Super Sunday 2019

A wide range of topics were featured at Optometry Australia’s (OA’s) Super Sunday event for 2019, with presenters drawn from across Australia and New Zealand. For the first time, OA NSW/ACT also ran a parallel Practice Staff Program. During the program, both the H Barry Collin Research Medal and the Josef Lederer Award for excellence were presented. Super Sunday’s popularity also continued to increase, with this year’s event attracting some 460 delegates.Beyond the eyeballsDr Kate Kalloniatis and Dr Chris Gilbert opened the formal part of the program with a presentation titled: What else is going on? Looking beyond the eyeballs. The thrust of the presentation related to communications between optometrists and GPs relating to the patients consulting th, using guidelines by the Royal Australian College of General Practitioners (RACGP).The key issues related to vascular disease are: age, sex, smoking status, cholesterol (total and HD lipoprotein), systolic blood pressure, diabetic status, and left ventricular hypertrophy. It is possible for an optometrist to make an Absolute Cardiovascular Risk Assessment of a patient for the next five years, based on statistical data backing the RACGP Guidelines’ cardiovascular disease charts.A GP’s interest is in prevention, and their heightened interest in cardiovascular disease kicks in at 45 years of age for the general Australian population. However, it starts a decade earlier for indigenous people. Current thinking on acceptable blood pressures (BP) is ≤140/90 mm Hg for adults and ≤130/80 for adults with chronic disease, measured on at least two occasions before a diagnosis of hypertension is made.Decisions on BP significance are based on risk, lifestyle, family history, measured BP, and ethnicity. A hypertensive crisis is defined as BP of ≥180/120 and the patient being unwell as judged by at least one body syst. Relevant issues include breathing difficulties, substance abuse, and pregnancy-related conditions, such as pre-eclampsia at ≥20 weeks gestation. Also of concern are: fresh, flame-shaped haorrhages, exudates, and papilloeda. If necessary, repeat BP assessments 10 to 20 minutes apart were suggested. If the patient ses well, optometrists are advised to refer the patient to their GP within 24 hours. If they are unwell, an ambulance ride to an ergency department was suggested.Screening for diabetes at least every two years was suggested in all those over 40 years of age or over 18 years of age if the patient is indigenous. A diabetic assessment was recommended every three years, or more frequently when there is a relevant history. The use of the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK) was recommended. Because symptoms do not become apparent until relatively late in the disease and progression can be rapid, screening was recommended strongly. Key risk factors are: the level of glycaic control, type of diabetes (1 or 2), hypertension, smoking, dyslipidaia, nephropathy, and pregnancy.Smoking should barely rate a mention since its probls and sequelae are so widely known, but smoking rates rain at significant levels despite punitive pricing, deterring packaging, and public anti-smoking campaigns. Importantly, if smoking has been avoided for 12 months an ex-smoker’s risk of heart disease is halved. Ocular diseases linked to smoking include: AMD, cataract, inflammation, thyroid, retinal artery boli, and strabismus if a patient’s mother smoked during pregnancy.When dealing with a smoker, the 5AS framework for practitioners was recommended: Ask, Assess, Advise/agree to targets, Assist, and Arrange. A pharmacotherapy approach to quitting smoking was stated to be a rational consideration and most products are available over the counter, with the exception of nicotine patches.Should an optometrist find papilloeda, the cause, usually raised intracranial pressure or benign intracranial hypertension (BIH), will not be immediately apparent. If the former is likely, an ambulance to an ergency department might be prudent. If BIH, the patient should be promptly seen by a neurologist, neurosurgeon, ophthalmologist, or at the very least their GP.If Graves’ Disease/thyroid eye disease is detected, a GP referral is necessary to get suitable investigations underway. Those investigations can involve an ophthalmologist or an endocrinologist, and the referring optometrist can play a monitoring role.The presenters gave the role of a GP as preventative health and chronic disease managent, and requested that optometrists copy the patient’s GP on any action taken or relevant findings uncovered. This is because patients assume incorrectly that all health professionals communicate with one another. Having patients carry their information from the referring optometrist to their GP is acceptable. Patients who consult optometrists on their own initiative were identified as potential barriers to communication because of the lack of a referring ‘authority’.

KEYNOTE SPEAKERS
Chris Gilbert	Kate Kalloniatis	Nicola Anstice

The dry eye invasionAssociate Professor Jennifer Craig from the Department of Ophthalmology at the University of Auckland, NZ gave a lecture on dry eye (DE) and its treatment. Craig is a senior mber of the Tear Film & Ocular Surface Society (TFOS) and filled the role of first author on the Definition and Classification Report in DEWS II.After presenting the updated definition of DE, she phasised that the new definition braced signs and symptoms despite, or perhaps because of, the accepted disconnect between those two factors. Confusingly, the prevalence figures span the range 5% to 50% depending on definition, assessment technique, age, sex, co-morbidities, and ethnicity. She estimated that about 10% of all optometric patients exhibit signs of aqueous deficiency (ADDE) and 15% show signs of anterior blepharitis. Surprisingly, she estimated that 35% of all patients exhibit signs of MGD.After providing an overview of DE subtypes and the ‘vicious circle’ of DE included in the DEWS II report, she condensed the DE cycle into a bidirectional continuum of tear hyperosmolarity, inflammation, ocular surface cell damage, and tear film instability. She simplified the practitioner’s task as one of ‘breaking the cycle’.Craig’s first line therapies include eyedrops and warm compresses, supplented with lid hygiene procedures in cases of moderate to severe DE. TFOS, via its DEWS II Report, recommends a 4-step, staged managent of DE, each stage tackling greater severity. Should a Dodex spp. infestation be found, tea tree oil rains the main treatment.Introducing her concept of ‘big guns’, Craig proceeded with cases showing little evidence of Meibomian gland dysfunction (MGD). She suggested methylprednisolone (1%, preservative-free, 4 times daily, tapering after 3 weeks), azithromycin (300 mg daily for 3 days), and regular use of ocular lubricants (Bion Tears, Theratears). As a result of some of her own clinical studies, she added that IPL therapy might also be helpful.Confounding the ‘vicious cycle’ are additional factors such as: Sjögren’s Syndrome and other autoimmune diseases, systic prescribed drugs, ocular surgery including refractive surgery, neurotrophic conditions, viral/bacterial conjunctivitis, environmental factors such relative humidity, CL wear, allergy, use of unrelated topical ocular medications, chalasis or lid margin irregularities, blepharitis or MGD, and sex steroid hormone imbalance.Anti-inflammatory therapy includes: topical corticosteroids, non-steroidal immunomodulators, inflammatory modulation with systic and topical antibiotics, and macrolide treatments using azithromycin.Managing inflammation requires its origin to be ascertained. For example, determining whether is it intrinsic or secondary to lid disease. Inflammation assessment can be done either subjectively using a rating scale or objectively using an instrument such as the Oculus K5M or the RPS InflammaDry Detector.For ADDE, Craig suggested that the use of ‘big guns’ was justified, starting with topical corticosteroids. However, numerous and serious side-effects are known, such as cataract, ocular hypertension, and increased susceptibility to microbial infection. As a result, only short-term use is recommended to break the DE cycle and even then, the use of non-penetrating steroids is recommended.Where a longer-term course of treatment is indicated, steroid alternatives were suggested. For ADDE, punctal plugs, cyclosporine, tacrolimus, lifitegrast (when available), nasal neurostimulation, and secretagogues were suggested. For evaporative DE (EDE), lid margin debrident with topical antibiotics, doxycycline, azithromycin, intense pulsed light (IPL) treatment, or thermal pulsation were suggested.For blepharitis, a topical antibiotic such as fusidic acid 1% was recommended, with an alternative therapy such as medical-grade Manuka honey worth considering. Systic antibiotics such as the tetracyclines, at less than bactericidal dosage, are useful due to their antibacterial and anti-inflammatory properties. However, its use is contraindicated in pregnancy and children.IPL using a broadband light source is widely used in the cosmetic industry for hair roval and facial melisma, and in medicine as a treatment for acne rosacea. More recently, ocular rosacea has also been an IPL target. Usually, a course of three treatments is undertaken without Meibomian gland expression, and the benefits last up to nine months. Thermal pulsation heats the whole eyelid and expresses the Meibomian glands simultaneously in a single treatment. Its efficacy is aided by the achievent of higher tperatures (>40 °C) resulting in lower meibum viscosity and, theoretically at least, easier and more complete expression. Benefits can last up to 12 months.However, according to Craig, thermal pulsation is no more effective than warm compresses applied consistently, along with regular gland expression. In view of the very significant cost of thermal pulsation, that claim is of great significance to many DE patients.Ocular surface repair has less relevance, with the exception of scleral and miniscleral CLs because amniotic mbranes, tarsorrhaphy, autologous blood serum, and keratoprostheses are outside the current scope of optometrical practice.Digital devices and children's vision: Curse or Cure?Second generation optometrist and current Head of Optometry, University of Canberra, Dr Nicola Anstice raised the possibility of using children’s favourite devices, such as smartphones, tablets, and computers, as a means to assess vision. However, the reverse side of that same ‘coin’ is the range of visual probls related to use, and possible overuse, of those same devices.According to a European study, 68% of children use a ‘computer’ regularly by 3 years of age, pre-schoolers spend up to 2.4 hours per day watching screen-based devices, and 80% of teenagers experience asthenopia associated with electronic displays. Anstice gave visual acuity (VA) measurent, fundus examination, and smartphone adapters for autorefraction as possible uses for digital devices for children’s vision assessments. Those same devices can be used for amblyopia therapy and as visual aids for children with vision impairment or low vision. On the downside, those same devices can contribute to digital eyestrain and alter, or cause probls with, binocular vision.Even the apparently simple task of taking VA in children is not necessarily straight forward. Aside from the well-researched issues of optotype legibility, scoring, and the decision on when to terminate a VA test, children’s VA assessments are more variable because cognitive function, the assessor, distractions in the environment, and how the test results are recorded, are additional considerations. In an attpt to address some of these issues, she and colleagues developed The Auckland Optotype (TAO) set of pictograms based on just four symbols.The concurrent exposure to a YouTube clip while a child is undergoing a fundus examination has been shown to be quicker and more successful in achieving what needs to be seen. Ideally, the video clip should be selected by, or be relevant to, the particular child.A smartphone attachment such as the D-EYE, marketed as the digital direct ophthalmoscope for smartphones, has been found to be useful for viewing the posterior pole but unsurprisingly, the image quality in the fundus periphery is inadequate. Studies using the GoCheck Kids vision screener, a ret reflex photorefractor attachment and app targeting anisometropia-based amblyopia, showed a sensitivity of 76% and a specificity of 67%.There are more than 40 smartphone apps targeting amblyopia therapy but relatively few have had eyecare professionals involved in their development. Almost half play binocularly, while some use anaglyphic separation. Others use the more expensive, albeit more advanced technically, VR headset approach. Quality assurance related to just what is being attpted, rains largely unknown.There are some erging amblyopia therapies, including the dichoptic contrast balancing technique donstrated by Australian expatriate Professor Robert Hess and colleagues at Canada’s McGill University over the last 6 years. One incarnation is based on a game of Tetris, an approach more likely to maintain interest than traditional methods. Unfortunately, larger RCTs delivered less promising results. More recently, binocular video games have been trialled successfully on older children, teenagers, and adult amblyopes.Digital eyestrain (DES), defined as a range of transient ocular and visual symptoms associated with digital device use, results in tired eyes, DE, ocular burning/itching, blurred vision, headaches, light sensitivity, and general ocular discomfort. DES can be measured subjectively or objectively. Tests that should be included when assessing children using digital devices are: refraction, especially noting small amounts of uncorrected astigmatism, amplitude of accommodation (subjectively), accommodative lag/lead, accommodative facility, relative accommodation, NPC, distance and near phorias at the distances required, presence of A or V- patterns, associated phorias, vergence facility, and base-in and base-out vergence ranges.Serious probls in children using smartphones excessively (at least 4 hours per day) include acquired comitant esotropia (15-45 prism dioptres) and DE. Refraining from smartphone use reduced the esophoria, but 5 of the 12 cases in one study still eventually required strabismus surgery. Unsurprisingly, there was little data supporting the use of blue-blocking spectacle lenses for any reason including circadian rhythm resetting.