Optometry Victoria’s Southern Regional Congress was back and better than ever during May, delivering Australia’s premier educational event for the optometry sector.
The annual Southern Regional Congress (SRC) featured lectures spanning the scope of ethics and business, management of chronic and acute ocular conditions and new frontiers for treatment. Highlights included a review and forecast of strabismic amblyopia treatment, a glimpse under the current umbrella of ‘dry eye’, a refresher on the overlooked but fundamental features of diabetic retinopathy, and an assortment of clinical pearls for practical implementation of both refractive and medical optometry.
Overall, SRC reminded us of the breadth of our potential influence as clinicians on many aspects of our patients’ quality of life.
Strabismic Amblyopia and Binocular Vision Disorders
When prescribing spectacle correction from cycloplegic examination, many of us refer to Leat’s (2011)1 age corrected recommendations for myopia, hyperopia, astigmatism, and anisometropia. Dr. Ann Webb advanced these recommendations, uniquely accounting for ocular alignment. For an ortho alignment, one should symmetrically reduce plus script by 1.00 to 1.50 from the full cycloplegic finding (correcting cylindrical powers and the difference found between the eyes). For an exo alignment, one may cut the plus further if it helps alignment. For an eso alignment, one should give full plus, correct cylindrical powers, and the difference found between the eyes. An add may be prescribed if the near angle is 10pd or greater than the distance alignment.
SRC reminded us of the breadth of our potential influence as clinicians on many aspects of our patients’ quality of life
For patients with strabismic amblyopia, spectacle correction should be tried as a treatment for 16 weeks before re-evaluating for further therapies (eg. atropine, patching). Under this method, 75 per cent of children had improved >2 lines, with 32 per cent of amblyopia resolved (Cotter et al 2006 & 2007, Stewart et al 2004).
Dr. Tuan Tran of Vivid Vision presented the potential value in virtual reality (VR) therapy. ATS-18 demonstrated that patching two hours/day, seven days/week was more effective at improving best corrected distance visual acuity (BCVA) when compared to binocular (anaglyph) game play for one hour/day, four to seven days/week over a span of four weeks. However, the binocular play still showed improvement, and is now perceived as having potential application since it has a higher dose-response rate (based on treatment time and log units of BCVA improvement),2 application to older children, and is less likely to have a stigma that can lead to self-esteem issues. By modifying contrast in dominant eye as an alternative to occlusion, this method maintains binocular fusion and thus trains stereoscopic vision. These games also train sensory/hand-eye integration, and have applications of virtual prism that can be reduced as vergence skills progress.
Dry Eye Disease
Dr. Ben Gaddie and Dr. Jim Thimons put the spotlight on certain emerging aspects of dry eye management. For one, there is an epidemic of exposure keratopathy, which is due to incomplete/partial blink causing secondary evaporative dry eye. The muscle of Riolan releases lipids into our tears and it is only activated upon full blink. In this way, we need to differentiate nocturnal lagophthalmos from incomplete blinking (via observation), manage the inflammatory component of evaporative dry eye, compensate for decreased secretion using lipid-containing ocular lubricants (e.g. Systane Balance), and counsel on blink awareness. This may sound silly but there are even YouTube tutorials on blink technique!
Another increasingly recognised condition is Demodex infestation. Once recognised as anterior blepharitis, the collarettes around lashes are actually exoskeletons of demodex mites (they have a two week life cycle). Demodex causes symptoms of eye watering, itching, and can be observed on rotation or epilation of the lash. It is a common cause of rosacea, and increases secretion of IL-17, stimulating inflammatory/allergic reactions, resulting in ocular surface damage. Current treatment of tea tree oil is effective, however stings on instillation, so Dr. Gaddie recommends the Blephadex preparation (tea tree oil mixed with coconut oil).
The Disease Profile of Diabetic Retinopathy
While most of us are familiar with our chairside references, National Health and Medical Research Council (NHMRC) clinical practice guidelines, and international clinical diabetic retinopathy (DR) and diabetic macular edema (DME) Disease Severity Scales, we lack depth of understanding of the mechanisms underlying presentation, risks, and classification of DR. Dr. Simon Chen shared a lot of insights, beginning with the foundational HbA1c. We know that HbA1c is a weighted average of blood glucose of approximately three months. More explicitly, it is a measurement of glycosylated haemoglobin, and is not a direct measurement of average glucose (AG). It is important we have an understanding of the relationship between the two so that we understand the measurements that the patient reports; a 6 per cent hbA1c correlates to about a 6.6 AG; 7 per cent HbA1c to about 8.3AG. Beyond this falls into poor diabetic control.
The compromised blood retinal barrier (BRB) in patients with DR makes them susceptible to macular edema (epiretinal membrane removal creates a 20 per cent CME risk; cataract removal can also exacerbate DME) since surgically induced inflammation releases prostaglandins which can further antagonise the compromised BRB. For this reason, best efforts to control DR must be made (beyond that, Nonsteroidal anti-inflammatory drugs (NSAID) therapy can be used).
Furthermore, this compromised BRB should be kept in mind when examining a seemingly featureless retina; reduced blood flow can cause dot-blot haemorrhages and microaneurysms to disappear (nb. cotton wool spots are transient), but ischaemic vessels can lead to perivascular sheathing and subsequent neovascularization. This is why it is imperative that dilated peripheral fundus and close disc examinations are performed.
One last noteworthy tip is that Lipidil (agonist of PPAR alpha) has been shown to reduce progression of DR in patients with Type 2 diabetes and existing DR. We should use our role as clinicians to make recommendations to GPs when relevant. Dr. Chen writes a report for optometrists referencing the benefits based on the ACCORD-eye and FIELD studies starting after eight months of treatment.
Miscellaneous Clinical Pearls
These pearls come from various speakers and aid many aspects of practical clinical practise.
With regard to assessing glaucoma risk, there is no correlation with visible lamina cribrosa. That is only indicative of cupping. Also, one should account for a 3mmHg underestimation of IOP for all patients who have undergone LASIK surgery.
Sometimes we have a non-invasive adjunctive role to ophthalmologist treatment, based on patient counsel. For example, normal tension glaucoma patients with an already low intraocular pressure (IOP), but advancing glaucomatous field loss, run the risk of hypotony if they were to use therapy that lowered their IOP further (beyond 8mmHg). It is within our role to advise them of the neuroprotective properties of red wine/grape juice.
Many of our patients will have autoimmune conditions such as psoriasis, rheumatoid arthritis, and Crohn’s disease. Therefore it is important we understand that anti-Tumor Necrosis Factor (TNF) medications, such as Remicade, increase a patient’s risk of viral eye disease (Simplex, Zoster), its recurrence, retinal involvement, and will warrant a prolonged duration of treatment.
It is similarly of use to know the risk profile of patients taking Plaquenil. Risk factors include total dosage >1000 mg (typically seven years on 400mg/day), concomitant Tamoxifen use, previous macular disease, renal disease, and age >70yrs. Work up should be made as baseline, at five years, and then on a yearly/two yearly basis.
Layal Naji graduated as an optometrist from UNSW (2014) with her honours research project focusing on Asylum Seekers’ access to eye care in NSW. She currently divides her time between working at Specsavers in Hornsby Sydney, the Asylum Seeker Centre in Newtown and UNSW where she is a visiting clinical supervisor. Ms. Naji is passionate about optometry’s role in public health, and ocular manifestations of chronic lifestyle related disease.
SRC Bounces Back
The challenges that came with moving Australia’s biggest educational event to a new venue in 2016 were overcome when Optometry Victoria opened the doors to the Southern Regional Congress in Melbourne in May.
The Pullman and Mercure Hotels at Albert Park provided ample space for over 800 delegates to explore the offerings of 28 exhibitors and to catch up with friends during breaks. The SRC dinner on Saturday night, hosted by Optometry Victoria’s Chief Executive Officer, Pete Haydon (dressed as chance Olympic ice skating medallist Steven Bradbury) provided ample opportunity for delegates to let their hair down on the dance floor.
Mr. Haydon said Optometry Victoria and its board were thrilled with the event, which despite a busy year of CPD events, managed to maintain attendance numbers. “We had 843 attendees, down only slightly on 878 last year. That slight decline takes into account our deliberate exclusion of non-final year optometry students. We were delighted, especially considering this year’s event calendar, which also includes Silmo and ODMA.”
Mr. Haydon said since the close of SRC, the Association had been “swamped by messages from delegates and exhibitors” expressing their satisfaction with both the education program and the amenity.
Optometrist Jim Papas from NOW Group, was just one of the delegates who appreciated the work Optometry Victoria had put into ensuring SRC’s success this year. “Optometry Victoria has worked to improve the event and they should be congratulated. It was more intimate and easier to get around, with great support from the student volunteers and IT crew. Even the coffee improved!
“SRC always provides a great opportunity to catch up with colleagues and update on the latest equipment available. I found the content relevant and useful for today’s optometry practice. The introduction of a new SRC App initiative provided a much improved way to log CPD and plan your course stream… I highly recommend attending SRC on many levels.”
Exhibitor Dr. Tuan Tran chose SRC to introduce Vivid Vision, a virtual reality treatment technology for amblyopia distributed in Australia by France Medical. He said the exhibition was a vaulable opportunity to create awareness and build business.
“We wanted to introduce optometrists to Vivid Vision and SRC provided a great opportunity to do that. With our equipment onsite we were able to demonstrate the potential of our virtual reality therapy. Optometrists were able to wear the headset, experience the immersive virtual environment and participate in the therapeutic games we have developed.”
Mr. Haydon said Optometry Victoria would continue to finesse SRC in its drive to further improve the experience. “People are passionate about SRC and we are absolutely committed to delivering the best experience possible. Of course there is always room for improvement and so we wont stop working.
“The way education both online and at conferences is being delivered is undergoing change. SRC is the largest and most important conference in the country and we are part of the conversation, which is looking at how we can deliver better education to time poor professionals,” said Mr. Haydon.