WAVE 2023 Advancing Optometry

Optometry Western Australia (OWA) President Stephanie Bahler opened the WAVE 2023 conference in Fremantle by welcoming on stage Nigel Wilkes Snr, a traditional Elder of the Whadjuk Noongar Nation and a cultural elder of the Swan River (The Derbal Yerrigan).

the most common failure in optometry leading to legal action – which is the failure to detect ocular conditions – most commonly glaucoma, retinal detachments, and papilledema

“Fremantle, known as the lungs of Perth, is a sacred place where many Elders gathered to discuss significant issues and traded shields and artwork from all over Australia,” Mr Wilkes said.

He encouraged all delegates to have clarity and strong ears, to listen carefully, and to be aware of the challenging stories that developed in the area. He also advised delegates to wander the streets and enjoy the rich history of Fremantle, and to use their eyes and look about, when walking in the Country.

Ocular Surface Tumours

Following the Welcome to Country, the educational component of WAVE began with consultant ophthalmologist Dr Olivia MacVie and guest speaker Dr Shivani Singh, a consultant anatomical pathologist. They presented together on the ‘Big 3’ ocular surface tumours: ocular surface squamous neoplasia (OSSN), melanocytic proliferations, and lymphocytic tumours. These conditions are particularly important for optometrists, who make up the majority of referrers.

OSSN has an incidence of 0.03–1.9% per 100,000 and can present as gelatinous, leukoplakic, or corneal frosting. Diagnosis is multifactorial, and the gold standard of investigation is to perform a biopsy, which allows the pathologist to differentiate between varying degrees of the disease process. Excision and chemotherapy are the treatments of choice for invasive carcinoma, with a significant recurrence rate of 40%.

In melanocytic lesions, the majority present as primary acquired melanosis. Other presentations include nevi, ocular racial melanosis, and ocular melanocytosis (which tends to occur congenitally). Conjunctival malignant melanomas are rare but can be devastating. They frequently present as unilateral, thickened, and raised lesions with prominent feeder vessels. Chemotherapy is the treatment of choice, with high recurrence rates of 40%, and a mortality rate of 18%.

Conjunctival lymphoma can present as a salmon patch sub-epithelial mass, with possible follicular conjunctivitis, and feeder vessels. It is difficult to differentiate between benign lesions and lymphoma clinically, so histopathological evaluation and diagnosis are essential. Following this, haematological investigations and external beam radiotherapy are the treatments of choice.

Optometry and Oral Medication Prescribing Rights

Dr Graham Lakkis delivered a thrilling presentation about the future of optometry, leaving the audience excited and optimistic. As a member of the Scheduled Medicine Advisory Committee of the Optometry Board of Australia (OBA), Dr Lakkis discussed the potential applications of medications that optometrists may soon be able to prescribe. He emphasised that this extension from topical prescribing would not be an expansion of scope, but rather an evolution of current practises to other modalities. Dr Lakkis noted that optometry has already proven itself ready for this evolution, through current meticulous topical prescribing practises.

For soft tissue conditions like chalazions, meibomian gland dysfunction, pre-septal cellulitis, Canaliculitis, and dacryocystitis, oral courses of antibiotic therapy are more effective than topical. Penicillins and cephalosporins are effective at interfering with bacterial cell wall synthesis. Macrolides, such as azithromycin, and tetracyclines such as doxycycline, inhibit protein synthesis and ribosomal protein synthesis, respectively. Doxycycline is bactericidal at 200mg/day and has an anti-inflammatory effect at lower doses of 25–50/mg per day.

In addition to antibiotics, Dr Lakkis discussed the potential of antiviral medications like acyclovir and famciclovir to reduce post herpetic neuralgia. Corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) were also addressed, with Dr Lakkis recommending short-term use for soft tissue inflammation and pain relief.

For allergic eye diseases, optometrists could prescribe intranasal sprays or oral antihistamines. Analgesics such as ibuprofen can be used for short-term pain management in conditions such as corneal abrasions, recurrent corneal erosion syndrome, or post-photorefractive keratectomy.

Looking to the near future, Dr Lakkis stated that no further qualifications would be required for therapeutic prescribing, and that optometrists would work from classes of drugs rather than lists. This shift will benefit patients and the medical community; and is favourable for state and federal governments, he said. There have been no rollbacks of extended prescribing rights in other jurisdictions around the world. Overall, Dr Lakkis left the audience buzzing with excitement for advancements in opportunities for prescribing in optometry.

Minimising Risk of Legal or Ahpra Action

Optometrist Stephen Leslie delivered a presentation that emphasised the importance of minimising the risks of litigation, and the lawful requirements to keep accurate and detailed clinical records as an insurance to defending against any potential legal cases. He highlighted the most common failure in optometry leading to legal action – which is the failure to detect ocular conditions – most commonly glaucoma, retinal detachments, and papilledema – especially in children.

He urged optometrists to be confident in their clinical records, which should withstand scrutiny by expert witnesses for the Australian Health Practitioner Regulation Agency (Ahpra) or lawyers.

Mr Leslie shared that there were 68 complaints against 61 Australian optometrists in 2021–22, and there has been a slight increase in complaints due to increased patient awareness of disease, and medical anxiety within the community. He urged optometrists to maintain a healthy level of suspicion with significant signs or symptoms, and to find a meaningful reason for them.

He suggested listening carefully to patients. “If you ask enough questions then many patients will give you the diagnosis before any testing is done.” He advised delegates to connect any relevant medical history with the patients’ visual issues. Mr Leslie recommended performing systematic eye examinations, maintaining comprehensive patient records, and ensuring diligent follow-ups.

For patients presenting with flashing lights and floaters, the standard of care requires dilation with binocular indirect ophthalmoscopy fundus exam. Amblyopia is diagnosed on exclusion of other disease and attempts should be made to identify amblyogenic factors. A mandatory optical coherence tomography (OCT) and dilated fundus exam is required in suspected papilledema and if diagnosed as pseudo-papilledema, a record of the cause should be noted, e.g., hypoplasia, disc drusen, or tilted discs.

Mr Leslie urged optometrists to be thorough and to follow the SOAP protocol of documenting Subjective symptoms, Objective results, Assessment, and Plan. Dilate, perform visual fields, and complete an OCT when indicated.

Kids and Contact Lenses

With the uptake and awareness of myopia control gaining significant traction within the community, optometrists are increasingly recommending contact lenses as a vision correction option for children and adolescents.

Optometrist Kylie McNeill gave a presentation about the benefits of contact lenses for children, and how optometrists should not be hesitant of fitting children into contact lenses.

When considering fitting children with contact lenses, optometrists should take into account the child’s maturity, fine motor skills, attention span, anatomical considerations, prescription, and psychosocial factors, she said.

Both parents and optometrists should consider the negative impacts of not applying myopia control, such as a one in 20 risk of retinal detachment if a child has a prescription of -5.00. The risk of microbial keratitis with soft contact lenses is one in 500 and is not higher in children and teens compared with adults. The risk of infection in orthokeratology is comparable to reusable soft contact lens wear.

Ms McNeill told delegates that to communicate with children, optometrists should begin by building rapport; ask about their interests, explain every test, and make it fun by being friendly and using age-appropriate language. She suggested using a trial lens for the child to feel. Prescribing eye touching practice, where the child holds their eyelids open and rests their finger against the white of their eye, can also be helpful, she said.

Parents can support their children by helping them put in and take out the contact lenses if they have difficulty.

Delegates heard that children can competently handle contact lenses from eight-years-old, and it typically takes 12 minutes longer for children to learn insertion and removal compared to adults. Ms McNeill said 90% of children prefer wearing contact lenses over glasses.

In summary, fitting children with contact lenses can be beneficial and safe when done with consideration and care. Optometrists should not be afraid to fit children with contact lenses, and parents can support their children through the process, Ms McNeill said.

Ocular Allergies

Optometrist Elisse Higginbotham presented a discussion on ocular allergies, highlighting that approximately 20% of the Australian population has allergic eye disease. She advised that it is important to ask about eye rubbing, especially in children, as this can indicate allergies. She focussed her talk on the two main forms of allergies – seasonal and perennial.

Seasonal allergies occur at a certain time of the year and can uncommonly present as vernal keratoconjunvtivitis in children with upper tarsal giant papillae, peri-limbal Horner-Trantas dots, or mucin strands. If a shield ulcer is present, referral is necessary. Vernal keratoconjunctivitis (VKC) is a type four hypersensitivity reaction and does not respond to antihistamines and mast cell stabilisers. In these cases, topical fluorometholone (FML) should be used initially every hour and then tapered off, Ms Higginbotham said.

She went on to discuss perennial allergies, which occur all year round and are often caused by dust mites or pets. Perennial allergic conjunctivitis tends to be chronic, with symptoms such as palpebral papillae and red eyelids. It can infrequently present as atopic keratoconjunctivitis (AKC), mostly in adults, with signs of atopic lids and mucin strands. AKC is another type four hypersensitive reaction requiring topical steroids.

Ms Higginbotham outlined treatment options for ocular allergies including vasoconstrictors (which can cause rebound redness), Livostin (an antihistamine to reduce the itch), Zaditen and Patanol (combined antihistamine and mast cell stabilisers to address the triggers), oral antihistamines (from age two upwards), and nasal sprays. High doses of steroids in nasal sprays can increase intraocular pressure in children, so caution should be exercised.
Immunotherapy with anti-allergy injections under the tongue is also an option, Ms Higginbotham said.

Sundowner

The conference sundowner after the first day of presentations was a lively event with an enticing array of food and drinks.

Optometrist Jeffrey Tambyrajah and his band provided entertaining music for the attendees. Additionally, optometrist Bjorn Russell delivered an entertaining stand-up comedy sketch, humorously reflecting on his experiences as an optometrist while being diagnosed with attention-deficit/hyperactivity disorder and managing the complexities that come with marriage and divorce.

The event provided an engaging and enjoyable break from the formal presentations of the day.

Close

Stephanie Bahler concluded the WAVE 2023 conference on day two, ending on an amusing note. She acknowledged the various reasons why delegates may attend, such as gaining continuing professional development points, striking deals with suppliers, and taking a much-needed break from children and chores at home.

She emphasised the importance of the conference allowing delegates to stay up-to-date with education and technological advancements in the field of optometry while being able to catch up with colleagues. She said she was inspired by the ways in which people manage work/ life balance, pursue big dreams, and plan for retirement.
Overall, the conference was revitalising and provided valuable opportunities for personal and professional growth, Ms Bahler said.

Kiran Sookroo BOptom (Hons), a University of Auckland graduate (2013), is a therapeutic optometrist currently practising at Eyes@Optometry Falcon, south of Mandurah, WA. He specialises in dry eye treatments, rigid gas permeable (RGP) contact lenses, and orthokeratology. Mr Sookroo served as the Chair of the Early Career Optometry Western Australia Committee from 2018 to 2021.