the CCLSA National President, Mr Alan Saks, CCLSA’s CEO, and the conference organiser Corporate Communiqué. Given many of the delegates’ age, CL-related education would not have been all they learned about over the three-day programme.
Scleral contact lenses
Sugar Land, Texas, optometrist and scleral CL specialist Dr Tom Arnold opened the scientific part of the programme. He is a Fellow of the Scleral Lens Education Society (FSLS).
He gave the dominant reasons for using scleral CLs as irregular astigmatism, keratoconus (KC), pellucid marginal degeneration (PMD), post-penetrating keratoplasty, and other post-surgical indications. He acknowledged that scleral CLs were not always the best option, such as when the origin of an optical problem was the posterior cornea and not the anterior cornea that a scleral lens can address effectively.
Where KC is the problem, solutions include GP, hybrid or scleral CLs and, more recently, SCLs designed especially for KC. He described the latter as becoming increasingly popular in the US. Despite what some claim, Arnold does not believe that an OCT is essential to scleral CL practice, but he admitted that it was “useful”.
In his experience, the surface profile of the scleras he has assessed are spherical in only about 6% of cases, toric in 29%, and asymmetrical in 41%. Importantly, the scleral profile is dynamic and changes according to eye movement because of the influence of the EOM’s activities and their points of insertion. KC and PMD were nominated as being the most difficult to deal with and fortunately, PMD is relatively rare.
The uses of topographical data recommended by Arnold were axial maps to reveal surface power differences and elevation maps for information on lengths/distances/radii. On the subject of the clearance or vaulting height of scleral CLs, he noted that the ‘settling’ (decrease in ocular surface clearance) was often more than 70 microns by 8 hours of CL wear, 75% of which occurred in just the first 2 hours and 50% of which occurred within 45 minutes of CL insertion.
He also noted that apart from possible formation of bubbles (dimple veiling), excessive clearance is a barrier to oxygen transmission given that the Dk of water is finite.
Anterior segment pearls
This segment, subtitled A Saucerful of Secrets (the title of Pink Floyd’s 2nd studio album) was delivered by the experienced ophthalmologist duo Professor Charles McGhee and Dr Sue Ormonde from Auckland, New Zealand.
McGhee occupies the M Paykel Chair of Ophthalmology and is Head of Department at the University of Auckland. Ormonde is currently the only female laser refractive surgeon in NZ and a Senior Lecturer in McGhee’s department with dual roles in Clinical and Teaching.
McGhee cemented his status as the world’s best ophthalmic entertainer bar none by opening the presentation with an extensive video production that he and Ormonde starred in. McGhee is an accomplished rock guitarist (appropriately, his guitar was decorated with false colour maps taken from a corneal topographer) who seriously considered a career in the music industry. Ormonde, who played a real guitar as an air guitar in the clip, is a budding video producer and editor.
The final product was a result of the combination of their two skills that is rumoured to have consumed between 80 to 100 hours of their ‘spare’ time. The audience owes them; it was an outstanding entertainment piece and will be a hard act to follow should anyone decide to rise to the challenge.
After showing their excellent video, the duo got back to the more serious topic of anterior segment surgery. McGhee acknowledged that despite being a well-established procedure, penetrating keratoplasty (PKP) has now been surpassed by the alternative lamellar procedures. These include DSAEK (Descemet Stripping Automated Endothelial Keratoplasty) and DMEK (Descemet’s Membrane Endothelial Keratoplasty), which only started gaining traction circa 2011.
Fuch’s Endothelial Dystrophy accounts for 49% of lamellar procedures and about 9% of PKPs are actually repeat PKPs. The life expectancy of a PKP can vary between about 10 and 30 years, with 15 years being an average. Other endothelial dysfunctions account for a further 9% of lamellar surgeries. Problems with lamellar procedures, such as DSEK, include the graft simply falling off or early graft mislocation.
Data suggests that the 12-month survival rate is 94%. DSEK and DMEK survival rates were stated to be about the same. However, detachment is more common in DMEK, whereas DSEK patients experience higher complication rates. Future developments include the use of Rho-kinase (ROCK) inhibitors for Fuch’s and the use of in vitro endothelial cell culturing, which are seeded subsequently onto the posterior cornea.
Ormonde discussed herpes simplex keratitis, noting that there were no benefits from the consumption of oral acyclovir or interferon antiviral therapy. However, topical steroids did slow progression of the condition and speed-up recovery, all without any adverse effects on vision. Interestingly, there is some evidence that oral acyclovir might decrease recurrence rates and can act as a prophylactic in PKP, as well as reduce the risk of graft failure.
Triggers of recurrent HSV keratitis include injury, corneal surgery, and previous episodes of stromal keratitis, as well as any event leading to the patient becoming immunocompromised. Menstruation, heat, stress, and sunlight have also been postulated as possible triggers. Antiviral therapy at the time of corneal surgery has been suggested. Ormonde advised the audience to think of HSV infection whenever an abnormal looking cornea was encountered.
She then turned her attention to iris and pupil defects and related problems, specifically repairing or ‘replacing’ irides either partially or fully. Tumours remain a major reason for iris removal and simple ideas to hide the altered appearance include tinted spectacles or sunglasses, cosmetic CLs, and bespoke custom tinted/artificial iris print CLs.
Surgical solutions include repair, excision, or replacement of excised tissue with artificial iris segments or a whole iris. Where possible, surgeons will attempt to conserve or reposition as much natural iris tissue as is prudent under the circumstances.
The artificial iris manufactured by HumanOptics of Germany is a siloxane elastomer alternative, but its use is predicated on extraction of the crystalline lens. Artificial iris segments, sometimes multiple segments in the same eye, are useful in partial tissue removal cases.
Switching topic to one directly relevant to the audience was preparation of current, especially long-term, CL wearers for IOL implantation. Ormonde advised that CL wear must cease prior to any anterior segment surgery because, until stability of the segment had been achieved, the outcome can be unpredictable. That time of cessation depends on the CL-wearing history and CL type. Examples include: DW SCLs need days to settle, toric SCLs take longer (poorer physiology, more corneal changes to be reversed or stabilised), corneal GP CLs, weeks or even months, EW GP even longer.
Importantly, she advised practitioners use the same topographer throughout the monitoring process because results between devices, models, and brands are not directly comparable. In cases of KC, she advised that managing patient expectations help all involved and they had to be realistic. Importantly, VA post-surgically was probably going to be inferior to the vision achieved with their best CLs before surgery. An ongoing problem is the difficulty of biometry in KC eyes.
Sometimes, a toric IOL can be useful. She also finds that a CL can be useful in ascertaining a refractive target before surgery. In the case of myopes, it is often a case of ascertaining what the patient wants as a refractive goal because it is not always emmetropia. If monovision IOLs are contemplated, she advised a monovision CL trial first. Similarly, if MF IOLs are contemplated, a MF CL trial before surgery is prudent as it is a reasonable first-order approximation of the likely result.
New awards recognise career achievements
A highlight of the event was the presentation of several awards, including two inaugural distinctions.
One of the new accolades, the Brien Holden Memorial Award, has been created to honour the contributions to CL knowledge made by the late Professor Brien Holden, who died in 2015.
The section of the congress allocated to the presentation of the award was subtitled Wish You Were Here, named after one of Pink Floyd’s greatest, and possibly saddest, hits.
The inaugural award was presented jointly to Holden’s first and third PhD candidates, respectively Dr Steve Zantos and the writer of this report. The writer also constructed the perpetual trophy, based on design input from Ms Yvonne Holden, Mr Alan Saks, and Dr Zantos, using archival items.
The objects are mounted on a hexagonal plinth. Research into the endothelium was a major ‘brick’ in the foundation of Holden’s research career, Zantos’ academic career, and the writer’s PhD. All continued the line of research initiated by Zantos’ discovery of endothelial blebs in the mid-1970s.
Items included are: the original Holden-Zantos adaptor for high magnification and endothelial photography mounted on an original Olympus OM-1 camera with an original 50 mm macro lens, an original Holden-type, glass-faced, SCL wet-cell, a Haag-Streit optical pachometer, two rolls of unexposed Kodachrome 64 slide film, a 20th anniversary CCLRU celebration badge, a Wratten G (15) deep yellow filter, and the pair of Holden’s place nametags from his address to the National Press Club of Australia in October 2005.
Inside the base is a somewhat more fragile Sharp programmable desktop calculator magnetic programme card (circa 1973) inside its paper sleeve, bearing Holden’s distinctive handwriting declaring it is for calculating the BVP of CLs. It is accompanied by a program listing printed on the special metalised paper roll used by the calculator’s integral printer – it is still as legible as the day it was created.
Following an introduction to the award by Saks and Ms Dorothy Carlborg, Zantos and the writer each gave brief presentations illustrated with numerous historical images of people, situations, publication banner pages, instruments created along the way, and buildings occupied by Holden entities. That was followed by a brief presentation by Ms Yvonne Holden and awarding the Brien Holden Award medals to the recipients.
The Dorothy Carlborg CCLSA Research Awards
In another change for 2019, the research awards presented by the CCLSA (and CLSA earlier) to post-graduate students are now to be known as the Dorothy Carlborg CCLSA Research Awards.
The naming is in honour of the service provided by Ms Dorothy Carlborg (earlier McDiarmid, or Boyer) to the contact lens industry and later the CLSA and CCLSA as their CEO. The 2019 recipients are: Ms Azadeh Tavakoli, Mr Hari Kumar Peguda, and Dr Ngozi C Chidi-Egboka, all from the School of Optometry and Vision Science, University of New South Wales.
Tavakoli is a MSc candidate researching the impact of pre- and probiotics on dry eye disease. Peguda is a PhD candidate endeavouring to develop fluorescein nanoparticles that can identify Acanthamoeba spp. in vivo faster. Chidi-Egboka’s very topical work is investigating the possible impact of smartphone usage on the ocular surface with a focus on visual comfort and eye health.
If history is any indication, the recipients will go on to make significant contributions to our knowledge in the short and long-terms, and could even create research entities to match those already existing.
The Kenneth W Bell Medal
Another highlight included the awarding of the already-established Kenneth W Bell Medal for 2019 to optometrist, CL pioneer, GP scleral innovator, and one-time CL manufacturer Mr Don Ezekiel from Perth. Ironically, Ezekiel and the late Kenneth Bell knew each other in the early 1960s when both practised optometry in Singapore. The inaugural recipient of the medal was none other than Professor Brien Holden himself, who received the award at the 1993 ICLC.