Short sharp presentations, interactive workshops, an intimate exhibition and the Sundowner cocktail party have become the hallmarks of Optometry Western Australia’s annual WAVE exhibition, held at the Rendevous Hotel on spectacular Scarborough Beach.
Optometrists from Western Australia and guests to the State were informed and educated by a solid line up of speakers at WAVE 2018, among them optometrists Mark Kozsek, Maria Marakoulli, Simon Hanna, Jessica Chi, Dr. Monica Jong, Rod Baker and ophthalmologist Dr. Celia Chen.
DRY EYE DISEASE
Sydney optometrist Mark Koszek set the tone for WAVE 2018 with an insightful presentation that provided optometrists with practical tips to simplify the dry eye work up and treatment. He said, “every optometrist tends to take a different approach to dry eye in terms of testing and treatment”.
Mr. Koszek described the two different dry eye conditions – aqueous deficiency (AD) and meibomian gland deficiency (MGD) – and made the point that “they are not islands… approximately 50 per cent of your patients will have some form of AD, 86 per cent will demonstrate signs of MGD and those who begin with AD will usually progress to having MGD as well”.
He highlighted the importance of two tests in particular; conjunctival staining using lissamine, and measurement of tear volume using the Schirmer test. He said those who don’t do conjunctival staining can miss much information about a patient’s dry eye disease. For example, a person with a lot of conjunctival staining will often have an auto immune condition such as Sjogren’s Syndrome. A Schirmer test enables diagnosis of AD and importantly, indicates severity of the condition.
Mr. Koszek said one of his ‘go to’ treatments for mild to moderate dry eye is Manuka honey because “studies have shown it helps control microbial overgrowth, improves meibum quality, helps control ocular surface inflammation, has a small effect on replenishing the acqueous, and on regenerating the ocular surface.”
He delved into the underlying causes of dry eye and spoke of the increasing understanding of the role that gut bacteria plays in maintaining a healthy ocular surface. “Rosacea, which is associated with meibomian gland dysfunction, is an inflammatory reaction of the intestine that can affect the eyes, lid margin and the cornea. IPL is effective at treating the symptoms of ocular rosacea however it does not address the underlying problem. Fortunately an increasing understanding of the impact of diet on gut bacteria is shedding light on how roscaea can be managed,” he said.
Optometrist Rod Baker lectured on managing children’s vision issues. He stressed the need to take a collaborative approach to children’s vision, working closely with teachers, occupational therapists, psychologists, carers, GPs, paediatricians, etc. who together are able to develop a full picture of where the child is now, how they reached that point and where they need help to fulfil their potential. He said a key to providing excellence in children’s vision care was to develop an appropriate referral process. Teachers for instance, have a very different perspective on a child’s vision issues based on their learning and classroom behaviour, compared to a paediatrician or parent/ carer, and this should guide the questions asked in referrals from each.
Mr. Baker also highlighted the need to be aware of changing classroom environments, which present different challenges to a child’s visual processing skills. He cited recent Australian based research on the visual demands in Australian classrooms. “Today a mean habitual near working distance for primary school children is 23cm – that’s where they spend 47 per cent of their time in the modern classroom – which means that we should consider carefully the working distance for binocular vision assessment before determining an appropriate spectacle prescription,” he said.
Examining children, especially those with learning or developmental difficulties, can be challenging. He spoke about the specialist Autism Clinic at Flinders University headed by Dr. Paul Constable, which has produced virtual 3D orientation videos and visual scheduling to introduce new patients to staff, equipment and the examination process. He said these videos are easy to create with a smartphone and can alleviate significant stress for individuals, especially children with disorders such as autism. Mr. Baker also spoke about winning the trust of a reluctant four year old patient by examining him in the practice lunchroom, with the child’s parent and trusted occupational therapist in the room. Having investigated the child’s interests, his practice staff set up tactile plasticine mats and purchased toy figures interesting to the child. The child-centric environment engaged the child sufficiently to enable an assessment of his condition.
Neuro ophthalmologist A/Professor Celia Chen delivered presentations on optic nerve swelling and ptosis. She said eye health professionals often view neuro ophthalmology as scary, however the trick when examining patients is, “to rule out what can kill a patient or blind a patient, then work through the remaining issues”.
Dr. Chen presented several examples of optic nerve swelling to demonstrate differences in optic nerve swelling: ‘the good’ – pseudo swelling; ‘the bad’ – conditions that can kill or blind a patient; and to recognise optic nerve appearances that can be associated with a systemic condition.
Her key tips for investigating swollen optic nerves were to look at the blood vessels over the disc and check for any change in calibre at the disc margin, and to look for spontaneous venous pulsation.
Dr. Chen said in the work up for bilateral optic nerve swelling, we need to look into possibilities of a mass lesion in the brain, venous sinus disease, or systemic causes. She said unilateral optic nerve swelling may be a sign of giant cell arteritis and the differentials include ischemic causes, compressive disease or infiltrative lesions. Dr. Chen said optic nerve swelling does not necessarily cause a change to visual acuity. When assessing optic nerve function, the five signs to check for are the patient’s visual acuity, visual field, pupil, colour vision and subjective brightness.
“When dealing with an optic disc drusen you need to convincingly show the pseudo optic disc oedema is from the drusen deposit and use as many optic modalities as possible including OCT across the optic disc, ultrasound, autofluorescence or CT brain with fine cut section across the optic nerve head,” she said.
During a workshop run by Simon Hanna, OA Professional Development and Clinical Policy Manager, feedback from audiences highlighted some of the confusion surrounding billing of Medicare items.
Mr. Hanna said it is important to be very clear about the rules because optometrists are personally responsible for incorrect Medicare rebate billing. He said Medicare compliance auditors now use sophisticated algorithms that highlight inconsistencies in Medicare billing across the sector.
“They look for patterns in billings – they don’t look for one offs. They compare an optometrist’s use of a particular number against their peers to check for considerable over-use… You need to be able to clinically justify relevance of the testing and that you’ve met the terms of the item descriptor,” said Mr. Hanna.
Mr. Hanna said Optometry Australia had been lobbying government for changes to Medicare rebates and these were expected within the next 12 months, though the scale of change remains unclear.
Optometry billing is relatively small compared to Medicare billing by GPs. In 2017, 9.2 million Medicare services were provide by optometrists at a cost to the government of AU$425 million. Costs for GP attendances in the same period were over $5 billion.
Dates are yet to be announced for WAVE in 2019.