A volley of questions from audience members during the Ophthalmology Updates! two-day conference in Sydney has illuminated areas where there is debate on the best way to treat and manage patients. Insight recaps the event.
A question from a delegate about potential treatment options for a 10-year-old patient with congenital toxoplasmosis who recently presented with a new lesion is the type of interaction Ophthalmology Updates! is known for, and this year’s event was no exception.
Presenter, Professor Justine Smith, was quick to respond, with the session’s chair, Professor Peter McCluskey, also contributing to the discussion about the importance of involving a paediatric specialist in treatment, in this particular case.
The question – and subsequent discussion – was one of many which took place over the two-day conference at The Fullerton Hotel in Sydney 26-27 August. For event convenor Professor Adrian Fung, the opportunity to ask questions is highly valued by delegates, with 200 people attending this year.
“The field of ophthalmology – and the subspecialities within it – changes fast. Treatment options have changed since Ophthalmology Updates! first started in 2016,” Fung said. “This event is an opportunity to learn from each other and share our real-world experiences. There is a lot of discussion on areas where there’s room for debate on the best way to manage patients.”
Fung said the conference model includes revision of a ‘common’ condition across a range of subspecialities, as well as exploration of a ‘frontier’ topic on a topical subject.
“With speakers presenting the newest data in their field, the event provides a yearly concentrated overview from experts on the latest diagnostic techniques and treatments across a range of subspecialties,” Fung said.
An internationally recognised expert in the causes, effects and treatment of uveitis, Smith’s presentation on toxoplasmosis summarised the findings of several papers she has published in the last few years, including one study jointly conducted with the International Ocular Inflammation Society.
However, perhaps most telling was an article she co-authored with Associate Professor João Furtado from The University of São Paulo in Brazil, published in Ophthalmology Retina, which “went viral” after being featured in the magazine The Conversation.
Across the world, it’s estimated 30-50% of people are infected with Toxoplasma – and infections may be increasing in Australia, Smith warned. To illustrate, she shared the details of Australian-first research by Flinders University which found more than one-third of lamb mince purchased from supermarkets over a six-month period contained Toxoplasma. Eating undercooked or raw meat is a major risk factor for this disease. About one in 150 people have scars in the back of their eyes consistent with prior infection.
As part of her presentation, Smith also spoke about the changes in medical journal publishing witnessed in her term as editor-in-chief of Clinical and Experimental Ophthalmology, including an increase in research compliance, plagiarism, generative AI, and the need to harness social media. Smith was the first to appoint a social media section editor (Dr Elsie Chan) to the journal.
“AI-generated content, like plagiarism, is a growing problem in publishing. So too is the rise of ‘predatory journals’. These journals have similar names to genuine peer-reviewed journals – therefore causing confusion – and take advantage of authors by asking them to publish for a fee without providing peer-review or editing services. It’s a scam,” Smith said.
Smith, who is the first female editor-in-chief of Clinical and Experimental Ophthalmology and the first to lead a top tier Q1 ophthalmology journal, is stepping down at end of the year after completing a four-year-term.
Professor Dinesh Selva, foundation chair of ophthalmology and visual sciences at the University of Adelaide, delivered a presentation on oculoplastics, bringing attention to a rise in cases of group A Streptococcus, resulting in him seeing more cases of necrotising fasciitis.
Selva also discussed the intricacies of Tenzel flap technique, periocular squamous cell carcinoma (SCC) risk stratification, gene expression profiling, and a new neoadjuvant immunotherapy for advanced SCC, which is showing promise of being a globe-sparing treatment, he said.
Highlights on Day 1
Emerging treatments for age-related macular degeneration (AMD) and geographic atrophy (GA) was presented by Professor Robyn Guymer, deputy director of the Centre for Eye Research Australia (CERA). Describing this space as “the dawn of a new era”, Guymer explained how some anti-VEGF patents are expiring (the intravitreal aflibercept patent will expire in November), and the sector is now witnessing more biosimilars coming to market, including Melbourne-developed OPT-302 (Opthea), and gene therapy, such as RegenXbio/Abbvie.
However, Guymer said there is still a gap between clinical trial outcomes and real-world outcomes, which needs to be addressed. To that end, she shared results of the VOYAGER study, an innovative, global, observational study to gain real-world insights into the long-term utilisation of the Port Delivery System (PDS) with ranibizumab and intravitreal faricimab for the treatment of neovascular AMD and diabetic macular oedema.
Guymer highlighted two intravitreal anti-complement therapies which have been recently FDA-approved to treat GA (SYFOVRE from Apellis, and IZERVAY (formerly Zimura) from Iveric Bio) plus others in the pipeline including a gene therapy in development from Gyroscope Therapeutics (acquired by Novartis).
“There are many emerging treatments for GA, but the complement inhibitors pathway is furthest along in clinical studies,” she said.
She warned of an increased risk of nAMD in patients treated for GA and real-world incidences of retinal occlusive vasculitis which were not reported in the clinical studies.
Live polls were held throughout the presentations, with speakers asking delegates multiple choice questions through the event app, shaping discussion.
Associate Professor Michael Lawless polled audience members on their most commonly used IOL during his lecture on the nuances of IOL technologies, discussing Rayner’s new RayOne EMV Toric and comparing EDOF lenses. He also shared 10 tips to improve cataract surgery.
“Use plastic, not metal inside the eye, and press on the primary wound to prevent reflux and toric IOL rotation. Discharge patients at six weeks only after having actively met their expectations. Continue to learn new techniques, and if you start to feel too comfortable, start to worry,” he said.
Lawless also spoke about what factors make a difference in near vision despite the same end points and hinted that the answer would be apparent in the next six months. Looking further ahead, he said chromatic aberration will likely be the next frontier in IOLs, and shared a new IOL concept from Dr Sri Ganesh, known as the swivel haptics IOL prototype.
Following presentations which addressed modifiable risk factors in uveitis (delivered by Associate Professor Anthony Hall) and an overview of MIGS devices (delivered by Dr Nathan Kerr), special guest speaker Dr Norman Swan gave an insider’s view on medicine in the media.
Citing current health issues making headlines in the media, such as The Voice referendum, and the rise and fall of Australian neurosurgeon Dr Charlie Teo, Swan discussed how the media controls the message.
“Media operates on an emotional level. For example, the case against The Voice – the ‘no vote’ – is framed by what you lose if you vote ‘yes’,” he said.
Swan also highlighted the media coverage of COVID and infectious disease epidemiology.
“There was a media divide, and the community didn’t know who to trust or believe, made worse by the Federal Government response. There was a crisis of trust. One of the most difficult problems that arose during that time was the clotting problem with the AstraZeneca vaccine, and how that was reported in the media,” he said.
Highlights on Day 2
“When does myopic traction maculopathy (MTM) require intervention?,” presenter Dr Mali Okada asked the audience on the second day of Ophthalmology Updates!.
Okada, a medical retina and vitreoretinal specialist at the Royal Victorian Eye and Ear Hospital, outlined tips on diagnosing MTM, and discussed macular buckling for myopic macular schisis, with one ophthalmologist in the audience volunteering to share their experience with this surgical procedure.
She also discussed with the audience whether to offer surgery to patients with myopic traction maculopathy and foveal detachment alone.
Speaking on novel drugs, devices and implants in her area of subspeciality, Okada informed the audience on a new drug treatment for proliferative vitreoretinopathy, as tested in the GUARD trial.
The GUARD trial assessed whether postoperative administration of ADX-2191 (intravitreal methotrexate 0.8%, Aldeyra Therapeutics) has an effect on rates of re-detachment due to PVR that requires surgery.
Okada said preliminary results from the trial show promise, with participants given 13 injections over four months, when the risk of PVR is at its highest.
On devices, she highlighted that although the previously mentioned PDS is currently voluntarily recalled due to septum displacement issues, the PAGODA trial has shown that in patients with DMO, implantation of the PDS with ranibizumab with refill/exchanges every six months maintains vision and controls oedema as well as monthly injections of ranibizumab.
She also touched on primary analysis results of the phase 3 PAVILION trial, involving PDS with ranibizumab in the treatment of diabetic retinopathy without centre-involved diabetic macular oedema.
Lastly, Okada summarised a study demonstrating efficacy of intravitreal delivery of ciliary neurotrophic factor (CNTF) using an encapsulated cell implant for the treatment of macular telangiectasia type 2.
Moving from the retina to the cornea, Dr Elsie Chan, a cornea specialist at the Royal Victorian Eye and Ear Hospital, generated discussion on the merits of taking one biopsy or two in cases of suspected cicatrising conjunctivitis.
“Not all cicatrising conjunctivitis is a subtype of Mucous Membrane Pemphigoid (MMP). If in doubt, repeat a biopsy,” Chan said, sharing real-world cases to highlight the importance of repeating a biopsy, even if the first result is negative.
Chan’s presentation also reviewed the ocular surface microbiome and potential treatments manipulating the microbiome. Her discussion on topical antibiotics in ophthalmology and their affect on gut health raised further questions, prompting chair Associate Professor Chameen Samarawickrama to share his experience and views on antibiotics stewardship as editor of the RANZCO therapeutic guidelines.
Paediatric ophthalmologist Dr Craig Donaldson, currently head of the strabismus unit at Sydney Eye Health, updated delegates on Duane Syndrome, a congenital rare type of strabismus which affects females more than males, and left eyes more than right. Donaldson suggested a hearing test for patients with suspected Duane Syndrome, a recommendation that chair Dr Loren Rose also agreed with.
Donaldson also reviewed real-life cases of Brown Syndrome, usually congenital but sometimes the result of trauma such as a dog bite, and Monocular Elevation Deficiency (MED).
Outlining what is new in paediatric ophthalmology, Donaldson spoke about peripheral retinal defocus lenses, including D.I.M.S lenses and H.A.L.T lenses, with Rose highlighting the importance of emphasising to patients that these only work when they are worn.
He also drew attention to repeated low-level red light therapy (RLRL), with an Australian made device recently receiving TGA approval, and raised the potential of preventatively treating ‘pre-myopes’, those at risk of developing progressive myopia. Finally, he underlined the importance of always checking a child’s pupil function.
Flinders University consultant neuro-ophthalmologist Professor Celia Chen provided a summary of arterial occlusion.
“Follow the roadmap, from carotid arteries to retinal emboli. Where is it from? Find the underlying vascular risk factors. Where will it go? Consider secondary prevention for stroke and heart attack,” she said.
She then turned her attention to the complexities of diagnosing idiopathic intracranial hypertension (IIH), a condition she described as on the rise. The condition was formerly known as Pseudotumor cerebri and benign intracranial hypertension, both of which are now considered inaccurate.
“IIH is not benign – you need a lumbar puncture to confirm diagnosis. Cases of IIH have doubled in the last 10 years and is essentially a diagnosis of exclusion,” she said.
Treatment options include, in order of preference, non-pharmacological (such as weight loss), medical (such as Diamox and Topamax), and surgical (such as venous sinus stenting).“There is no such thing as a quick fix,” Chen said.
Radiologist Dr Geoffrey Parker, who provides diagnostic and interventional radiology support to the Ophthalmology, Head and Neck and ENT Services at Royal Prince Alfred Hospital, used real-life cases to demonstrate where a radiologist can help in diagnosing a range of conditions.
“Imaging is improving. We can see remarkable detail,” he said.
The final speaker, ocular oncologist Dr Li-Anne Lim, zeroed in on uveal melanoma, and a new approach to management of metastatic disease with TGA-approval of Tebentafusp.
“It’s the only drug which makes a meaningful difference to overall survival rates,” she said.
Lim is a clinical senior lecturer at the University of Sydney and involved in the ocular oncology multidisciplinary team at The Kinghorn Cancer Centre at St Vincent’s Hospital in Sydney.
At this year’s conference, she also reported on a promising neoadjuvant therapy being trialled at St Vincent’s Hospital in Sydney. The drug, Darovasertib, and the corresponding NADOM trial, shows it has the potential to save eyes with uveal melanoma from enucleation.
Channel Nine news aired a report, ‘Cancer drug trial saves Queensland man’s eye from massive melanoma’, in June this year.
“It’s changing the paradigm,” Lim said.
More reading
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