Around 1,500 attendees and a further 240 virtual delegates attended the Congress, also taking the opportunity to peruse 141 exhibition stands supported by 60 exhibitors, as Alan Saks reports.

PLENARY SESSIONS

Six hundred and sixty delegates attended the opening RANZCO plenary session in October, featuring an impactful talk, ‘Against all odds – the story of the 2018 Tham Luang cave rescue’, by renowned adventurer, Dr Craig Challen SC OAM.

He focussed on leadership in challenging environments, emphasising effective communication, trust, adaptability, and resilience, while maintaining a calm and composed demeanour in stressful circumstances. He drew parallels to the challenges faced by medical professionals and explored critical decision-making processes, emphasising the need for a thorough assessment of risk, quick thinking, and making calculated choices when lives hang in the balance.

Doctors Kristin Bell (Hobart, Australia) and Justin Mora (Aotearoa/New Zealand) provided updates on RANZCO’s Vision 2030 and beyond program, covering Aboriginal and Torres Strait Islander, and Māori and Pasifika communities respectively. Launched in 2020, the goals are to enhance equitable service provision by developing and maintaining a sustainable, well-distributed ophthalmology workforce, eliminating avoidable blindness, and ‘closing the gap’. They noted the challenges: shortages of staff, funding, and resources, but acknowledged the efforts of all concerned.

Dr Mora noted the benefits of increasingly partnering with optometry to improve service delivery and reduce delays, including six-week cataract post-op checks, collaborative care in glaucoma, refraction, myopia management, screening for age-related macular degeneration (AMD), diabetic retinopathy, and keratoconus, which has a higher prevalence in Māori and Pacific Island communities.

Dr John Kennedy (Sydney, Australia) presented an update on RANZCO’s philanthropic arm, the Australian and New Zealand Eye Foundation (ANZEF), including key initiatives, grants, regional programs, and scholarships to grow the First Nations ophthalmology workforce. To close the gap, you have to put Indigenous health in Indigenous hands, he said. First Nations patients are more likely to access medical care when it’s provided by First Nations doctors, within a culturally safe healthcare setting. He described Dr Kristopher Rallah-Baker – Australia’s first and only Indigenous ophthalmologist – as a trailblazer and inspiration. ANZEF has developed scholarships through an Aboriginal and Torres Strait Islander Ophthalmology Vocational Training Program (VTP) where VTP trainees receive AU$30,000 towards the cost of their five-year training program, along with other incentives. Forty applications, totalling $1.47 million have been received, but only $185,000 in grants have been delivered so far, due to limited resources. ANZEF is continuing its attempts to raise funds and recruit student doctors into ophthalmology.

Dr Jennifer Arnold (Sydney, Australia) delivered the 2023 Council lecture, during which she illustrated how clinical research can be combined within everyday ophthalmic practice. Varying methodologies and the gradual evolution of knowledge modify patient management. Through excellent images and comparison of strategies for acute and chronic phases/conditions she detailed multimodal imaging in diagnosis, classification, and management. She presented examples such as reticular pseudodrusen (RPD), macular neovascularisation, and photodynamic therapy in central serous chorioretinopathy. Refinements in management of neovascular AMD, from clinical trials to clinical practice – through real world evidence, showed the effect of different drug therapies when fluid was present. She elaborated on how colour fundus images, optical coherence tomography (OCT) and en face technology can be used to define subretinal changes, phenotypes, and RPD.

RPD is more prevalent than we think, affecting 13–18% of people over age 75, rising to 35–50% of those over age 85. It increases the risk of AMD in fellow eyes of AMD sufferers, as well as a likely increase in geographic atrophy.

CHANGING GEAR

Professor Shigeru Kinoshita (Japan) presented the Sir Norman Gregg lecture, ‘Toward corneal regenerative medicine’.

He focussed on novel cultured human corneal endothelial cells (CHCEC) and detailed the process of the injection of CHCEC, with Rhoassociated protein kinase inhibitor (ROCK) into the anterior chamber. CHCEC repopulates the corneal endothelial layer, improving corneal deturgescence (reducing oedema), and restoring normal function and clarity. He also discussed treatment for early-phase corneal endothelial disease using ROCK-based eye drops, which have proved effective in treating partial endothelial dysfunction.

Prof Kinoshita showed some impressive images illustrating dramatic reductions in corneal swelling, e.g., 964 microns to around 540 microns, maintained at one, five, and nine years; hazy corneas showed remarkable improvement in clarity within two months post-op.

In her glaucoma update talk, ‘Making blebs beautiful again: insights into collagen remodelling and the future direction of anti-fibrotic strategies’, Professor Tina Wong (Singapore), cited Aulus Cornelius Celsus’ tetrad from 1AD, which described the signs of inflammation (rubor, calor, tumour, and dolor). If such inflammation is not checked, it ultimately leads to function laesa (loss of function). She detailed the more recent history of the 60-year war on scarring in glaucoma surgery, citing the development of modern trabeculectomy in the 1960s, and adjunctive use of fluorouracil and mitomycin C, for improved outcomes. A major issue with trabeculectomy is wound healing. Prof Wong considered a healthy bleb versus long-term topical intraocular pressure (IOP) control, saying she uses both for best outcomes. Bleb forming surgery remains an important option for achieving target IOPs of low teens to single digits. Minimally invasive glaucoma surgery (MIGS) devices enhance surgical options. She mentioned the Molteno cocktail: colchicine, prednisolone, NSAID (diclofenac), and the role of systemic suppression of immune response to local injury, as well as valproic acid as a collagen architecture modulator. Future strategies for inhibition of fibrosis include harnessing the immune system and restoring normal tissue health and architecture.

Associate Professor Fred Chen (Perth, Australia) delivered the Retina update, ‘Deep phenotyping, pitfalls in pivotal trials and precision genetics.’ He noted that geographic atrophy (GA) is thought to affect around eight million people, representing around 20% of AMD sufferers.

He detailed the complexities of genetics and how this influences GA, AMD and tumours, noting the importance of large datasets and deep learning in the analysis of multimodal imaging. Current treatments for GA were discussed and he noted, disappointingly, that two years of complement factor inhibition treatment had minimal impact on visual acuity decline in GA. New methods of drug delivery for AMD, diabetic macular oedema (DMO) and macular telangiectasia type 2, as well as personalised gene therapy were detailed. Additionally, he covered circulating tumour DNA in the management of choroidal melanoma, the Australian led development of antisense therapy for retinitis pigmentosa type 11, and the role of full-field stimulus threshold measurement in comparing outcomes of different drug and treatment research.

Multimodal imaging and molecular genetics are now the standard of care in ocular oncology and retinal dystrophy diagnosis and management.

BOOTCAMPS, WORKSHOPS AND MORE…

Experts from Australia and New Zealand delivered a valuable uveitis bootcamp titled, ‘Everything you need to know to confidently manage uveitis as a comprehensive ophthalmologist’. Useful tips were offered on what tests to do and avoid, making the correct diagnosis, and how to best treat the different presentations/causes of anterior and posterior uveitis. They delved into the immune system, inflammation, viral, bacterial, and autoimmune causes. The importance of raised IOP and progression to glaucoma were covered, as were OCT, visual field testing, and co-management with glaucoma specialists. Avoid pilocarpine (it might aggravate/cause uveitis) and avoid laser in active phases. MIGS devices can become blocked by inflammatory cells, so are not indicated.

Uveitis sufferers are likely to develop cataracts earlier, adding risk with more complex surgery, floaters, early presbyopia, cystoid macular oedema, recurrence of uveitis, and posterior capsule opacification. A panel discussion, along with further in-depth presentations, covered a variety of cases and drug management.

Glaucoma was further dealt with by speakers and a panel of experts from Australia, New Zealand, and Singapore, in the ‘Australian New Zealand Glaucoma Society symposium and audit – controversies in glaucoma’. Topics covered included when to refer to a glaucoma specialist for poorly or uncontrolled IOP, which was explained with detailed cases demonstrating visual field (VF) progression and management. More frequent VF testing is indicated to detect progression sooner. The benefit of selective laser trabeculoplasty (SLT) was discussed. SLT may be the primary choice, then drops, and finally surgery. It was concluded that trabs and tubes have similar IOP lowering capability, and both have failures. The trab pathway has more options, is more cost effective, and does not reduce the success of a subsequent tube.

The actions, pros and cons of different drops, and combination therapy were covered. There’s a drop-related increase in meibomian gland dysfunction and it may be best to avoid preservatives, especially benzalkonium chloride. When considering peripheral iridotomy (PI) versus cataract surgery to manage IOP, lens extraction may be advisable for anyone with angle closure disease. PI reduces the risk of primary angle closure. MIGS can be combined with cataract surgery to manage IOP reduction. Build rapport with patients, it wins their trust. Take your time, discuss options/pros/cons of drops, cataract surgery, SLT, PI etc. Let the patient have their say in the decision. If a patient is tolerant and well managed with one drop, then no other options are needed, unless things change.

A NEW DAY

Dr Anthony Bennett Hall (Newcastle, Australia) delivered the Fred Hollows Lecture, ‘Preventing blindness from diabetes in lowand middle-income countries – The Diabetic Retinopathy Network (DR-NET)’. With his extensive experience in Africa, he noted that the number of people with diabetes mellitus in sub-Saharan Africa (SSA) is projected to increase to about 47 million by 2045 (19.4 million, 2017) with global projections of 629 million by 2045. Diabetic retinopathy (DR) will increase proportionally. Health systems across the African region must prepare for the growing burden of non-communicable disease. There are very few screening programs in SSA. It’s frustrating and challenging getting people diagnosed with diabetes to attend DR screening programs; as many as 50% do not attend. DR-NET collaborates with various bodies and runs dedicated free training programs. It’s hoped that mobile autorefractors, portable cameras and artificial intelligence-enhanced screening will help, along with mobile clinics and dietary education.

Professor Neil Miller (USA), a godfather of neuro-ophthalmology, delivered a standout talk, ‘Neuro-ophthalmology updates: information that will change your practice tomorrow!’ He used detailed cases to illustrate his points, the first being that acute optic neuritis (ON) is not simply typical/ atypical, and that the notion of idiopathic ON should be thrown out. He mentioned that these may be related to neuromyelitis optica or anti-AQP4 (auto-antibodies against aquaporin 4) and anti-MOG (where the immune system mistakenly attacks myelin oligodendrocyte glycoprotein or MOG), related to chronic relapsing inflammatory optic neuropathy – apart from the more commonly understood causes of ON. He stressed treating all ON patients with high dose steroids unless due to a proven infective cause. Next, he described a case of primary pseudotumor cerebri, also known as idiopathic intracranial hypertension, advising to do nothing if there is no headache/mild papilloedema, or prescribe analgesics for headache (mild papilloedema only), then consider high dose acetazolamide. Weight loss – possibly with bariatric surgery – remains a cornerstone of treatment, along with sleep apnoea management.

Whereas historically we might have assumed a patient with visual snow was ‘nutty’, this condition is now recognised as real, benign, and organic. We should acknowledge that the patient is not ‘crazy’ and will ‘not go blind’ from its effects. Consider lifestyle modification (e.g., dull paper, tinted glasses, reduced ambient brightness). There is inconsistent benefit from medication. Refer to a neurologist where appropriate, or if the patient so desires. In another talk, Prof Miller discussed post-cataract surgery anterior optic neuropathy and the need for counselling for fellow-eye cataract surgery where this had previously occurred.

In the Australian Vision Research (AVR) plenary, an expert panel and presenters delved into some interesting topics. Associate Professor Michele Madigan (Sydney, Australia) delivered an enlightening talk, ‘Emerging from the darkness: cells in the choroid that detect light?’ She mentioned many types of opsins, some recently detected and discovered. Other speakers dealt with topics as diverse as choroidal tumour margins while another looked into myopia in children and asked whether it could be a result of inadequate melatonin production and circadian rhythm dysfunction. Another talk covered ‘Preventing glaucoma blindness – a new drug to control postoperative scarring’. In a later AVR Best Paper talk, ‘Visual field loss and crash risk: A population-based study’, Dr Siobhan Manners (Perth, Australia) showed an 84% increased risk of crashes associated with visual field loss (see page 24 of this issue for further details). There were many other complex and interesting AVR best papers presented.

BUT WAIT, THERE’S MORE…

The, ‘What did I miss that I really need to know today!’ session covered many of the sub-specialties in ophthalmology, elaborating on some of the issues reported in previous talks as well as a number of other innovations that ophthalmologists should consider including in practice.

Professor Kathryn Burdon (Hobart, Australia) delivered The Dame Ida Mann memorial lecture on ‘Why is my child blind?’ Genomics provides the answers patients and parents seek. She shared amazing insights into the complexities of the human genome and genetics and understanding/managing related conditions. There are now genetic therapies available and in clinical trials. Early intervention is important. To make genetic testing comprehensive, we need to discover all the genes that cause disease and understand the effects of variants in those genes. In paediatric cataract, 50–60 related genes have been discovered but there are likely hundreds. Prof Burdon presented a case of a family that had lost a child to Nance-Horan syndrome. Genetic counselling/testing/scanning led to early termination of another pregnancy. The family subsequently underwent in vitro fertilisation, resulting in a healthy child.

Refractive laser and cataract surgery were well covered throughout the conference. In the ‘Cataract update’ lecture, surgeon Mr Vincenzo Maurino (UK) shared insights into ‘Challenging cataract surgery and new trends in cataract surgery’. He covered management strategies in zonulopathy, the benefits of capsular tension rings, and shared financial and practical benefits of the emerging trend toward immediate sequential bilateral cataract surgery (ISBCS), which he predicts will become the norm, with minimal risk compared to sequential cataract surgery. Additionally, he discussed extended depth of focus intraocular lenses (EDOF IOLs) and management of IOL opacification.

Mr Maurino joined Professor Graham Barrett on his home turf, along with the rest of the Australasian Society of Cataract and Refractive Surgeons (AUSCRS) team in presenting the AUSCRS Symposium 2023. They covered important aspects of patient counselling, planning, biometry, calculations, formulae, astigmatism, intraoperative tips, presbyopia, and keratoconus with much valuable Q&A and panel discussion.

In the ‘Refractive update’ lecture, Professor Dan Reinstein (UK) covered, ‘What innovations is a practice offering to be at the forefront of refractive surgery?’ He discussed a form of modified, binocular, laser blendedvision, where induced spherical aberration is used to create overlapping intermediate vision between the dominant distance enhanced eye and the near enhanced eye. Additionally, he covered fine tuning implantable collamer lens (ICL) implantation and management, including the use of AS-OCT data for ICL sizing via formulae, as well as updates for small incision lenticule extraction.

An ‘Update of common paediatric conditions for all ophthalmologists’ covered aspects of the ophthalmologist’s role in myopia management, the language-based nature of dyslexia, retinopathy of prematurity, eyelids, (including lagophthalmos and ptosis), allergic conjunctivitis (whether immune therapy should be considered) as well as the assessment of optic nerves in kids.

Myopia received further, broader coverage, in the ‘Myopia: General and retinal management’ session. Presenters covered causes, risk factors and management, as well as surgical, medical retina and cataract surgery implications, including post refractive surgery eyes. Time spent outdoors is important. Data from the posterior cornea in post refractive surgery IOL calculations helps improve refractive end points. Multimodal imaging is important in classification of conditions like posterior staphyloma and myopia maculopathy, monitoring and management of complications.

SUMMING UP

Throughout the Congress, there were dozens more excellent talks for ophthalmologists, support staff and managers, as well as business and committee meetings.

In the exhibition area there were interesting lunch time talks, a film festival display, and well-attended poster sessions, all encouraging plenty of interaction and discussion. The many fantastic instruments on display were demonstrated by industry specialists, with presentations and a variety of surgical simulators at exhibitors stands.

Visit ranzco2023.com for program details, award winners and more.

All in all, RANZCO 2023 was well organised, with a diverse program, in an excellent setting, where sustainability also featured. Don’t miss the 55th RANZCO 2024, Adelaide, 1–4 November 2024.

You won’t be disappointed!