RANZCO marked a jam-packed 2023 congress in Perth by inducting 46 new fellows, recognising Australia’s top performing eye doctors and outlining its workforce blueprint. The event was also punctuated with a high-powered speaker line up, featuring heroic tales and insightful updates on glaucoma, neuro-ophthalmology and more.
The 2023 RANZCO Congress speaker sessions started with an incredibly tough act to follow. Dr Craig Challen, a retired veterinarian and cave diver from a town just 40km north of where this year’s conference was held, recounted his involvement in the famous 2018 Thai cave rescue of 12 boys, sharing bizarre and miraculous insights from the event that changed his life forever.
While it soon became apparent that cave divers would hold the key to the rescue, in the Opening Lecture at the Perth Convention and Exhibition Centre, Challen told delegates of the extreme measures people entertained to try save the boys, including the use of drill rigs, the search of alternative cave entrances, pumps to reduce the water table and locals using picks and pipe upstream to divert water away from the cave.
“There were also other plans you might say that were verging on the bizarre, not least of which was Elon Musk who turned up on site with his so-called submarine,” he said.
Challen’s keynote speech was a gripping way to kick off this year’s RANZCO Congress that welcomed around 1,500 in-person delegates alongside 243 online attendees. The event kicked off in a big way on Friday 20 October when a record 170 people attended the Global Eye Health Workshop, followed by the morning of Saturday 21 October when more than 660 delegates turned up to the morning session, which included Challen’s Opening Lecture.
Discussing the proposed use of a submarine for the Thai cave rescue, Challen said it was an impressive piece of equipment, but would have been impossible for cave divers to manoeuvre into the cave where the boys would then climb inside and been pulled to safety.
“But there were a couple of technical problems with this plan. The first was there didn’t seem to be any sort of life support system and, by this stage, we had a pretty good idea that it was going to take about three hours to swim out from chamber nine where they were located,” he said.
“The second thing was this device was made from super high-tech alloy of lithium and aluminium and weighs next to nothing, which isn’t so good for diving [which requires a weight belt] … but unfortunately, the one outstanding difficulty was that this was too big to fit through some of the restricted areas in the cave.”
It was going to be down to cave diving experts, including Challen and fellow Australian Mr Richard Harris, a trained anaesthetist; both would become the joint 2019 Australian of the Year for their heroics.
Both had a unique skillset that would set them up for the next part of the outlandish rescue plan – to render the boys unconscious with a formulation containing ketamine. Some of the boys didn’t know how to swim, and diving can be a disconcerting experience for first-timers, especially in 10cm visibility.
“If they started panicking and thrashing around in the cave underwater, they were certainly going to kill themselves and quite likely take a diver out with them,” Challen said.
Then came another challenge. The anaesthetic would only last for 45 minutes, so the non-medical members of the dive team were given a crash course so they could administering the drug through a thigh injection mid-rescue.
Fifteen days after the boys went missing, the rescue commenced, and the gravity of the situation began to weigh on Challen. “To be perfectly frank, we had no hope at all that we were going to get all of these kids out alive, we fully expected casualties – and to be honest – if we lost a whole lot of them, I wouldn’t have been all that surprised,” he said.
Miraculously, every boy was returned to their family alive. Challen says if confronted with the same situation today, he would be just as daunted by the prospect. But out the other side, the situation has taught him some life lessons.
“All of us are going to face a test in our lives which can come in many different forms. It might be difficulties in your professional life, financial or health problems. You might be caught in a war or natural disaster, which in one way you’re completely unprepared for,” he said. “But in another way, we’ve been preparing our whole lives for these moments, and it’s behoved upon all of us to take the opportunities we’re presented with.”
The latest from the college
Immediately after Challen came the RANZCO Plenary Lecture, offering a glimpse into the college’s activities and priorities. The session was chaired by president Dr Grant Raymond, and featured Dr Kristin Bell, Dr Justin Mora, Dr John Kennedy and Professor Nitin Verma.
Bell, a Tasmanian ophthalmologist, delivered an update on some of the biggest issues facing the ophthalmology workforce and access to eyecare in Australia. This was against a backdrop of growing demand for healthcare (now growing faster than the rate of GDP), inadequate funding of preventative health and poor coordination and funding of chronic diseases.
“In this challenging funding environment – where healthcare strategy and funding largely remain focused on acute disease presentation and inpatient services – ophthalmology, which in large part is an outpatient and elective surgeries specialty, is a canary in the coalmine,” she said.
“We must also meet the additional challenge of navigating a complex, fragmented funding environment, rife with cost-shifting and lacking in governance and accountability, our current cost of living crisis, a widening income gap, and a low rate of private health insurance.”
Notably, she pointed to the “stagnant” funding of public eyecare, with just 13% of services delivered in the public setting, insufficient accredited training post opportunities, longer waiting lists, and the threat of closure of public eye departments.
Part of the solution, Bell said, could be an atlas of healthcare delivery standards to define what services need to be delivered where, and the mandatory reporting of outpatient waitlist data. She also called for greater collaboration across the eye health sector, including a consensus on the roles and scope of each “craft group” i.e. optometry, so the sector can go to government united in its approach, led by ophthalmology.
Meanwhile, Kennedy updated fellows on the activities of the Australian and New Zealand Eye Foundation (ANZEF) – RANZCO’s philanthropic arm – with a major focus on increasing the First Nations ophthalmology workforce, which currently stands at one (A/Prof Kristopher Rallah-Baker).
Quoting the late Professor Fred Hollows, he acknowledged that “to close the gap, you have to put Aboriginal health in Aboriginal hands”.
Current barriers to First Nations participation in the ophthalmology workforce include the $50,000-$60,000 cost over five years for registrars to cover RANZCO’s Vocational Training Program (VTP) and exams.
“Now of course, registrar’s are well-paid, but this is a large amount of money for a young person, particularly if you come from a financially challenged background and are away from home and family for the duration of your training,” Kennedy said.
To counter this, ANZEF is providing $30,000 scholarships to Aboriginal and Torres Strait Islander RANZCO trainees, comprising $10,000 towards the first year, and $5,000 for every year after. Plus, the $1,800 application fee for the VTP has been waived for all First Nations applicants.
Currently, Kennedy said two Indigenous trainees started receiving the $30,000 scholarship last year (in WA and Victoria), while a Sydney trainee began receiving the funding this year and another trainee is expected to in Melbourne next year.
“Soon we will have four indigenous trainees in our scheme,” he added.
Finally, the ANZEF Indigenous Award in Ophthalmology at UNSW is offering two Indigenous students $10,000 each to undertake research in the fourth year of medical studies to provide exposure to ophthalmology. This will be overseen by the Prince of Wales Hospital ophthalmology department, including outreach clinics, and the UNSW Faculty of Health and Medicine.
“And if this is successful, we hope to replicate this at other universities. This program is also fully funded for the next three years,” Kennedy said.
Next, Kennedy provided an update on the ANZEF’s 2023 grants round where projects can receive up to $50,000 where they promote eye health equity and access. This year ANZEF was “swamped” with 40 applications from RANZCO members and affiliates. Six projects were selected totalling $185,000. These were:
• The Western Murrumbidgee LHD Indigenous eyecare project, led by A/Prof Geoffrey Painter, Dr Dominic McCall and Mrs Kerrie Legg.
• Bad sugars, bad eyes – a culturally appropriate diabetic retinopathy screening campaign in the Kimberley, led by A/Prof Angus Turner, Lions Eye Institute
• Expansion of support for the Global Eye Health Workshop at RANZCO Congress, led by Prof Mark Radford, Queensland Eye Institute
• Mentoring workshop in Auckland for Maori and Pacifika applicants to the VTP, led by Dr Justin Mora
• Lions InReach Vision: improving eyecare for Indigenous Australians, refugees, and asylum seekers in Perth’s metropolitan regions, led by Dr Marcel Nejatian andA/Prof Hessom Razavi, Lions Eye Institute
• Sponsorship of Pacific Islands participants for microsurgical skills training, led by A/Prof Graham Wilson, A/Prof Con Petsoglou and Dr Yves Kerdraon.
Make blebs great again
In the Glaucoma Update Lecture, delegates heard from the Singapore National Eye Centre’s Professor Tina Wong who provided a thought-provoking and entertaining update on glaucoma and trabeculectomies.
She focused on the downside of bleb forming surgeries, namely unpredictable scarring and the potential for loss of function, stating the industry has been waging a 60-year war on this issue – that’s yet to be entirely resolved.
Wong said modern trabeculectomy was first described in the 1960s. Then, several years later when the adjunctive use of 5-Fluorouracil (5FU) and Mitomycin C (MMC) were first introduced to address wound healing and improve surgical outcomes, the industry thought it had addressed the problem.
“But after a while things started to go a little bit south. There was more understanding of other factors which could lead to failure of our trabeculectomies that may be out of our control, such as ethnicity and racial differences, but also data from David Broadway’s work showed the adverse effects of topical anti-glaucoma medications that not only causes problems with compliance, but also on how the patient will scar when we perform surgery on them.”
Thus, the quest continues for a Holy Grail approach. Fundamentally, Wong believes trabeculectomies work, but she says it’s important to think of blebs as a “surgically-created living organism” that is in constant change and evolution.
“It’s like you’ve given birth to a new child. At the beginning, everyone’s delighted and commenting how cute they are, and as you go through the years, they start having tantrums, they don’t behave the way you want them to, and you have to chastise them,” she said.
“And then after a while, they rebel as they grow older. And this is exactly what happens with the bleb, they can either remain perfect or become something that you don’t recognise anymore, or they are a major disappointment.”
When looking to future strategies to avoid scarring, Wong said it’s time to search beyond the inhibition of fibrosis.
Firstly, this includes harnessing the immune system. Secondly, there needs to be a focus on the restoration of normal tissue health and architecture: “This is the absolute cornerstone of a healthy functioning bleb, you want near normal conjunctival vascularity. I’m obsessed with conjunctival vascularity and the appearance of blebs post-op, because that’s the only way to overcome the wound healing response post-op and strive to get long term healthy bleb function and better control of disease progression.”
On the issue of harnessing the immune system, Wong presented a study she co-authored showing that oral ibuprofen prescribed in the weeks following treatment is associated with a reduced likelihood of early bleb failure after trabeculectomy in high risk patients.
In terms of restoration of normal healthy tissue, she said it is the quality, not the quantity, of collagen that matters most. But what approaches exist to modulate collagen? Valproic acid has been used since the 1960s to prevent seizures, but has widely been shown to have anti-inflammatory and anti-fibrotic effects. Wong’s team was among the first to interrogate its potential in the eye, culminating in more than 10 years’ work.
She reported that valproic acid in combination with low dose MCC has been shown to reduce collagen maturation (and reduce tube shunt obstruction), and preserve conjunctival tissue while maintaining bleb function. It’s also important to remember that cross talk between the Tenons fibroblasts – the main cells involved in wound healing and scarring after a trabeculectomy – with resident and circulating inflammatory cells, heavily influences the wound healing outcome – and it’s important both are targeted for long term success.
“I encourage everybody to remember blebs are a living organism that are surgically created by us. It’s in a constant change of evolution, so we need to know how to look after them,” she said.
“Collagen still remains the main target and cornerstone in anti-fibrotic drug development. I believe the future direction of targeting collagen remodelling will help us to achieve that long awaited, perfect, long-term healthy bleb that we’re all striving to give to our patients.”
Rethinking neuro-ophthalmology cases
One of the major drawcards of the speaker program was Dr Neil Miller who flew in from the US where he works as the global authority on neuro-ophthalmology at the Johns Hopkins University School of Medicine.
In his jam-packed presentation, he promised key takeaways that delegates could begin implementing tomorrow – and he delivered, offering new and important insights for acute optic neuritis [as well as chronic relapsing inflammatory optic neuritis (CRION)], visual snow syndrome and idiopathic intracranial hypertension.
Starting with acute optic neuritis, Miller urged delegates to avoid thinking of the disease in “typical vs atypical” terms. Previously, the main aetiologies were broken into idiopathic, multiple sclerosis (MS)-related, systemic infections like syphilis and Lyme disease, or drug or vaccine related. In the absence of a systemic infection or history of potential causative medication, the usual assumption was either idiopathic or MS.
But Miller warned of new evidence showing that acute optic neuritis can also be associated with anti-AQP4 antibodies or anti-MOG antibodies – an important factor that alters the treatment approach.
For example, acute optic neuritis associated with anti-AQP4 antibodies requires emergency treatment with systemic steroids, opposed to the idiopathic variety where patients are advised steroids will help speed recovery, but ultimately they will reach the same point in their recovery. In addition, the use of MS drugs in so-called “neuromyeliis optia”-related optic neuritis can make the condition worse, highlighting the importance of testing for this aetiology.
Meanwhile, as far as anti-MOG antibody-related cases are concerned, these can be easily confused with idiopathic acute optic neuritis, but, again, the urgency of steroid treatment followed, if needed, by plasmapheresis is crucial to the prognosis, he said.
Starting immediately, Miller urged delegates to consider performing assays for both anti-AQP4 and anti-MOG antibodies in all patients with acute optic neuritis – even though it can take up to one week to receive results – and to treat all presentations with systemic steroids, unless there is evidence of an infectious cause.
In the case of CRION, Miller said it is now known that in most cases this is a form of MOG antibody-positive optic neuritis. Therefore, patients suspected with CRION should be assessed for MOG antibodies and treated accordingly.
“What does this mean for your practice? If you have a patient with chronic relapsing recurrent optic neuritis that is steroid sensitive and dependent, and you haven’t done so, check that patient for MOG antibodies. Those patients shouldn’t be treated with a steroid each time they have an episode but rather with some type of immunosuppressive such as rituximab,” he said.
In his next update, Miller delivered the latest findings on IIH, also known as primary pseudotumor cerebri.
In many cases, the condition can be managed with acetazolamide (Diamox) and weight loss, but Miller said acetazolamide has been shown to reduce intercranial pressure (ICP) more effectively than weight loss alone.
Previously, patients were started with 1gm/day divided doses, with the belief that the maximum tolerated dose was 2gm/day – and if there was no improvement or intolerance, surgery was often considered.
But the Idiopathic Intracranial Hypertension Treatment Trial out of the US showed there was an acceptable safety profile of up to 4mg/day.
“So if you are managing a patient with pseudotumor cerebri and they are tolerating, but not improving, on Diamox 1-2mg/day, don’t be afraid to increase the dose slowly up to a maximum of 4mg/day, and in many cases that will take care of the problem,” he said, adding they should be warned about side effects.
In the case of weight loss, Miller said this was one of the mainstays of IIH treatment, with a loss of 7-10% found to be highly effective. But ultimately sticking to a formal program of exercise and diet has proven difficult for many patients.
The randomised Idiopathic Intracranial Hypertension Weight Trial enrolled 64 women with active IIH and a body mass index consistent with obesity in the UK and assessed ICP at 12 months.
“Patients were separated into those receiving bariatric surgery, and those enrolled in a community weight loss program. What was found was that bariatric surgery was far better than a weight loss program – and the effects were continued for at least two years,” he said.
Overall, the study found weight loss of 24% was associated with complete disease remission that was unlikely to be achieved without bariatric surgery.
“What’s your change and practice tomorrow? For patients with mild-to-moderate papilledema – without optic neuropathy and not requiring emergency surgery – at the beginning of your management, discuss not just the importance of weight loss, but the potential weight loss obtained by bariatric surgery,” he said.
“The other thing that’s useful is if you have a practice that sees patients with [IIH], try to collaborate with colleagues who deal with weight loss, so that if you have a patient who needs surgery, either at the beginning or later, then they can be fast-tracked for treatment because it’s not a simple thing – they have to undergo psychological testing etc.”
Miller rounded off his presentation on the topic of visual snow syndrome – a condition he emphasised is an organic condition. Patients describe their vision as if looking through snow or static, even though their examiation findings are completely normal.
“I have to admit, I used to think all these people were nuts … and I’m embarrassed about that because it turns out this is an organic condition,”
he said.
“These patients have normal retinal structure on OCT, but they have abnormal electrophysiology, compared to control patients. There’s an increased b-wave and flicker amplitude on the ERG and there’s increased sensitivity of both the rods and the cones.”
Miller urged ophthalmologists seeing these patients to emphasise to them that no permanent damage has be found in their eyes and to reassure them that what they are seeing is a “real but benign” condition that won’t lead to blindness.
“Some patients respond to lifestyle modification, using dull paper, tinted glasses, lowering the ambient brightness in the room, and some respond to various medications that the neurologist can prescribe, but it’s very inconsistent,” he said.
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