AVC 2023 Beyond the Horizon

The conference opened with a welcome from OQNT President Melinda Toomey and a breakfast session sponsored by platinum sponsor Bausch and Lomb with a broad ranging presentation from Simon Hanna. He elaborated on pertinent aspects of contact lens (CL) wear, dropouts, ocular surface issues, and how the latest CL material technologies can enhance success. He stressed the need to ask leading questions that delve into patients’ comfort and success – it’s often possible to markedly improve comfort while providing optimal eye health.

Subconjunctival haemorrhages can be suspicious: a deeper look may show typical associated retinal haemorrhages

The plenary sessions kicked off with a neuro-ophthalmology talk ‘Migraine in the primary eye care setting’ presented by Dr Mark Paine.

He defined migraine as an inherited, common, chronic, incapacitating, neurovascular disorder characterised by attacks of severe headache, autonomic nervous system dysfunction, sensory sensitivity, and in some patients, an aura involving neurologic symptoms. Migraines are most common in women. He added that migraine is the second most disabling medical condition and went on to detail current treatments.

Dr Phillipa Sharwood followed with an enlightening talk titled ‘The odd optic nerve’. She stressed the importance of red desaturation/brightness, with a >20% difference being important to investigate further. Visual fields are, of course, highly diagnostic. She stressed same day referral for swollen disc conditions with visual loss.

Paediatrics

The session on paediatrics began with Dr Richa Sharma speaking on red eye in paediatrics. Discussing the challenges involved in examining and managing children with common conditions, Dr Sharma noted some red flags: Don’t miss a shield ulcer associated with vernal keratoconjunctivitis (VKC), or red eye that may be related to uveitis or a complication from a bone marrow transplant in paediatric cancer patients. We should also be on the lookout for signs indicating non-accidental injury (NAI). Subconjunctival haemorrhages can be suspicious: a deeper look may show typical associated retinal haemorrhages.

Courtenay Lind presented on optometry care for children with disability or developmental delay. Autism spectrum disorder (ASD) has a prevalence of around 1:100, has unknown aetiology, and a 4:1 male:female ratio. Early intervention is essential. Ocular manifestations include hyperopia with astigmatism (48.4%), strabismus (15.4%, with exotropia more common than esotropia), nystagmus, convergence insufficiency, and optic nerve abnormalities. In Down syndrome, some of the ocular features include strabismus, amblyopia, nystagmus, duct obstruction, keratoconus, cataracts, glaucoma, lid, optic nerve, and retinal abnormalities. She explained how to prepare for/ streamline your optometric exam, by obtaining history prior to the exam, and photos of the child’s eye condition.

Glenn Barltrop shared case presentations of dysfunctional binocular and accommodative vision disorders. Device driven prolonged near work seems to be creating an increase in accommodation issues and inflexibility/infacility in today’s teens. Retinoscopy and measuring and monitoring the AC:A ratio are useful. He recommended using a trial frame and good illumination. He went on to discuss congenital 4th cranial nerve paresis signs and use of the cover test, the Parks 3 step test, and other examination and prescribing pearls. His take home message was if people have symptoms, and there’s supporting data, then we should initiate treatment and correction.

At an Alcon-sponsored talk, Joshua Clark explained the features and benefits of the long-awaited release of Total1 and Precision1 for astigmatism. He noted that 47% of patients have astigmatism ≥ 0.75D in at least one eye, yet only 22% of all soft lens fits are toric. Prescribing toric CLs improves vision in astigmats and provides great potential for growth.

Workshops

Workshops ran in parallel to some plenary sessions. Highlights included ‘The business of dry eye management with Optilight’, sponsored by Lumenis and delivered with gusto by Jason Holland. I volunteered for an intense pulsed light (IPL) lid treatment, with the compact, narrow beam OPT hand piece, which has made upper eyelid treatment much easier. Delegates had a chance to apply a treatment and experience it for themselves.

Kylie McNeill hosted a well-attended workshop on keratoconus fitting, which gave delegates hands-on experience fitting lenses, as well as information on available lens options and lens selection.

Susan Gaskell and Monica Lette of Alcon delivered an interactive workshop on presbyopia correcting IOLs, detailing the role optometrists play in managing cataract patients.

In the CSL-Seqirus-sponsored workshop on dry eye, Martin Robinson covered DEWS II, B.E.I.S.T.O (Bugs and bacteria, Enzymes, Inflammation, Stasis, Temperature, Obstruction), and the importance of a stepped approach, then detailed the mechanism and benefits of cationic nanoemulsion and ciclosporin eyedrops in managing dry eye and inflammation.

‘Managing myopia: to treat or not to treat?’ was the question raised and answered by Marissa Megaloconomos in her interactive workshop. She covered risk profiles, clinical assessment, and available treatments, showing practitioners how to develop myopia management protocols for effective results.

Back To The Plenaries

In a session titled ‘Dumbfounding diagnoses and mollifying management: anterior segment conditions to remember’, Dr Nick Toalster shared cases on keratitis management, demonstrating the need to ‘hit it hard and fast’. If keratitis isn’t responding to treatment, re-examine, culture, prescribe additional antibiotics, and in extreme cases arrange corneal biopsy. He discussed use of steroids in a small subgroup of infiltrative keratitis with central involvement, to prevent or reduce severe vision loss. He provided pertinent information to aid differential diagnosis in developing logical treatment plans.

Associate Professor Nicole Carnt continued the theme, focussing on management of microbial keratitis. She provided interesting information on relatively rare acanthamoeba, increasingly common chlamydial infections, pseudomonas keratitis, and fungal and viral infections.

Although acanthamoeba keratitis is relatively rare, we must do everything possible to prevent every case, as it’s a severe, sight-threatening, painful condition that’s hard to treat. Simply changing a contact lens wearer to daily disposables can decrease the risk by four times.

Dr Katie Edwards followed with a world exclusive preview of the 2023 Tear Film and Ocular Surface Society (TFOS) Lifestyle Epidemic Workshop – Findings of the Nutrition Subcommittee, A lifestyle epidemic: ocular surface disease, available online at tearfilm.org.

Associate Professor Mark Roth delivered a pragmatic talk putting ‘Oral therapeutics in focus’. In the lead up to Australian optometrists being allowed to prescribe oral medications, he covered some of the conundrums, things we can manage, and how to do it best.

Assoc Prof Roth followed with a talk on neurotrophic keratitis, explaining how a lack of nerve innervation due to pathology can lead to a cascade of changes and problems. He detailed cases, diagnostics, therapeutics, how the pain pathways work, some unusual symptoms like ‘pain without stain’, and nociceptive vs neuropathic pain. He suggested that the old mantra ‘don’t give a steroid’ is obsolete and should now read ‘don’t give a steroid alone’ (i.e., provide adjunct or combined antibiotic cover, where indicated).

He suggested considering amniotic membranes with their anti-inflammatory properties and autologous serum, which is biocompatible.

Sunday Sessions

Joe Tanner and Julia Kwok presented platinum sponsor CooperVision’s Sunday morning breakfast session ‘What we’ve learned and what questions remain after the 7-year MiSight 1-day clinical trial’, sharing compelling data from one of the longest studies undertaken in the field of myopia management. They noted that untreated fast progressors changed a lot in the first three years of the study but once treated, the rate reduced significantly. Ninety per cent of eyes responded but we must try to understand why 10% are non-responders. We should start early and continue until progression stops. Without an instrument to measure axial length, cycloplegic refraction is a reliable measure. By practising myopia management, we can make a difference.

Dr Geoffrey Ryan discussed the ever-increasing burden of glaucoma, sharing insights on Selective Laser Trabeculoplasty (SLT), collaborative care, future treatments, and monitoring. He discussed virtual reality visual field (VRVF) testing. I experienced VF2000 NEO, VRVF, a micro medical device which is available from BOC Instruments. I found it easy to use, intuitive, and comfortable. It can be run off the included tablet in normal illumination with habitual reading glasses and is space saving. VRVF includes active eye tracking, aids visual field testing in people of all ages, and helps minimise postural issues we find in testing older people. It includes stereopsis and colour vision tests, with reports, analysis, and reliability similar to the ‘gold standard’.

In the presentation, ‘Is this glaucoma? Honing your diagnostic spidey-sense’, Inez Hsing delivered an entertaining presentation with home-made animated videos and graphic cases. She drew attention to SITA FAST 24-2C testing, which is faster and offers additional threshold testing compared to previous strategies. Important take home points were to test for relative afferent pupil defect. If there’s no cupping, it’s unlikely to be glaucoma: look for other causes that might masquerade or confuse diagnosis (like migraine).

Dr Jack Phu, in addition to his workshop on personalised treatments for glaucoma, asked ‘Are visual fields still relevant in your clinical practice?’. He delved into some of the complexities of testing thresholds to be considered in visual field testing, when teasing out the most effective strategy.

Low Vision

Nabill Jacob, Clinical Relationship Manager at Vision Australia, discussed some of the evolving technology aiding vision impaired patients, such as interactive white canes that provide GPS-like verbal guidance, live Braille, and IrisVision electronic glasses. A visit to the website provides access to support, a large variety of technology and aids in the Vision Australia store, as well as a referral portal: www.visionaustralia.org.

Continuing the low vision theme, Dr Ursula White presented ‘Paediatric low vision: who are they, what do they need, and how can I contribute?’ She discussed the main causes of vision impairment in this cohort, noting that the majority occur prenatally (approximately 60%). Dr White also delved into examination techniques, aspects of function and perception, and several low vision aids. Optometrists play an important role in supporting these children.

The Home Run

After lunch on Sunday, the discussion returned to myopia management with Dr Samantha Lee presenting the Essilor sponsored talk ‘Myopia in young adulthood – risk factors, management, and why should we care?’. Dr Lee noted that risk factors for myopia include east Asian ancestry (6.1 times higher than for Europeans), parental myopia (1.6 times) and female sex (1.8 times risk). We should implement the best myopia management treatment, with the highest compliance, tailored to an individual’s lifestyle.

Associate Professor Anthony Kwan provided a methodical overview of retinal conditions associated with myopia, noting that optical coherence tomography has been a breakthrough for observing and managing myopia related retinal changes and pathology, with things like macula schisis (affecting 9–34% of high myopes), now easily visualised.

He detailed the pathway of myopia to blindness and noted that myopic maculopathy was more than three times more prominent in the East than the West.

Ever popular, Dr Nathan Walker spoke on ‘Fluid at the macula, how the optometrist can assist with management’. He discussed a variety of pan retinal conditions. He showed how to utilise and interpret various types of imaging to help determine the nature, urgency, initial management, and referral.

In his presentation, Professor Chris Layton stated that diabetes has one of the greatest impacts of any disease. There are 333 million people with diabetes globally and half of people with diabetes will develop some form of visual disturbance. In Australia, 100,000 people have long-term visual loss from diabetes. Microaneurysms are common. Alarmingly, 20 years after onset, 60% of people with type 2, and most with type 1 diabetes have retinopathy.

Optometry plays a critical part in diabetic care. He explained the nuances of many aspects of retinopathy, the importance of glycaemic control, the role of anti-VEGF and laser.

Artificial Intelligence (AI) and gene therapy are becoming part of diabetes detection and management and will only get better. Already, AI detects 95% of retinal changes. He stressed the need to ‘be human in treating humans’.

It’s A Wrap!

Dr Sunil Warrier’s presentation, ‘Intraocular tumours and masqueraders’, kicked off with a useful mnemonic that aids differential diagnosis: SPOTS US. This refers to Size, Position, Orange lipofuscin, Thickness, Subretinal fluid and Ultrasound. He explained how to evaluate these to differentiate, for example, a choroidal melanoma from a nevus. He discussed many other aspects of life-threatening melanoma, its management and treatment, including brachytherapy, as well as elaborating on other types of intraocular tumours, what and when to refer, or observe.

Dr David Gunn provided a synopsis of keratoconus and noted that with the evolution of corneal cross linking (CXL) and improved, earlier diagnosis, far fewer patients require invasive procedures such as corneal transplant. New treatments include BOOST epithelium-on CXL, delivering reduced pain and faster healing. He discussed a pioneering case of Corneal Allogenic Intrastromal Ring Segments (CAIRS), which involves femtosecond laser crafted segments derived from donor corneal tissue. He said this is more effective than intra corneal ring segments and biocompatible. His illustrative case showed a dramatic improvement, taking his patient from 6/24 unaided to 6/9 unaided, allowing the patient to continue as a truck driver.

Worth a Visit

AVC 2023 was a great meeting with a good mix of talks, presenters, workshops, and a large trade exhibition. There were many insightful polls and continuing professional development-boosting multiple choice questions, all managed via an app. The website and program were well designed and easy to navigate with easy access to recordings, including some virtual, online only talks available to registered delegates to view at their leisure.

AVC is well worth attending.

Save the Date

AVC 2024 will be held at The Gold Coast Convention Centre, April 6 – 7.