International

Western Australian Vision Education (WAVE) 2016 exceeds expectations

The annual WAVE (Western Australian Vision Education) conference, hosted by the Western Australian branch of Optometry Australia, was this year held from Saturday 13 to Sunday 14 August at the Rendezvous Hotel Perth Scarborough. The event coincided with Optometry WA’s 100th anniversary.In addition to the two-day conference program, the event included clinical workshops on the Saturday to provide delegates with a more intensive learning experience in a smaller group environment.The Saturday evening also featured the CR Surfacing Sundowner function, which provided delegates with an opportunity to network and socialise in a more relaxed setting.As usual, WAVE included a trade exhibition across the two days, which this year showcased the products and services of 30 exhibitors.The event was also preceded by an Optometry WA Graduate Group lectures series on Friday 12 August, with the education program specifically targeted to optometrists who were up to nine years into their careers since graduation.The WAVE lecture series and clinical workshops were delivered by 14 presenters across the two days, and some of the sessions are summarised below.COLLABORATING WITH REFERRAL PARTNERSIn two of her lectures, Ms Heidi Hunter, principal optometrist and co-owner of Custom Eyecare in Newcastle, NSW, relayed her own personal experiences to encourage optometrists to build their relationships with referral partners.Ms Hunter explained how optometrists could work with ophthalmologists in the co-managent of patients with corneal disease, how they could manage shared patients with GPs, and how they could work with both in the therapeutic treatment of various anterior segment conditions.Over her 15 years in practice, Ms Hunter has worked in two ophthalmology practices. One was a laser refractive surgery clinic and, more recently, she worked in the private rooms of a corneal specialist.She noted that while it was not essential to work in an ophthalmologist’s rooms, doing so would help the optometrist get to know the medical practitioner better, providing a clearer understanding of the ophthalmologist’s motivations, mode of practice and how they interact with their patients.{{quote-A:R-W:450-I:2-Q: There’s so much to be gained, both personally and professionally, from working with ophthalmology -WHO:Ms Heidi Hunter, principal optometrist and co-owner of Custom Eyecare in Newcastle, NSW}}In terms of co-managing corneal disease patients, Ms Hunter advised optometrists to ensure their clinical skills were current so that they could “keep up” with the ophthalmologist, and recommended obtaining therapeutic endorsent.“Develop an interest and expertise in speciality contact lenses (CLs) as this is an area that most corneal ophthalmologists need help with as they lack the time, resources, and expertise to do it thselves,” she suggested.She also acknowledged that working with ophthalmology was not “all butterflies and cupcakes”, phasising that it was hard work that could be time consuming.“But I wouldn’t trade it any day,” Ms Hunter said. “In my opinion, nothing beats ophthalmology referrals, especially if you have an interest in specialty CLs, therapeutics or pathology.”She added that referral pathways could work both ways: “It doesn’t have to be optometrists referring patients to ophthalmologists. Optometrists can co-manage many corneal disease patients. It saves the ophthalmologist time, saves the patient expense, and boosts our reputation and expertise.“There’s so much to be gained, both personally and professionally, from working with ophthalmology, and it’s absolutely in the best interests of our patients.”Speaking on the value of building a relationship with a GP, Ms Hunter explained, “Patients who are referred to you by their GP do not question your consultation fees like the average punter, as they were sent directly to you for your expertise, and the recommendation came from someone they trust and value.”Ms Hunter suggested optometrists write reports addressed to each of their patients’ GPs to increase the likelihood of gaining more referrals, and to open the lines of communication further by calling GPs directly for complicated patients.She noted that having a patient’s GP onside could be beneficial as they are able to provide access to further medical resources such as blood tests, MRIs and neurologist referrals.She also encouraged optometrists to “think outside the square”: “It doesn’t have to be just GPs and opthalmologists that we work well with. There’s loads of untapped potential, such as allied health practitioners and school teachers. You just have to be able to imagine the possibilities.”DIAGNOSIS AND MANAGENT OF KERATOCONUSMs Margaret Lam, optometrist and co-owner of Sydney-based theyecarecompany, adjunct senior lecturer at the UNSW’s School of Optometry and Vision Science, and NSW president of the Cornea and Contact Lens Society of Australia, also touched on the topic of patient co-managent in her detailed update on the diagnosis and managent of keratoconus.Primarily addressing those seeking to develop and/or maintain their specialty CL expertise, Ms Lam phasised the importance of optimising patients’ vision in both preventing and complenting surgical managent of both keratoconus (KC) and other ophthalmic cases. It was said the prevalence of KC ranged from one in 400 to one in 2,000 people, depending on the dographics of the population in questionMs Lam noted that despite the fact that the condition was defined more than two decades ago, many patients with KC rained undiagnosed after multiple eye tests, with up to 25% of patients presenting to ophthalmic practice for refractive laser surgery being diagnosed with or suspected of having KC.“This is important as this is a condition where early intervention is key to optimal managent,” Ms Lam stated. “It can reduce the severity of the condition due to the progressive nature of this disease.”It was recommended that optometrists take a thorough history of patients, looking for clues such as a history of eye rubbing, frequent changes in spectacle prescription or the axis of their astigmatism, and glare at night time. Key diagnostic signs included Fleischer’s Ring, an unexpected decrease in best corrected visual acuity (BCVA), and, in the end stage of the disease, Munson’s sign and distorted or irregular keratometry mires with steep readings, among others.In discussing appropriate CL sizing and fitting, Ms Lam recommended optometrists start out with smaller rigid gas permeable (RGP) lenses before progressing to larger lenses. However, Ms Lam also noted, “As a clinical rule of thumb, if you have more than 300 μm of elevation difference that you can see on topography within the cornea, it may be a good idea to go with a larger lens first.”Ms Lam also spoke about ongoing care plans and follow up. She pointed out that KC patients had very fragile eyes and that the condition could escalate quickly, leading to complications. As such, she recommended close monitoring of KC patients, suggesting an assessment two weeks after initial successful fitting, then subsequent follow-ups at one month, three months and six months. “You don’t want to see these patients any less than once every four to six months,” she advised.While she acknowledged that the specialised care KC patients required meant they would always present challenging cases, Ms Lam said successful managent of these patients was also rewarding on many levels because “patients literally have sight restored that they thought they had lost”.“As first-line practitioners for eye care, I think it’s important that we maintain considerable efforts to improve our proficiency in diagnosis and [that we] follow [patients] closely to make sure they get timely referral to prevent progression,” Ms Lam stated.“To complent that, we need to develop expertise in specialty CL managent or understand that referring a patient for specialty CL managent, optimal co-managent and optimal care is very appropriate.“On optometry and ophthalmology working together, especially with KC, I think the best model of care is when there is a considerable amount of mutual respect for complenting areas of expertise,” she added.DRY EYE MANAGENT AND NEW BLEPHARITIS TREATMENTSIn addition to being national director of optometry at The Optical Superstore, Mr Jason Holland operates a dry eye, glaucoma and advanced contact lens clinic out of The Eye Health Centre in Brisbane.Addressing some of the confusion over how IPL (intense pulsed light) works and its application in eye care, Mr Holland explained that the technology is able to warm the meibum in the meibomian glands, which facilitates their expression. The calibrated pulses of light can help to kill bacteria around the eyelid margins in people who are suffering from anterior blepharitis. In addition, the IPL’s infrared red wavelength stimulates the mitochondria in the facial nerves, which signals the meibomian glands to secrete more meibum.Mr Holland pointed out that if a patient has significantly blocked glands, launching straight into IPL could create a backlog of meibum behind the blockage. “It’s quite important that you assess the meibomian glands and check if they are blocked before proceeding to IPL,” he said.Mr Holland showed delegates a series of meibography images, discussing how the gland morphology could be examined to identify whether or not the glands were suitable for treatment – a stage he described as a critical part of using IPL effectively.“IPL for me is a significant advancent in the ability to treat meibomian gland dysfunction (MGD) compared to our historical approach of managing symptoms using eye drops,” Mr Holland commented.Another dry eye-related lecture Mr Holland delivered discussed the syndrome’s relationship with tear osmolarity. Mr Holland said the advent of the TearLab had caught his interest because it allowed optometrists to measure osmolarity – something that has so far largely been the domain of researchers.It was said that dry eye syndrome is caused by a “cascade of events”, starting with an unstable tear film followed by hyperosmolarity and then inflammation. If elevated osmolarity is present, it means the tear film is too salty, which Mr Holland said should affect patient managent in terms of potentially choosing a hypo-osmolar eye drop over one that is buffered to a normal tear film.If the tear film is particular salty, and has been so for a long time, he suggested this meant there was potentially inflammation as well, which he said was “the most commonly mismanaged component of dry eye”.“Measuring osmolarity offers a simple way to diagnose and define the severity of dry eye disease and the degree of intervention required,” he stated.Mr Holland’s third lecture phasised the need to consider managent of the dodex mite in the treatment of anterior blepharitis. A UK study undertaken in 2015 found that dodex was present in 100% of people suffering from chronic anterior blepharitis.“This paper stood out to me because none of our traditional treatments for anterior blepharitis – antibiotics and surfactant-type cleansers – are effective against dodex,” Mr Holland stated.He said the only way to kill dodex was to either smother and suffocate the mites with a bland ointment or to use a product with a tea tree oil base. In his own practice, Mr Holland uses the BlephEx device from OptiMed to clean and scrub the lid margins and lashes, but he noted that other products were available on the market that could be used as an at-home treatment, including the Blephadex, Oust Dodex and OCuSOFT Lid Scrub Plus cleansers.He briefly discussed some key clinical findings surrounding dodex and anterior blepharitis, such as the fact that collarettes at the base of the eyelash can indicate a 30-fold increased likelihood of dodex being involved in that patient’s blepharitis case.“If the blepharitis is not getting better using traditional treatments, you need to consider that dodex is involved and manage that appropriately,” Mr Holland concluded.TESTING AND DIAGNOSING CONVERGENCE INSUFFICIENCYSydney-based optometrist Ms Liz Jackson, an Australasian College of Behavioural Optometry fellow who was also a clinical supervisor at the UNSW School of Optometry’s paediatric/vision therapy clinic for nine years, conducted both a lecture and workshop on convergence insufficiency.The complentary presentations allowed participating delegates to gain an overview of current, evidence-based convergence insufficiency treatment options as well as a ‘hands on’ learning experience with the tests and techniques used to diagnose the condition.According to Ms Jackson, approximately 4–7% of people have convergence insufficiency, which is generally defined as having a greater exophoria at near compared to distance (>4 PD difference), reduced near point of convergence, and reduced positive fusional vergence at near.{{quote-A:L-W:450-I:3-Q: [OK Contact Lenses] are not hard to fit and they are not hard to wear when fitted correctly -WHO:Dr Russell Lowe, honorary senior lecturer at the University of Melbourne’s Department of Optometry and Vision Sciences}}She noted that people with convergence insufficiency can be highly symptomatic, with possible indicators including headaches and eye strain/pain with near work, loss of place when reading, and near blur or diplopia. Children and adults with convergence insufficiency may also avoid extended periods of near work.During the workshop, participants were given an opportunity to measure near cover test, near phoria using the Howell phoria card, near fusional ranges using a prism bar, near point of convergence, and vergence facility – tests which Ms Jackson said formed a basic framework for specific assessment of convergence insufficiency.“I believe that all optometrists should be able to test for and diagnose convergence insufficiency,” Ms Jackson stated. However, she acknowledged that there is no single clinical test that can be used to give a clear diagnosis of convergence insufficiency.“A number of vergence tests should be carried out to get a clear picture of how the vergence syst is functioning as far as vergence range, posture and facility are concerned,” she advised.In her lecture, Ms Jackson introduced the Convergence Insufficiency Survey as a tool that was developed to help distinguish between children with convergence insufficiency and those with normal binocular vision.The Survey uses a questionnaire format to ask 15 symptom-related questions and applies a scoring syst of zero to four for each question, with a score of more than 16 indicating the possible presence of convergence insufficiency.In terms of treatment, Ms Jackson said in-office vision therapy with home activities had been shown to be the most effective when compared to pencil push-ups, home-based vision therapy and placebo vision therapy.“Vision therapy for convergence insufficiency should include eye-movent training, vergence ranges and jump vergence training, as well as accommodation training. Activities such as Brock String, loose prisms, vectograms, tranaglyphs, and free space fusion activities can also be used to gradually improve and develop convergence skills,” she added.ORTHOKERATOLOGY – EASIER THAN YOU THINKDr Russell Lowe – honorary senior lecturer at the University of Melbourne’s Department of Optometry and Vision Sciences, and past president of the Orthokeratology Society of Oceania and Cornea and Contact Lens Society of Australia – also conducted a clinical workshop where he set out to donstrate that orthokeratology (OK) is not as difficult as some might believe.He opened the workshop by phasising that myopia was becoming a global epidic, citing statistics that indicated the condition was present in:

  • 44% of people aged 25–34 years in the US, having almost doubled in the past 30 years, with 1.6% of that group having high myopia
  • 96% of people in China aged 14–42 years (20% with high myopia)
  • 97% of 19-year-olds in South Korea (22% with high myopia).

In Australia, the rate of myopia in 12-year-old children of European Caucasian descent doubled from 2005 to 2011 and more than 50% of Australian children of East Asian origin are myopic.Dr Lowe championed OK CLs as one myopia control option that was steadily growing in popularity. “OK CLs are typically manufactured in RGP materials, and although they may feel hard compared to soft hydrophilic lenses, they are not hard to fit and they are not hard to wear when fitted correctly,” he said.After explaining how pre-treatment maps could be used to determine whether or not a patient was a suitable OK candidate, Dr Lowe described the anatomy of an OK CL and walked delegates through the ideal CL fitting pattern.This was followed by a brief ‘wet lab’ donstration of the fundamentals of OK fitting, where participants were able to observe a significant change in the refraction of the eye – secondary to benign apical corneal flattening – after only a short period of exposure to the treatment lens.Commenting on the success of Paragon CRT, a brand of OK lens available at his own practice, Dr Lowe said, “After a short period of adaptation, children love th. Our paediatric patients are encouraged to self-manage their lens treatment systs independently from an early age.”He noted, however, that all OK patients in his practice were advised to regard contact lens discomfort as an early warning sign and to take redial action immediately. “This is an important safety message and needs to be reinforced at aftercare visits,” he stated.Dr Lowe added that increasing community awareness regarding effective clinical interventions to slow myopia progression meant optometrists would be required to do much more than simply prescribe a stronger pair of glasses for young myopic patients.“OK is not that hard,” he said. “In fact it’s child’s play – with the proviso you need to be well armed with accurate corneal topography maps and you take care with patient selection.”POSITIVE OUTCOMEAccording to Optometry WA chief executive officer Mr Tony Martella, 220 delegates participated in WAVE 2016, with interstate delegate attendance up 10%.“We were extrely pleased across the board,” Mr Martella said. “Delegates, exhibitors, the education program and venue [were all] well above our expectations and satisfaction levels. This has been evident both anecdotally and with post-event surveys.”WAVE 2017 will again be held at the Rendezvous Hotel Perth Scarborough from 12–13 August.