Acting fast in response to the cancellation of O=MEGA21 due to the ongoing pandemic, an agile Optometry Victoria/South Australia team re-grouped to deliver Southern Regional Congress (SRC) Online.
The virtual three-day event delivered on the high calibre CPD content that optometrists in Australia, and around the world, have come to expect from this talented group.
SRC came together within a matter of weeks following the cancellation of the O=MEGA21 conference and trade show. As Melbourne’s lockdown hardened, the team boosted efforts to transfer much of the clinical CPD content planned for O=MEGA21 over to SRC.
The limitation of scope of practice is not simply what other people have set for us; you must understand where your limitations in practice are
Clockwise from left: Host Sophie Koh with Janelle Scully and Laura Carson.
Optometrists Sophie Koh and Cassandra Haines hosted the three day event, adding an unsurpassed level of professionalism. Experts in eye health delivered presentations from the comfort of their living rooms and home offices, on topics that ranged from topical and oral therapeutics through to orthokeratology, neuro-ophthalmology and paediatrics.
An incredible 950 optometrists took time to engage with the SRC Online CPD program, attending from Australia, New Zealand, Fiji and the United States. We review a selection of the presentations they attended here.
ORAL PRESCRIBING
Associate Professor Daryl Guest (University of Melbourne) spoke on a topic he is passionate about – the optometric prescribing of oral medications.
He said oral therapeutic prescribing will require optometrists to step outside the traditional optometric mindset to consider the patient in front of them as a “whole body system”.
Optometrists will need to reflect on their personal limitations in terms of knowledge base, evidence and experience, and when there are gaps in their knowledge, they will need to know where to access appropriate resources. A/Prof Guest described the prescribing of oral therapeutics as “a thinking process” as opposed to a “memory test”.
A/Prof Guest’s daughter is a GP and the two of them collaborate and share knowledge, when appropriate, to determine treatment plans for individual patients. Using examples from their collaborative efforts, he demonstrated the thought process behind committing to a course of action, which includes:
Rule out other pathologies, (e.g. fever, systemic malaise etc.),
Consider likely causative factors,
Consider patient safety, and
Consider the likelihood of patient compliance and access to medication. Often there will be multiple solutions for treatment. Cost and accessibility may come into the equation.
Optometrists in New Zealand gained the right to prescribe oral therapeutics in July 2014 (despite gaining topical therapeutic rights long after Australian optometrists). As such, we often look to New Zealand’s optometric prescribing behaviours in an effort to understand how oral therapeutic prescribing rights will play out in Australia.
A review of orals prescribed in New Zealand, published by Dr Philip Turnbull and Professor Jenny Craig (University of Auckland), found azithromycin – a macrolide antibiotic – represented 39% of all optometrist-prescribed oral medications. They were mostly for meibomian gland dysfunction as opposed to managing infection.
Limiting Bacterial Resistance
To prevent and control the spread of antibiotic resistance, Assoc/Prof Guest recommended health professionals:
Prevent infections by ensuring hands, instruments, and environment are clean,
Only prescribe and dispense antibiotics when they’re needed, according to current guidelines,
Report antibiotic resistant infections to surveillance teams,
Talk to patients about how to take antibiotics correctly (complete the course etc.), antibiotic resistance and the dangers of misuse, and
Talk to their patients about preventing infections (for example vaccination, hand washing, safer sex and covering nose and mouth when sneezing).
“Just because you can prescribe antibiotics – it doesn’t mean you should,” he said, explaining that there is just a small pool of aging antibiotics, and few new antibiotics coming through the pipeline due to limited financial return for the pharmaceutical companies. “We should prescribe carefully to prevent resistance over time.”
Encouraging Australian optometrists to embrace oral therapeutic prescribing when the time comes, Assoc/Prof Guest said, “The limitation of scope of practice is not simply what other people have set for us; you must understand where your limitations in practice are. Reflect on what you’re doing, what you’re doing well. Where there are limitations in your understanding of care you will need to sort out how you can address these deficits. Where do you want your scope of practice to be in the future and how are you going to ensure that you practice safely within it? In future, rather than all optometrists seen to be practising identically, we will need to be addressing the ocular needs of our local communities and applying our unique skill sets to those needs.”
GETTING STARTED IN ORTHOKERATOLOGY
Melbourne optometrist Jessica Chi gave a talk on orthokeratology, and how to get started. She highlighted the importance of taking time to gather reliable baseline data before proceeding with orthokeratology, with an emphasis on good topography. Topographical capture should consist of a well centred, wide image, devoid of any ‘ring-jam’ that is caused from dryness.
Ms Chi then spoke of the principals of orthokeratology, and showed how to interpret orthokeratology fitting patterns and how to resolve fitting problems when the lenses were not fitting properly. She detailed the topographical outcomes for orthokeratology and what to do when the ideal outcome – i.e. a ‘Bull’s Eye’ – did not eventuate. The other topographical outcomes were ‘smiley-face’ i.e. decentred superiorly, ‘frowny-face’ i.e. decentred inferiorly, and ‘central island’ i.e. incomplete treatment.
Ms Chi reiterated the importance of not being tempted to change the back optic zone radius of the lens when the treatment was not working as expected, and also the importance of not making hasty changes with the treatment. She finished by saying the key to success with orthokeratology is selecting the right patient and setting realistic expectations.
MANAGING SIDE EFFECTS OF MEDICATION AND MORE
Melbourne Optometrist and Associate Director at Optometry VIC/SA, Laura Carson, presented a series of three ‘tales from the city’, focussing on anterior eye conditions. One of the tales she presented drew delegates’ attention to the complexities of managing an orthokeratology (OK) patient who was having an adverse ocular reaction to Isotretinoin (a medication to treat acne and rosacea), compounded by the liberal use of make-up.
The 15-year-old patient had presented with red, painful eyes and what looked like the beginnings of a stye. Despite following advised regular use of hot compresses and lid hygiene, the discomfort continued, accompanied by variable vision. Return assessment a few months later found anterior eye signs of lid margin staining with fluorescein, congested, inflamed and hyperaemic meibomian glands, traces of makeup on the eyelid margins, moderate conjunctival hyperaemia (palpebral only), and superficial punctate keratopathy (SPK).
Upon further discussion, Ms Carson learnt the patient had been prescribed isotretinoin for acne and her eye symptoms had worsened when the medication doubled (isotretinoin is typically prescribed 10mg for the first two months then 20mg for a further one month). Dry eye from systemic medication changes was the most likely diagnosis – isotretinoin is secreted in tears by the lacrimal gland and induces atrophy of the meibomian glands but does not clinically affect lacrimal gland production, i.e. tear production should not be reduced.
Ms Carson reinforced previously advised use of hot compresses and lid hygiene, including Optimel Manuka Honey eye drops (which she has found works well to reduce redness and bacterial load), along with lubricant drops, all while not wearing OK lenses. She sent a report to the patient’s dermatologist which was followed by a discussion around OK continuation. It was decided that, as the patient was coming to the end of the course of isotretinoin, continuation with OK lenses would be appropriate.
Additionally, Ms Carson took the initiative to instruct the patient on the safe use of eye makeup, which generally optometrists may not routinely be comfortable discussing. “I told her to remove makeup appropriately, every night, and not to ‘tightline’ with eyeliner (the application of eyeliner on the inside edge of the eyelashes), as this actively blocks the meibomian glands, in turn damaging them.
“Research shows eyeliner application causes acute irritation 96% of the time when applied on the inner line of the eyelashes, as opposed to the 20% of the time when applied on the outer line,” she added.
Ms Carson concluded that, “isotretinoin can be quite an aggressive destructor of meibomian gland ability, with many ocular side effects to be aware of in our patients on this medication. Management of common anterior eye conditions can still be challenging due to other conflicting factors”.
She referred delegates to the DEWSII reports and a paper Ocular side effects possibly associated with isotretinoin usage1 for more information on the adverse ocular side effects secondary to isotretinoin.
“Certain” adverse side effects include abnormal meibomian gland secretion, blepharoconjunctivitis, corneal opacities, decreased dark adaptation, decreased tolerance to contact lens, decreased vision, increased tear osmolarity, keratitis, meibomian gland atrophy, myopia, ocular discomfort, ocular sicca, photophobia, and teratogenic ocular abnormalities. Those that are “probable/likely” are decreased colour vision (reversible) and permanent loss of dark adaptation. Side effects with a “possible” association include permanent keratoconjunctivitis sicca.
Ms Carson also recommended optometrists review the DEWSII papers available at: www.tfosdewsreport.org.
THE CORNEA AND ITS REGENERATION
Dr Holly Chinnery presented a recap on corneal anatomy and histology, revisiting the tear film and corneal barrier properties. Additionally, she discussed new imaging technologies enabling researchers to ask more in-depth and insightful questions about the interaction between corneal and epithelial nerve structures. Dr Chinnery went on to speak about therapies that cause ocular surface inflammation before sharing recent work from her lab. This includes work with decorin therapy – of which evidence has been found of its beneficial properties for corneal wound healing, nerve regeneration and inhibiting inflammation.
Decorin is a small proteoglycan located in most connective tissues and in very high concentration in the corneal stroma. It is associated with collagen fibrillogenesis. In addition to being a structural protein, it interacts with many other chemicals, including cytokines and growth factors, in particular TGF-β.
Having reviewed research showing that decorin promotes neuroregeneration in spinal cord injury models, Dr Chinnery and her team were interested to test whether decorin could improve corneal nerve regeneration after injury.
Excitingly, she said their findings suggest this could become a possible treatment for corneal neuropathy after refractive surgery where corneal nerves become damaged, taking years to get back to baseline levels. It could also be used to treat other conditions that cause small fibre neuropathy such as diabetes, which affects corneal nerve homeostasis. Additionally, decorin could be used to restore the corneal surface following damage caused by long-term use of preservative-based eye drops.
To conduct their study using a mouse model of corneal epithelial injury (2mm Alger Brush), Dr Chinnery and her team applied decorin or saline topically, then observed the epithelial recovery, nerve length and inflammatory response at one week post injury.
She described the healing property of decorin as “remarkable” – within 12 hours, decorin appears to promote healing of a sterile central corneal epithelial abrasion.
She said topical decorin was shown to:
- Induce recruitment of corneal epithelial dendritic cells,
- Improve corneal epithelial recovery,
- Improve corneal nerve regeneration, and
- Inhibit macrophage infiltration into the cornea.
“In a counter intuitive way, we found that decorin was causing a pro-inflammatory response, and recruiting more dendritic cells into the epithelium, which is associated with better outcomes for nerve regeneration and inflammatory response at later stages in the wound healing process,” she explained.
Now Dr Chinnery is looking to explore other models of inflammation – her next major lab project will test whether decorin can mitigate BAK-induced corneal nerve damage and ocular surface damage in mice.
ENERGY AND SUCCESS
Outgoing CEO of OV/SA, Pete Haydon, said he was delighted with the success of SRC Online, especially in light of the challenges associated with its delivery.
“We were really sad to have to cancel O=MEGA21. We love the O=MEGA product and our collaboration with ODMA will continue,” Mr Haydon told mivision. “Given we had no choice but to cancel, we wanted to make sure our members still had access to all the CPD they need because so many people rely on us for that. So we brought the majority of the O=MEGA clinical program across and rebranded as SRC Online because we knew many people would still recognise and respect that name. A huge shout out here to the OV/SA team for being able to pivot so quickly and with such effect. They’re amazing and seemingly tireless.
“The feedback I’ve had is that those 950 or so people who came along really enjoyed it. We were lucky to have so many very high profile speakers presenting, and I have been told the content was thought-provoking, and relevant to day-to-day practice. We were also really delighted that Sophie Koh and Cassandra Haines stepped in to act as optometrist hosts across the three days. The way they seamlessly handled all of the intros, transitions, and encouraged dialogue between everyone who attended made a big difference to the delegate experience.”
Mr Haydon concluded, “It’s the last major conference I’ll be involved with for OV/SA and I’ll miss the energy that we all get from delivering these events. I’m sure OV/SA’s CPD programming will continue to grow into the future and I wish everyone the best in that endeavour.”
Hero image: Host Cassandra Haines and speaker Assoc/Prof Daryl Guest.
Reference
- Fraunfelder FT, Fraunfelder FW, Edwards R. Ocular side effects possibly associated with isotretinoin usage. Am J Ophthalmol. 2001 Sep;132(3):299-305. doi: 10.1016/ s0002-9394(01)01024-8. PMID: 11530040.
