WAVE: The Return of Live Learning

AGE-RELATED MACULAR DEGENERATION

Wave was underway with the first presentation delivered by Dr Hessom Razavi from Lions Eye Institute. Dr Razavi delivered a fascinating presentation on our evolving understanding of age-related macular degeneration (AMD); a disease which accounts for 10.3% of blindness among non- Indigenous and 0.95% of blindness among Indigenous populations in Australia.

Dr Razavi described AMD as a “multifactorial disease spectrum” – an overlapping number of diseases with different pathways comprising an interplay between ageing, genetic susceptibility (genetic influence in late AMD is thought to be as high as 70%), and environmental risk factors. It is characterised by the accumulation of drusen, which can eventually lead to the loss of photoreceptors and retinal pigment epithelium, resulting in central vision loss in the worst cases.

Almost 14.8% of the Australian population has early AMD; 10.5% have intermediate, and 1% have late AMD. However, because it is a disease associated with age, 6.7% of people over 80 years of age have late AMD, with the incidence higher in women than men.

Optometrists are now appreciating the multiple facets and different types of dry eye which require different treatments

The classification of neovascular macular degeneration (nAMD) stages is important to revisit. The simplest way to think about it is to assess the size of drusen present. Drusen over 125.m – roughly the diameter of a retinal vein as it exits the optic disc – or smaller drusen plus pigment deposition within the retina, indicate intermediate AMD; smaller drusen without pigment indicate early AMD or normal macular ageing changes, and late stage AMD is characterised by geographic atrophy or macular vascularisation (leading to fluid and bleeding within or beneath the retina).

We may hear the term ‘macular neovascularisation’ used instead of ‘choroidal neovascular membranes’. This is because we now know that not all neovascularisation originates from the choroid; it can originate from the retina or other locations, and determining the point of origination is important because this can affect prognosis. While the right anti-VEGF therapy and the right volume of treatment for nAMD is key, the strongest predictor of a patient’s long-term outcome is their vison acuity when they are first diagnosed, and when treatment is commenced. With early commencement of treatment being critical, optometrists should err on the side of caution – if you’re not sure whether a patient’s optical coherence tomography (OCT) imaging indicates AMD, refer them to an ophthalmologist.

Reducing Risks of AMD Progression 

We used to believe the only modifiable behaviour that would reduce the risk of AMD progression was smoking cessation (which reduces progression by 200-400%). Now, emerging evidence from the EYERisk Consortium in Europe, among others, has shown a Mediterranean diet – rich in fruit, vegetables, fish, and olive oil; moderate in red wine; and low in red meat and dairy – is associated with 41% reduction in onset of advanced AMD. Processed meats and high salt diets can worsen progression.

Physical activity has also been shown to reduce AMD progression by up to 20%. Meta-analysis of data from several studies finds high levels of physical activity are effective – e.g. heavy gardening or heavy lifting. Previous research has also shown that more moderate activity, such as walking or bike riding, may have an effect in delaying the onset of new AMD, or slowing the progression of existing disease.

Summing up Dr Razavi said, “So, it’s looking pretty good for patients with earlier stages of AMD if your patients are prepared to eat well and exercise. This appears to have the greatest effect on people in their 60s – so start talking about it to people in their 50s with early signs. The message is, ‘Just move your body please – and the more the better – and eat a nutritious diet that’s rich in colourful fruit and vegetables’… there’s no way we can say now there is nothing you can do about AMD. Patients actually have a lot of power to influence the course of their disease, and we should be there to guide them along the way.

“For patients that do need intravitreal therapy for nAMD, there are excellent treatments available, and new treatments emerging. The most important one of these is Faricimab, a novel anti-VEGF agent which may only need to be injected three to four times per year in many patients, and should be available for use in Australia in the next one to two years.”

Interestingly, strategies to prevent noncommunicable diseases being developed by the United Nations and the World Health Organisation include developing sustainable cities – with greater access to fresh food as well as more cycle paths, walking paths and parks, and work opportunities closer to homes, all of which will provide time and facilities for more active lifestyles. Dr Razavi said these preventative, whole-of-society interventions may ultimately have more impact than drugs on reducing the incidence of lifestyle related diseases, including AMD. With this criteria in mind, Canberra has been named as the world’s most sustainable city, which bodes well for us here in Australia.

FUNDAMENTALS OF OCT

Dr Graham Lakkis delivered multiple lectures over the two-day WAVE 2022 conference on the topics of retinal and optic nerve haemorrhages, glaucoma management, and the fundamentals of OCT analysis.

In his very practical lecture on OCT analysis, he reaffirmed that OCT instruments are an essential tool for diagnosis and management of eye disease, however there was potential for incorrect clinical interpretation if the practitioner did not fully understand the limitations of the instrument or how to select the appropriate OCT scans.

A number of clinical studies have demonstrated that about 25% of OCT scans show defects that are in fact false positives. It was his view that this is most problematic when using OCT as a routine screening test rather than on clinical suspicion of disease, where it could lead to unnecessary or inappropriate referrals. Dr Lakkis described strategies to limit false positives, such as taking multiple baseline scans, using an instrument with high resolution fundus imaging, gaze tracking, accurate automated layer segmentation, a robust normative database, and accurate progression analysis software.

Successful progression analysis, especially for glaucoma where practitioners are looking for changes of only one or two microns, required a consistent and careful approach to ensure the exact same retinal area was scanned at follow-up visits. Due to frequent involuntary eye movements and head tilt, an instrument with a separate scanning laser ophthalmoscope (SLO), gaze tracking and accurate image registration provided the best test-retest repeatability, and allowed the earliest detection of change over time. Dr Lakkis also discussed the inherent limitation of normative databases in all OCT instruments.

The databases were created with limited ethnicity, a low number of subjects, limited refractive error and age ranges, and the exclusion of all other ocular comorbidities. This resulted in a database of “supermodels” that didn’t always reflect the real-world nature of the patients that were being scanned, and potentially flagged them as abnormal when they were simply different to the database. His suggestion was to perform multiple scans over time, and if there was stability this indicated the patient was likely healthy – they just fell outside the normative database. If there was deterioration then treatment could be initiated or referral made.

Summing up, Dr Lakkis stressed the importance of ensuring OCT scans are of the highest possible quality, right from the baseline, to allow for accurate progression analysis. “A high-quality artefact-free OCT scan, localised on and taken simultaneously as a high resolution fundus image, acts as an ideal baseline for future comparison. A lowquality OCT scan with artefacts, localised on a low resolution fundus image that was taken at a different time to the OCT scan, is almost useless for progression analysis.”

GLAUCOMA UNDER VS OVER DIAGNOSIS

In other presentations, Dr Joshua Yuen presented on glaucoma, highlighting issues associated with both under and over diagnosis.

While it has been reported that around 50% of people with glaucoma may remain undiagnosed, over diagnosis is also a problem – studies have shown that 15-50% of patients treated for glaucoma with anti-glaucoma medications did not meet criteria of glaucoma. Additionally, he saia proportion of glaucoma patients with very slow progression may not notice any symptoms in their lifetime, even without treatment; and there is a minority (around 10%) who are ‘rapid progressors’ even with treatment.

The causes of under diagnosis include the asymptomatic nature of glaucoma, a lack of accessibility to eye care and loss to follow-up. The consequences of which are irreversible glaucomatous structural and functional optic nerve loss.

The causes of over diagnosis are medico legal fear and patient anxiety, the consequences of which are unnecessary treatment burden /side effects and financial /resource costs to the patient and the health system.

Appropriate evaluation of glaucoma suspects will reduce both under and over diagnosis. Identifying what is normal and what represents typical glaucoma features, then appropriately timed follow-up of suspects to measure possible progression is essential.

Dr Yuen ran through the risk factors for glaucoma but primarily focussed on ocular hypertension, which he said is a strong risk factor for glaucoma but has a variable effect on peoples’ optic nerves. Risk stratification is important; high risk patients should be considered for treatment and low risk patients should be monitored. Ongoing monitoring is critical, as demonstrated by Ocular Hypertensive Treatment Study (OHTS)’ which found that the risk of glaucoma conversion continues throughout the patients’ lifetime, whether a patient is being treated or not. Reiterating Dr Lakkis’ presentation, he said to be confident of diagnosis, practitioners need to optimise accuracy of OCT and visual fields, and generate sufficient data points.

CONTACT LENSES IN PRACTICE

Optometrist Jessica Chi was a returning speaker at WAVE, delivering presentations on contact lenses for presbyopes, ortho-K, and contact lens complications.

A self-confessed contact lens advocate, Ms Chi said the best approach to managing contact lens complications is to avoid them in the first place. She gave tips to educate patients on the importance of compliance from the beginning, before detailing the treatment and management when complications do occur. She also stressed the importance of avoiding tap water with contact lenses as this can potentially lead to devastating Acanthamoeba infections.

In her presentation on contact lenses for ortho-K, Ms Chi echoed Dr Lakkis’ sentiments, stressing the importance of acquiring accurate baseline information, in this case to enable treatment analysis.

“Taking time to obtain the baseline data in the beginning will save time in the future for ortho-k,” she said. This includes the acquisition of good quality, well centred and accurate topography maps. She recommended obtaining a few captures to ensure reliable data.

Ortho-k involves moulding the cornea with reverse geometry rigid gas permeable contact lenses to correct a wearer’s refractive power. Simple ortho-k is very easy, she said, however difficult ortho-k can be really difficult. Fortunately, there are many lens options available in Australia and she advised optometrists in the room to make the most of laboratory technicians who are there to help when required.

Ms Chi said to understand ortho-k is to understand how to interpret corneal topography. She spoke of the humorously named topographical outcomes with ortho-k (bull’s eye, smiley face, frowny face, central island, fake central island) and how to trouble shoot the fit of the ortho-k lens to achieve the desired outcome – bull’s eye.

She concluded her presentation by saying that although ortho-k lenses are very safe when worn properly, it does require overnight contact lens wear, which has risk for complications, so it is important to stress proper care and compliance.

DRY EYE AND SWOLLEN LIDS

Other speakers at WAVE included Dr Kylie McNeil, who discussed evaluation of early ectasia and keratoconus, and shared pearls on the management of mask associated dry eye (MADE).

Adrian Bell delivered an entertaining lecture on paediatric eye care, reminding us that the consulting room is a frightening place for children, so we need to make them comfortable and engage them with activities that while fun, give an immediate indication of the status of their vision before probing further. Outlining some of the red flags associated with paediatrics, he said amblyopia is the most common cause of vision impairment in children and it’s important to work out what the amblyogenic factor is and convince parents of the need to do something about it. If you have one bad eye you have twice the chance of something happening to the other eye. Children learn to read and then they read to learn. If a child is uncomfortable focussing, they will avoid learning to read which will hold them back in their education, and potentially throughout life.

Pauline Kang spoke about identifying and managing premyopes. While there are treatments available for myopes, only behavioural modifications can be recommended to prevent onset of myopia among premyopes and those at risk. However, studies are emerging. The ATOM 3 study is looking at premyopic children aged five to nine years to determine the impact of 0.01% atropine on myopia onset and progression – results are due soon and they will tell us whether we are able to prevent myopia onset altogether. This “would be the holy grail of myopia research”. In the meantime, recommending 1.5 hours of outdoor time per day, with appropriate UV protection for the eyes, will aid in reducing the risk of onset and progression.

Dr Kang noted the effects of COVID lockdowns on myopia, which caused children to spend more time indoors and on screens. Consequently, axial length and refractive measurements increased in 2020/21 compared to 2019, however post-lockdown, anecdotal evidence suggests myopia control has returned to pre-COVID times.

Dr Charlotte McKnight delivered a presentation on ‘swollen eyelids’ covering off the many causes including infective, metabolic, allergic, tumour, trauma, vascular, iatrogenic, congenital and degenerative causes, complete with some stomach-churning visuals. She also provided a straightforward framework for diagnosis to determine treatment.

Discussing therapeutics to aid repair following chemical exposure, she said the most common error is over-treating with antibiotics and undertreating with steroids. After a chemical injury, antibiotics can be used for prophylaxis, however they should be prescribed appropriately. For example, using more than four times a day is likely to be over treatment and risks causing toxicity. These patients need preservative free lubricants every hour throughout the day to flush off inflammatory mediators from the ocular surface, and create an environment in which damaged cells can repair and regenerate. It is very reasonable to prescribe steroid eye drops every two hours by day initially, and in cases referred with corneal thinning or corneal melt, doxycycline, vitamin C and amniotic membrane may be used.

EXHIBITORS ENGAGED

Optometry Western Australia made a point of encouraging optometrists to visit the WAVE trade show where a variety of suppliers, from Optometry Finance Australia and ProVision through to Device Technologies and Seqirus, hosted stands. A competition, which gave delegates the chance to win back their registration fee, prompted deeper engagement with suppliers during morning tea and lunch breaks.

Carl DuToit, National Sales and Service Engineer at BOC Instruments, said interest in his company’s stand, and particularly in its suite of dry eye products, was high at WAVE.

“Optometrists are now appreciating the multiple facets and different types of dry eye which require different treatments.

“At WAVE the newest product we had to demonstrate was Activa from SBM. It’s a goggle set that, over a 15 minute cycle, warms meibomian glands to 42. and massages the lids to break up any clogged meibomian glands. After that the practitioner can do expressions etc. Exhibitors to the stand were interested to understand it.”

Naomi Moir, National Eyewear Manager at Rodenstock, was thrilled with the number of delegates who visited the company’s stand. “We were showcasing Porsche eyewear on its 50-year anniversary and among the collection we had two limited edition frames on display in a box set, which created a lot of interest. Only 1,972 pieces of each frame were made and we order them in for customers on request. We also took a frame to Perth that was completely handmade from wire. That was a one off for Australia and an optometrist purchased it at its first showing.”

Nicola Peaper, National Sales and Professional Services Manager for Rodenstock lenses, enjoyed the opportunity to return to face-to-face conferencing. “We had a dinner to introduce optometrists and practice managers to BIG Norm, our new AI technology for lens calculation. The concept of BIG Norm is easy to understand and people liked it. There weren’t as many people at the tradeshow as there usually are but it was successful – we had the DNEye scanner there which enabled us to scan people’s eyes and arrange new lens and frame packages. WAVE is always very relaxed and enjoyable.”

Anissa Connor, National Business Manager Eyecare at Seqirus, said WAVE had been a “fabulous” opportunity to introduce Cationorm and Ikervis to a new market.

“At every break we were swamped with interest – with Seqirus being new to the industry, it was a great opportunity to meet people face-to-face over one weekend and inform them about what Seqirus can bring to the eye care industry.”

Her colleague, Irina Savinykh added, “Everyone who visited our stand was engaged and wanting to know more.” As a newcomer to the ophthalmic industry she said the trade show enabled her to build valuable relationships.

WAVE will return to Fremantle in 2023.