The importance of Optical Coherence Tomography (OCT) for patient screening, diagnosis and management, and the significant outcomes that can be achieved through effective collaboration were the emphasis of this year’s Specsavers’ dynamic two-day clinical conference in Melbourne.
Specsavers annual Clinical Conference in September attracted a strong turn-out of franchise partners, employed optometrists and non-Specsavers optometrists, including representatives from Australia’s Early Career Optometrists group. Twenty five per cent were at the conference for the first time.
Opening the conference, Optometry Director Peter Larsen announced that the Oculo referral platform has been fully integrated into the organisation’s Socrates practice management system. This clears the way for information sharing with ophthalmology and other health care providers, which will lead to improved ocular disease diagnosis and management, as well as measurement and monitoring of outcomes.
In preparation for a national roll out of the Topcon Maestro optical coherence tomographer, the conference included a half day of clinical education sessions focussed on the use of this technology followed by a full day of presentations from ophthalmologists, who spoke about how “collaboration, technology and efficiency converge to deliver a sustainable eye care model”.
the Oculo referral platform has been fully integrated into the organisation’s Socrates practice management system
Understanding OCT and its Applications
Dr. Carl Glittenberg from the Netherlands opened the Saturday lecture series, describing the specific features of Specsavers OCT model and how it can be effectively used to screen every patient. Dr. Glittenberg said it was important to analyse results against Specsavers’ normative database and described the deviations from the norm that should trigger a referral. In an age of increasing litigation, he said the ability to capture images, analyse and store patient documentation over the long-term was important for legal compliance. He said a fundus image and/or OCT provides the information to evaluate disease according to the RANZCO guidelines for macular degeneration and diabetic retinopathy. Visual fields are also required in the case of glaucoma.
Disease-specific OCT presentations followed Dr. Glittenberg’s presentation. Dr. David van der Straaten spoke about the interpretation of OCT for age-related macular degeneration in the context of referral guidelines, cautioning that it did not replace a slit-lamp examination and it is important to look clinically at the patient. Dr. Elaine Chong spoke about understanding and interpreting OCT for diabetic retinopathy as well as strategies for co-management of diabetic patients with GPs, endocrinologists and ophthalmologists; and Dr. Lance Liu spoke about the interpretation of OCT for glaucoma disease. He said images should be used to document rather than diagnose glaucoma and when interpreting images it was important to correlate them with the patient’s clinical appearance. Dr. Lance spoke about the difference between patients at risk of glaucoma and glaucoma suspects, and said the RANZCO referral pathway can be quite difficult to follow. Dr. Mitchell Lawlor’s presentation on glaucoma reaffirmed the complexity of diagnosing glaucoma and the need to use multiple datapoints when diagnosing the disease. Describing glaucoma as “a heterogenous group of diseases that ultimately led to characteristic damage by way of cupping at the optic nerve head”, he outlined the components of a comprehensive glaucoma examination, described the role of investigations when diagnosing the disease and reviewed new surgical treatments. He emphasised the value of learning the “challenging” skill of gonioscopy, and told optometrists that while OCT is a good adjunct, an optic nerve exam is essential. He said demographics mandated collaborative glaucoma care between optometrists and ophthalmology and that “we must all speak the same language to ensure patients are protected”.
Remote Eye Health
Associate Professor Angus Turner provided an update on remote eye health in Australia, describing the service provided by the new Lions Outback Vision Van. He said with the van now “better equipped than teaching hospitals”, the extent of services that can be offered meant his team needed to operate clinics for longer in each town. A/Prof. Turner spoke about the practical advantages of using telehealth for collaborative care – in terms of saving time and distances travelled for patients and surgeons. He said a problem for remote eye care was getting around the country regularly enough to offer frequent treatments such as anti-VEGF injections. He is currently working towards a hub, based in the Kimberley, from where surgeons can fly out to provide services.
Diabetic Eye Disease
Dr. Simon Chen presented nine clinical pearls for the management of diabetic retinopathy in practice, namely: always ask about HbA1c because the results give a rough indication of the patients motivation to control their diabetes; monitor rapidly improving diabetic control which can progress to retinopathy; monitor pregnant diabetic patients more frequently; optimise treatment for diabetic retinopathy before referring on for cataract surgery; monitor diabetic patients more frequently after cataract surgery; beware of the featureless retina which indicate severe retina ischaemia; assess the peripheral retina in all diabetics; consider advising GPs of your Type 2 patients with diabetic retinopathy to start Fenofibrate; and consider referring Optos and OCT for hard to examine patients.
Dr. Peter van Wijngaarden continued the discussion on diabetes and diabetic retinopathy, highlighting the implications of this “health tsunami” for the health system and the economy. 1.2 million Australians have been diagnosed with diabetes. Indigenous Australians are at least four times more likely than non-Indigenous Australians to develop diabetes. He said 37.1 per cent of Indigenous Australians are diagnosed with diabetes; and of those 39.4 per cent have diabetic retinopathy with 9.5 per cent have vision threatening diabetic retinopathy.
Associate Professor Mark Daniell turned delegates’ attention to corneal disease with a comprehensive presentation on keratoconus, viral keratitis and adenoviral keratoconjunctivtis. He spoke about diagnosis and treatment strategies for each disease and emphasised the complexities of viral keratitis and the importance of referring on when appropriate.
Professor Robyn Guymer delivered an enlightening presentation on age related macular degeneration (AMD). New classifications of AMD (Beckman Classification and Classification of Atrophy – CAM), were described. The Beckman Classification defines normal ageing changes, early and intermediate AMD as well as the late stages of disease on colour fundus images. The CAM classification is a 2017 consensus classification based upon OCT defined staging of atrophy.
Prof. Guymer also spoke about the Australian, first in human nanosecond laser (2RT) intervention study (LEAD trial) for intermediate AMD using imaging changes to define endpoints and inclusion criteria, which concludes in April 2018. The laser trial aims to slow progression from intermediate AMD to late AMD by applying either nanosecond laser or sham laser at six monthly intervals for three years.
Dr. Carl Glittenberg concluded the clinical conference by providing an historic overview of the evolution of OCT and an insight into a future. He spoke about aspects of his own OCT research and development, and about how artificial intelligence and deep learning are already improving our understanding of ocular diseases and our ability to further improve diagnoses and patient outcomes.
In 2018, the Specsavers conference will take place from 7–9 September.