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OA NSW/ACT’s Super Sunday lives up to its name

The annual Super Sunday CPD event followed immediately after the SILMO Sydney trade show and was attended by more than 550 delegates. The wisdom of not holding CPD events concurrently with trade exhibitions was apparent, as there was no tptation to divide one’s attention between both events.ergency departments and the eyesDr Julie Kiel is a UNSW optometry graduate who was a senior staff optometrist in the School of Optometry and Vision Science for more than five years. Kiel then studied medicine at USyd before eventually specialising in ergency Medicine (). Currently, she is an ergency Staff Specialist at St George Hospital and the Westmead Children’s Hospital and therefore well equipped to talk about to an optometric audience.According to Kiel, for the reporting year 2013/2014, there were 7.2 million visits to ergency Departments (ED) in Australia. The main age group of patients was 20 to 35-year-olds, and estimates are that between 38–45% of those visits belong in the GP domain rather than the ED.In a typical tertiary Sydney ED there are an average of 80,000 presentations per year, which equates to around 220 cases per day – of which generally only one or two are eye-related.On arrival, a priority is allocated to a patient on the basis of whether they need resuscitation (top priority), a bed, a chair, or can be returned to the waiting room (lowest priority). Triage categories range from Category 1 (immediate review) to Category 5 (non-urgent – average waiting time 120 minutes). Most eye cases presented fall into Category 4, which is classified as si-urgent – some pain but looks well, average waiting time 60 minutes.Based on a study at two Brisbane EDs, about 60% of those presenting for eye-related issues arrived carrying incorrect diagnoses. Kiel pointed out that there are no in-house, after-hours ophthalmology services in NSW hospitals, although they do have on-call and phone services to provide guidance or possibly attend.Kiel also gave some advice on how to refer to an ED. A covering letter along with relevant findings (VA, IOP, slit-lamp findings, etc.) is essential. If truly an ergency, it is prudent to phone the admissions office at the target hospital’s ED and seek advice. That step also forewarns the ED of what to expect.The second part of her presentation focused on specific conditions, starting with metallic foreign bodies (FBs). Often, an ED’s services are not required and simple roval measures should be tried first. If metal is corroding a prompt but non-urgent referral to an ophthalmologist was recommended.Chloramphenicol (available OTC) four times per day was suggested until they are treated. Additionally, if it is five or more years since their last tetanus injection the patient should immediately be referred to their GP immediately.Each FB case could involve a penetrating injury and that possibility needs careful consideration. The instillation of a minimal amount of fluorescein may show Seidel’s Sign, confirming leakage of aqueous from the eye and therefore a perforating injury. Penetrating injuries are ED cases and some form of imaging – e.g. a CT scan of the orbit or an ultrasound of the globe – is required to confirm where and what the projectile is. Again, tetanus is a consideration and intravenous antibiotics might be prescribed.Kiel also discussed how ocular trauma from automotive, motorcycle, sporting injuries or altercations between individuals can cause a hyphaa. If the cause is unknown (e.g. intoxication or patient is unconscious) referral to an ED was recommended as blow-out fractures of the orbit are a possibility and require further investigation and imaging.If the hyphaa is an isolated event, oral analgesia, and possibly a cycloplegic, were suggested to improve patient comfort before applying an eye shield (not a patch/pressure patch). The patient should be kept upright at all times and any agent that might contribute to continued bleeding, such as aspirin, should be avoided until medical care and advice is available. Such hyphaas are the domain of an ophthalmologist rather than the ED.Meanwhile, chical burns require irrigation for at least 20–30 minutes. In cases of a cellulitis, there is a need to differentiate the less serious prespetal from the more serious post-septal (orbital) cellulitis. In general, referral to the ED was recommended.Children with sticky eyes should be referred to their GP for the causative agent to be determined, as many agents are quite contagious. However, if a school-aged child has bilateral conjunctivitis and an accompanying fever for more than four days, they should be referred to an ED as the possibility of Kawasaki disease (body-wide blood vessel inflammation with an accompanying fever, enlarged lymph nodes, a rash in the genital area, hyperaia of eyes, lips, palms, and soles of the feet, possibly diarrhoea and a sore throat) has to be considered.Other medical ergencies requiring an ED include central retinal artery occlusion (needs a workup for stroke) and some cases of transient vision losses due to transient ischaic attack (a TIA has a 3.5% chance of being followed by a stroke within two days which increases to 9.2% within 90 days). A central retinal vein occlusion (CRVO) is not for the ED.In the ‘Weird and Wonderful’ category was superglue – generally leave it alone and it will spontaneously resolve (disintegrates) and fall out. If close monitoring is not possible, roval, such as cutting the eyelashes, may be prudent or hot compresses may loosen the glue. Severe corneal damage is unlikely, however, and, depending on practitioner confidence a follow-up ophthalmological opinion could be sought.A chalazion is usually a matter of education, hot compresses, and some time – normally weeks to months – so only refer if it persists for 12 months. Kiel recommended that optometrists educate their local GPs to not send chalazia to the ED as it is usually unnecessary.Concussion – The eyes do have it!General practitioner and developer of the HeadSafe programme, Dr Adrian Cohen, provided a general overview of concussion. While the forces involved are not defined, a loss of consciousness is not part of the definition, a point of confusion for many health and sports professionals.{{image2-a:l-w:400}}Concussion is more common than reported, often because of attitudes surrounding perceived toughness and dedication, the tendency to trivialise the incidents involved, and a reluctance to self-report for fear of engendering negativity towards self. There are no objective criteria to define the condition and CT or MRI cannot diagnose the condition.Assessment by a medical practitioner was recommended, preferably within 24 hours of the incident. Most cases resolve without treatment within two weeks and, although most Australian footballers return to the field an average 4.8 days after injury, 20% of cases still showed symptoms more than a week later. However, outcomes are not always uneventful as some 10–13% of cases donstrated symptoms one year after injury.The long-term outlook can be serious and cognitive disorders, depression, or chronic traumatic encephalopathy (CTE) can result. Vision symptoms that should be examined include: blurred vision, double vision, and light sensitivity. One test that is available as an app is the King Devick Test, which indirectly assesses saccadic eye movent in relation to reading ability.It scores for speed and errors but is also affected by attention and language issues as well. Other tests are available to assess predictive visual tracking that monitors, among other factors, the player’s ability to draw circles adequately (baseline ability is measured and stored for comparison so the test is assessing performance changes, not artistic skill).According to Cohen, the afferent and efferent visual pathways account for more than 50% of the brain’s circuitry and they are particularly vulnerable to shear forces during head trauma events. He believes that optometrists have a role to play in early and later concussion presentations by looking for blurred vision, convergence insufficiency, photosensitivity, eye-tracking difficulties, reduced performance at school/work, and migraines/headaches.AmblyopiaQueensland optometrist Mr Adrian Bell gave a detailed overview of vision, visual development, and amblyopia, which lead into to information about new treatments of amblyopia. He noted that although amblyopia was the most common cause of vision impairment in children, there was still the need to convince parents (and the child) of the need to invest time and effort in its treatment. This is despite it having twice the incidence of bilateral vision loss.Bell advised his audience use their retinoscope, an instrument more likely to be forgotten in the bottom drawer in the era of autorefractors. He recommended that ret results be trusted and that near retinoscopy, a very uncommon procedure generally, be considered relevant as well. Furthermore, he advised the use of a fundus camera and OCT, paying particular attention to the maculae.If a refractive error is found, Bell suggested it be corrected because about a third of all probls resolve completely by doing so and around 75% of cases have their VA improved by two or more lines using an Rx. He recommended spectacle wear be close to full-time, but did advise that all recommendations need to be practical if they are to succeed. A re-check of progress at 4–6 weeks was suggested as the next step.If patching was required it should be applied to the sound eye for 2–6 hours each day depending on the depth of the amblyopia, and the covering of the sound eye needed to be phasised and reinforced to the parents. At just two hours per day, Bell claimed that 62% of cases with moderate amblyopia (6/12 to 6/24) can gain three lines of VA in about four months. Near activities should also be encouraged.Bell believes compliance levels are around 40–60%, which is high compared with many health procedures requiring unsupervised patient participation. Atropine was suggested if compliance was a probl. If treatment is successful, he recommended that the patching be tapered rather than stopped suddenly as a reduction in VA or even recurrence is more likely with the latter.Those who fail to respond or respond in a limited way might have subtle retinal, optic nerve, or gaze-control abnormalities. He gave brief overviews of some of the work being done by Professor Robert Hess, which uses a tablet computer, and also Queensland optometrist Dr Ann Webber, who uses a modified Nintendo game of Tetris. Gamification of amblyopia treatment using VR was also detailed in the Silmo 2017 report in the March issue of Insight.The Josef Lederer Award for excellence in optometryThe Josef Lederer Award, offered periodically on an as-earned basis, was this year presented to optometrist Mr Tim Duffy who has practised in Gunnedah continuously since 1985. Duffy continues to serve local, rural, and rote communities via his main practice and a Narrabri satellite branch. He acknowledged the support of his family, especially his wife whose nursing background has been helpful on many occasions. The eponymous award was named after Josef Lederer, the pioneer of NSW optometric education and also the first full professorial appointment in Australia.

KEYNOTE SPEAKERS

Julie Kiel

Kwon Kang

Clare Fraser

Andrew McKinnon

Adrian Bell

Tim Duffy

 

Posterior segment manifestations of ocular trauma

Continuing the the of ocular ergencies was Dr Kwon Kang, a medical retina ophthalmologist specialising in retinal vein occlusion, AMD, and macular holes.

Kang stated that the main aim of trauma managent was the maintenance of vision in the long-term. Of paramount importance to that aim was a good history, because trauma cases are almost always unpredictable and injuries usually have a ‘long tail’, meaning that the prognoses should always be guarded to cover most eventualities.

{{image3-a:r-w:400}}Epidiologically, most patients are young, male, often from a rural location, and occupied in a trade. Severe eye injuries are uncommon, however, Kang did note that they were increasing in developed nations, which suggests that despite easy access to personal protective equipment, workers are not using it and suffering the consequences.

Other causes of ocular trauma include chical and radiation including laser light. Laser damage typically tends to be slightly suprafoveal due to Bell’s reflex and the damage can usually be imaged by OCT.

A further classification of eye damage is open or closed globe, i.e. rupture, penetrate (entry wound only), or perforate (entry and exit wounds). Closed globe damage encompasses laser damage along with contusion, or breaks in the choroid and/or retina. Blunt trauma is usually infero-tporal and results in globe deformation and expansion.

However, the gel-like properties of the ocular media, especially the vitreous, damp the mechanical aspects of the trauma. Furthermore, the optic nerve itself acts to resist eye movent and deformation but can be subjected to a contrecoup injury (that which occurs in a closed syst opposite the point of impact).

Other outcomes are commotio retinae, which is apparent as a reduction in vision a few hours after injury. The fundal appearance includes greyish-white or white opaque peripheral areas with apparently normal blood vessels. It is not a benign condition and complications can include changes in the photoreceptor layer and the RPE, including rupture as well as haorrhages. Retinal detachment is a worst-case scenario.

The unfortunate shaken baby syndrome falls into this category of ocular trauma. Most babies have their condition resolve but, given that haorrhages occur in all retinal layers and sub-retinal haorrhages can follow involvent of the choroid as well, some signs can rain. Choroidal tears can appear as a crescent adjacent to the optic disc. If the crescent is white (the underlying sclera showing through a tear) it will probably not heal well.

Retinal tears at or anterior to the equator can occur from a blunt injury and a laser retinopexy (spot ‘welding’) might head-off the risk of a retinal detachment.

Should an eye be filled with blood or that is suspected, Kang recommended a vitrectomy. Sometimes, injury results in proteins entering the vitreous and vitreal liquefaction can follow. A further examination at two weeks was recommended to follow progress in such cases, as fibrosis can result if left untreated. Giant retinal tears (defined as >3 clock hours in extent) often have a relatively good outcome (comparable to the results of a retinal detachment) despite their apparent size.

If a practitioner is presented with an orbital or globe trauma case, it is advisable that no food or drink be given before medical advice is available. As a measure of the forces that can be involved in trauma cases, reports exist of IOLs being relocated to the sub-conjunctival space. Given the small mass of an IOL, such relocation is testament to the forces involved.

Kang said globe rupture should be considered a possibility if confronted by a red eye with a distorted pupil and a low IOP. Enucleation some 7–10 days after trauma is often considered as a way of decreasing the possibility of sympathetic ophthalmia, although a paper at the recent RANZCO NSW Annual Scientific Meeting intimated that a rethink might be necessary.

The imaging and treatment of penetrating FBs depends on their nature. A complication is when the FB type is unknown. Metals corrode in situ, and an MRI cannot be performed on cases with retained ferrous/ferromagnetic materials such as iron, cobalt, or nickel, because of the very strong magnetic fields inherent in the scanner’s technology. Stones generally are less of a probl but their cleanliness may be another matter.

 

Headache – More than a pain in the neck

Neuro-ophthalmologist and strabismus surgeon Dr Clare Fraser opened her presentation by acknowledging the ophthalmic professions are the only health professionals likely to identify common ophthalmic causes of ocular pain and headache (while there are non-ophthalmic causes of headache most are outside the domain of eye care providers).

{{image4-a:l-w:350}}After detailing the branches of the triginal nerve usually involved and the anatomical areas they service, Fraser delved into the importance of a detailed history that recorded duration, aggravating factors, and response to analgesia.

In cases of herpes zoster ophthalmicus (HZO), her recommendation was firstly a referral to the patient’s GP for immediate, oral, anti-viral therapy followed by a referral to an ophthalmologist. Long-term HZO episodes tend to sensitise neurons, which can lead to heightened sensations to even minor stimuli, such as wind on the face.

Meanwhile, factors aggravating asthenopia include: computer monitor flickering, flickering lights, glare, desk and chair position and ergonomics, and neck strain. An assessment by an occupational therapist or a visual ergonomist was suggested.

Fraser’s presentation was illustrated by several artworks created by sufferers of various conditions that have headaches and/or pain as symptoms. Judging by the depiction of knives, daggers, screws, nails, and distorted or pained facial expressions, the symptoms are obviously extre and difficult to endure. Personal graphic interpretations of migraine aura were also presented.

She put to rest the belief that migraine and POAG were associated, by quoting a large Taiwanese study and also the local Blue Mountains Study and noted in passing that, generally, migraine patients do not require any extra monitoring. However, based on somewhat limited data available, there is a suggestion that migraine sufferers have a higher relative risk of a stroke (overall – 1.55X, haorrhagic stroke – 1.15X, ischaic stroke – 1.65X).

Fraser’s parting advice was for optometrists to rule out ophthalmic causes and if necessary, refer to their GP or a neurologist.