RANZCO NSW Conference: Honouring Eye Care

A Welcome to Country is an important part of any conference and the welcome to this event, from First Nation’s man Michael West, was particularly educational as he provided insights about land and community. Mr West presented some fascinating cultural history then went on to speak about how, through respect and treating people with dignity, we can all become better people.

… it was the inaugural Con Moshegov lecture, delivered by Dr Diana Semmonds, that stole the show and brought tears to attendees’ eyes

The conference organisers, including Dr Alina Zeldovich and Prof Adrian Fung, paid due respect to the passing of their popular colleague Dr Con Moshegov in late January this year and welcomed his wife Natalie, to the event.

NSW RANZCO Chair Dr Alina Zeldovich also congratulated optometrist Arveen Venzon, who became the first recipient of the Dr Con Moshegov scholarship. The scholarship enabled Mr Venzon, from Moree in western New South Wales, to travel to Sydney and attend the conference.

But it was the inaugural Con Moshegov lecture, delivered by Dr Diana Semmonds, that stole the show and brought tears to attendees’ eyes.

In honour of Dr Moshegov, Dr Semmonds prepared a lecture comprising stories of inspirational people – beginning, of course, with the story of Dr Moshegov, who was born in Harbin, China, grew up in Australia, and established the refractive practice, George Street Eye, in Sydney. She described Dr Moshegov as “so loved” and with diverse interests ranging from performing cataract and refractive surgery through to involvement with RANZCO and teaching. He was an Honorary Associate in the University of Technology Sydney Discipline of Orthoptics, and a Protodeacon of the Russian Orthodox Church.

As well as acknowledging the RANZCO NSW scholarship, she highlighted The Dr Con Moshegov Memorial Award in Orthoptics, which has been established by the University of Technology Sydney to support its Orthoptics students, commencing from 2022, who reside outside Sydney in rural, remote, or interstate areas, or with a refugee background, to succeed in this rewarding and vital field.

Dr Semmonds went on to tell the history of ophthalmologist Dame Ida Mann, who was born in 1893 in England and studied at the London School of Medicines for Women, becoming the first female surgeon at Moorefields Eye Hospital. She moved to the warmer climate of Perth, Australia, in 1947, with her husband who was unwell. Dr Mann was active in ophthalmology until her passing in Perth in 1983. During her career she travelled to the Kimberleys, where she identified the disease trachoma and, noting 10,227 patients with signs of the disease, 144 of whom were blinded from it, observed that this was the most widespread eye disease among Aboriginal people.

A diversity of clinical lectures ensued across the weekend, among them one by Dr John Males who spoke about the increasing complexity of cataract surgery in much of intraocular lens (IOLs) options. Opining that cataract surgeons now spend most of their time with the patient discussing what can (and cannot) be achieved, he said “Patients want everything from cataract surgery without any downsides”.

A growing range of presbyopia correcting IOLs is now available, offering good unaided distance and intermediate vision with some assistance needed for near.

Comparative studies show that all extended depth of focus (EDOF) IOLs offer good uncorrected distance and intermediate vision. Those with a little bit more near vision are compromised by more dysphotopsias and less contrast. For patients who prioritise near vision, Dr Males said he doesn’t feel confident recommending an EDOF, preferring instead to implant trifocal IOLs.

With all of this in mind, he stressed the need to carefully assess patient suitability for EDOF IOLs and set realistic expectations.

Dr Males concluded this presentation by saying he insists on at least two consultations with patients to discuss IOL options before going ahead with cataract surgery, “because once you’re in the operating theatre, you can’t go back”.

MYOPIA MANAGEMENT

With myopia management in children increasingly catching the attention of ophthalmologists, and ahead of hosting the inaugural Myopia Progression in Children conference for optometrists, Dr Loren Rose spoke at RANZCO NSW on this “huge public health problem”.

Dr Rose described myopia as a problem “that will impact our children’s eye health and will affect our adult patients into the future”.

Interferometry has become the main way to diagnose and measure myopia progression. Untreated, epidemiological growth curves demonstrate that we can expect axial length growth of 0.2-0.3mm per year up to the age of 16, though this will differ across ethnicities. The main aim of management is to slow this progression of axial length growth to reduce progression into high myopia, where it is more likely to result in significant vision loss as an adult.

Exposure to natural outdoor light, for two hours per day, seven days a week, is a recommended strategy to do this. Near work is also a risk factor for myopia progression and it can be difficult to argue that children should spend less time on academic work, so Dr Rose recommends reducing recreational near work.

Dr Rose says refraction is where myopia management is “getting exciting”. While there is a strong view to under-treat refraction associated with myopia, some evidence shows this may accelerate progression. The eye’s periphery governs its growth as opposed to the macula and, for this reason, dual focus lenses, like MiyoSmart by Hoya, are having success. Stellest HALT (Highly Aspheric Lenslet Target) spectacle lenses, by Essilor, are expected to be available in Australia later this year and DOT (diffuse optics technology) spectacle lenses, developed by Sight Glass Vision, are being fast-tracked.

Dr Rose was less keen on orthokeratology due to the link to pathogens.

When treating with atropine, Dr Rose, who completed a study looking at children with fast progressing myopia, said she gets “more bang for her buck” with higher doses. However, higher doses can lead to a higher frequency of side effects, so it is important to titrate the patient. Eikance 0.01% has recently been approved by the Therapeutic Goods Administration.

RETINOPATHY OF PREMATURITY

Dr Jeremy Smith (Children’s Hospital at Westmead) spoke about retinopathy of prematurity (ROP); a major cause of childhood blindness. With the increasing survival of babies born at 23–27 weeks gestational age due to the high standards of neonatal care, we are seeing a higher incidence of severe sight-threatening ROP. All babies born at 31 weeks gestational age or less and/or birthweight less than 1,250g, should be screened for this potentially blinding condition. Mild cases can regress; laser treatment is used for ‘high-risk’ ROP detected in mid and anterior retina, and anti-VEGF intravitreal injection is now used, with success, for severe sight-threatening posterior ROP.

Dr Smith is exploring the use of digital widefield imaging to document disease and, in the future, it is expected that artificial intelligence will be useful in grading ROP.

One significant ROP-related problem in Australia is a lack of human resources and equipment to screen and treat the growing number of babies with ROP. In NSW, we currently have nine high-care level-three nurseries, served by nine ROP ophthalmologists, several of whom are attached to two or more hospitals. Across the nurseries, there are just five functioning Retcams and five lasers. The additional eight level-two nurseries in NSW require ophthalmology services for ROP screening and follow-up, and are more seriously under resourced, threatening the retention of ‘high-care level-two’ status for some of these nurseries.

Confronted with this current and impending manpower and equipment shortage across nurseries, a working group of ROP treating and screening ophthalmologists in NSW is liaising with RANZCO to implement neonatal competency and skills education in trainees. Additionally, the group is liaising with NSW Health to install digital imaging capability and lasers in all level-three nurseries, and to implement an appropriate reporting, and a standard proforma that will allow photos to be uploaded and transferred from one unit to the next.

UVEAL MELANOMA

Australia is leading the way in vision-saving strategies and adjuvant strategies for ocular melanoma, according to Prof Anthony Joshua (St Vincent’s Hospital, Sydney) who spoke about studies evaluating new drugs that both shrink tumours and stop them from metastasising or returning.

Previous work by Ideaya Pharmaceuticals, showed that darovasertib (IDE196) monotherapy can be used to shrink metastatic uveal melanoma, however more progress was needed. Positive interim Phase 2 clinical results of a trial of darovasertib and crizotinib (Xalkori) together, has shown that this revolutionary combination of drugs is successful in shrinking even more tumours.¹

The results, which were publicly released post conference, showed a 50% overall response rate and greater than five months median progression free survival, observed in first-line metastatic uveal melanoma patients (MUM).

The partial responses shown in first-line and any-line MUM patients were clinically significant, building on previously-reported results for any-line MUM patients, with a larger patient data set.

Top line results included:

• 89% of patients show tumour shrinkage in any-line MUM: 31 of 35 evaluable patients showed tumour shrinkage as determined by target lesion size reduction,
• 83% disease control rate (DCR) in any-line MUM: 29 of 35 evaluable patients showed stable disease or better as determined by target lesion size reduction,
• 50% overall response rate (ORR) in firstline MUM: four of eight evaluable patients had a confirmed partial response (PR),
• 31% ORR in any-line MUM: 11 of 35 evaluable patients had a confirmed partial response (PR),
• 43% of patients with >30% tumour reduction in any-line MUM: 15 of 35 evaluable patients observed PRs with >30% tumour reduction, including 11 confirmed and four unconfirmed partial responses,
• Median study follow-up of 6.5 months for first-line MUM patients and 7.8 months for any-line MUM patients,
• Median duration of response (DOR) in evaluable first-line MUM patients has not yet been reached and four of four patients with confirmed PRs in first-line MUM remain in response; median DOR in evaluable any-line MUM patients has not yet been reached and seven of 11 patients with confirmed PRs in any-line MUM remain in response, and
• Median progression free survival (PFS) in first-line MUM patients has not yet been reached and is >5 months in evaluable firstline MUM patients; median PFS for evaluable any-line MUM patients is ~5 months.

Building on these results, in a phase 2 proof of concept study, called NADOM, led by Prof Joshua, the safety and efficacy of darovasertib alone is being investigated in patients with localised uveal melanoma destined for enucleation.² It is hoped that the treatment will shrink the tumour and prevent recurrence. At the time of Dr Joshua’s presentation, two of 10 patients had been recruited.

The other good news for patients is that Tebentafusp, a registered drug, activates Tcells to gravitate towards the cancer, doubling patient survival with metastatic disease compared to the control group.³ 

Dr Joshua said, “I can now tell patients that we have a more effective treatment available on compassionate access scheme for those with metastatic ocular melanoma. Patients live longer, even if the tumour progresses, because it slows the cancer down”.

He observed that careful monitoring of patients diagnosed and treated for cancer has contributed to lives saved. International patient-based analysis showed that from 1995 to 2010, most patients died within 10 to 12 months of diagnosis. While we now know to “watch patients like a hawk” for signs of relapse for up to five years posttreatment, we don’t really know when to stop monitoring because relapses can occur for the rest of a patient’s life.

RANZCO NSW ASM 2023 will take place from 10 to 11 March at the Nex in Newcastle.

Thank you to Dr Lucy Yang for supplying the photographs. 

Pictured in hero image: Dr Diana Semmonds.

References 

1. IDEAYA reports clinical data from phase 2 expansion dose of darovasertib and crizotinib synthetic lethal combination in heavily pre-treated metastatic uveal melanoma. IDEAYA Biosciences. Published December 7, 2021. Accessed December 9, 2021. https://bit. ly/3GKmGNJ 
2. clinicaltrials.gov/ct2/show/NCT05187884 
3. Paul Nathan, M.D., Ph.D., Jessica C. Hassel, M.D., Piotr Rutkowski, M.D et al. Overall Survival Benefit with Tebentafusp in Metastatic Uveal Melanoma. The New England Journal of Medicine, Sep 23, 2021