Optometrists and Dispensers Combine for Historic WAVE

The hybrid event, in March, attracted more than 500 delegates attending in person or online from around the world.

Dr Craig Donaldson, Head of Strabismus Department at Sydney Eye Hospital, commenced the conference by sharing an array of clinical pearls on diplopia, a common presentation to optometrists.

He emphasised the importance of a good clinical history in a diplopia work up and reviewed the assessment and measurement of diplopia. Sinister signs to watch for include diplopia reported in children and vertical diplopia.

It is important to always ask about and document any headaches, pupil reactions, and signs of papilloedema. Dr Donaldson urged optometrists to refer urgently or review early when concerned, and to ensure a referred patient has been seen by following up.

Later in the day, Dr Donaldson returned with a presentation on ocular pain. He discussed conditions that can cause pain around the eyes including sinusitis, temporomandibular pain, optic neuritis, and trigeminal neuralgia.

Patients with cavernous sinus fistula will often have retro-orbital pain along with diplopia and reduced vision. This tends to present with a classic triad of pulsatile proptosis, orbital bruit, and chemosis, as well as dilated arterialised limbal and retinal vessels.

In the case of headaches, it is important to be cautious in cases of persistent or worsening pain, headaches upon waking, unexplained vision loss, accompanying neurological symptoms or, if there are signs of papilloedema, diplopia or visual field loss.

Dr Donaldson said a battery of tests, such as ultrasound imaging, optical coherence tomography (OCT), fundus autofluorescence, and the presence of spontaneous venous pulsation, can assist with differentiating papilloedema from other types of disc elevation such as optic disc drusen.

ALZHEIMER’S DISEASE AND THE EYE

Dr Flora Hui, Research Fellow at the Centre for Eye Research Australia, shared updates on Alzheimer’s disease and the eye. Currently, over 421,000 Australians live with dementia of whom up to 70% have Alzheimer’s disease (AD). With the ageing population, this number is predicted to rise, and optometrists are expected to see more patients with AD in practice over time. People with AD are more likely to have outdated spectacles and visually significant cataracts.

Dr Hui explained that although diagnosing Alzheimer’s can be challenging at present, accuracy is critical as misdiagnosis can lead to patients taking part in clinical trials or receiving treatment where it is not appropriate. Amyloid deposition in the brain is a hallmark of AD and there is evidence that pathological changes can precede clinical signs and symptoms by up to 20 years. There are advantages in looking for amyloid in the retina as it is an extension of the central nervous system. Using curcumin and a scanning laser ophthalmoscope has been shown to be promising in imaging retinal amyloid deposits in both animals and humans.

In optometric practice, Dr Hui acknowledged that clinical ocular signs in AD can be confusing. Studies suggest that macular ganglion cell inner plexiform layer thickness may be a biomarker, although superior retinal nerve fibre layer thinning and ganglion cell loss can be confused with glaucoma. AD can cause narrowing and increase tortuosity of retinal blood vessels. Although amyloid deposits can resemble drusen, they tend to deposit in the superior and inferior-temporal retina. OCT can help differentiate further, as amyloid deposits appear above the retinal pigment epithelium (RPE) as opposed to drusen which is sub-RPE.

There are a variety of resources available to optometrists for upskilling in the care of patients with dementia, including online courses and chairside references. Dr Hui urged optometrists to “focus on the person in the chair” when communicating with patients living with AD. She recommended optometrists use clear, direct language and to be aware of cognitive fatigue during exams.

AGE-RELATED MACULAR DEGENERATION

Associate Professor Zhichao Wu, Principal Investigator and Head of Clinical Biomarkers Research at the Centre for Eye Research Australia presented two talks on age-related macular degeneration (AMD). The first presentation focussed on early AMD and common biomarkers seen on OCT including drusen. Hyperreflective foci appear as wellcircumscribed, hyperreflective lesions above the RPE on OCT and are correlated with hyperpigmentation at the macula in 70% of cases. Reticular pseudodrusen (RPD) appear above the RPE as subretinal drusenoid deposits. OCT is important as RPD is missed in 50–75% of eyes when observing coloured fundus photographs alone. RPD is a risk factor for progression when seen in eyes of patients with choroidal neovascularisation (CNV) in the fellow eye, and is associated with impaired dark adaptation.

The clinical implications of these biomarkers include selecting appropriate review frequency, patient counselling, and clinical trials. Dr Wu shared results from the laser intervention in early stages of age-related macular degeneration (LEAD) randomised clinical trial, which assessed the safety and efficacy of a subthreshold nanosecond laser intervention for AMD. The study was conducted due to preliminary findings that showed selective injury to the RPE using a nanosecond laser triggered a beneficial healing response in the retina. Dr Wu said 292 participants with bilateral large drusen were randomised to receive either laser or sham in one eye in six-monthly intervals. An increase in late AMD progression was observed in eyes with RPD, whereas the opposite was seen for eyes without RPD.

A two-year follow-up observational extension study showed that there was persistence of potential beneficial effects in patients without RPD. Dr Wu’s presentation on late AMD emphasised the importance of using OCT in the monitoring and detection of neovascular AMD (nAMD). It is not infrequent for patients who have good vision and no obvious haemorrhages visible on fundus images to have changes on OCT including intraretinal cysts, choroidal neovascular membranes, RPE breaks, subretinal fluid, and subretinal hyperreflective material. Early detection is key as the presenting visual acuity at the time of intravitreal injections is highly predictive of long-term visual acuity in cases of nAMD.

Geographic atrophy (GA) refers to the complete loss of photoreceptors and RPE, resulting in increased signal transmission on OCT and increased visibility of the choroidal vessels clinically. Nascent geographic atrophy (nGA) refers to the earliest signs of atrophy development on OCT imaging, evidenced by the subsidence of the inner nuclear layer and outer plexiform layer or hyporeflective wedge-shaped bands. Intravitreal pegcetacoplan and intravitreal avacincaptad pegol have been approved for the treatment of GA by the Food and Drug Administration (FDA) in the United States. Both drugs have demonstrated slowing of GA growth rate in clinical trials. In the real world, a study reported that 14 eyes from 13 patients developed retinal vasculitis after pegcetacoplan treatment, an outcome that was not reported in trials. To date, there have been no cases of retinal vasculitis seen in trials or the post-marketing period for avacincaptad pegol. There is currently no outcome of either drug from the Therapeutics Goods Administration (TGA) in Australia, Dr Wu said.

GLAUCOMA AND MACULAR HEALTH

Dr Jeremiah Lim, Senior Lecturer at the University of Western Australia, delivered a presentation on the importance of macular health in glaucoma. Although the macula only accounts for 2% of the retina, more than 30% of retinal ganglion cells are in this region. The macular vulnerability zone (MVZ) is a high-risk inferior-temporal region where early damage can occur, thus it is important to take OCT scans of the macula in addition to the optic nerve for glaucoma patients and suspects. For optic nerve scans, one way to identify early signs of macular damage is to display nasal-superior-temporal-inferior-nasal (NSTIN) plots rather than temporal-superiornasal-inferior-temporal (TSNIT). Although it uses the same information, the configuration of results places the high-risk inferiortemporal area in the centre of the plot, making it easier to identify any signs of loss.

Current visual field paradigms and local ganglion cell displacement means that most ‘vulnerable’ parts of the macula can be routinely missed by the 24-2 test. Despite current grading scales, there is evidence to suggest that central visual field defects can appear in early glaucoma. Dr Lim explained that while the 24-2C visual field contains 10 extra central points and has been suggested to be equally sensitive in detecting the presence of a central defect, the 10-2 has shown better structure-function concordance. The 10-2 may be particularly useful in conjunction with 24-2 in cases where there is presence of macular structural loss, presence of a functional vulnerability zone, in myopic eyes or notching, and in patients with identified loss on 24-2 visual field testing.

Dr Hui returned in the afternoon session to share research updates on neuroprotection in glaucoma, which refers to the protection of neurons that are likely to be damaged in the disease. One challenge faced in this area is that it can be very difficult to quantify neuroprotection.

“Practice and technology are very good at detecting loss, but not so good at neuroprotection,” she said.

In recent years, scientists have explored the idea of supporting mitochondrial health and their function. Small clinical studies on neuroprotection supplements, such as certain antioxidants, have suggested positive results. A multinational clinical trial on the use of vitamin B3 (nicotinamide) is currently underway, and emerging studies on optic nerve regeneration and cellular reprogramming are expected.

OPTOMETRY AND DISPENSING COMBINED LECTURE

Nicola Peaper, National Sales and Professional Services Manager of Rodenstock Australia, delivered an interactive session to both optometrists and dispensers at a joint lecture. The seminar focussed on non-tolerance problems experienced by patients and a variety of cases commonly experienced in optometric practice were presented to delegates. Ms Peaper highlighted the implications of frame fit, wrap, and back vertex distance on inducing prism and power in spectacles. She reminded delegates about the importance of taking precise monocular measurements and avoiding practices such as averaging height measurements between eyes, as this could have significant visual implications for the wearer.

PAEDIATRICS

Presentations on Day Two started with a series of talks on children’s vision, presented by Dr Jennifer Simonson, Clinical Director at Boulder Valley Vision Therapy Center in Boulder, Colorado. Dr Simonson suggested implementing a history form to give to parents to submit prior to the appointment. It is crucial to engage the child during testing so having all history details beforehand means that during the visit, testing can commence straight away, Dr Simonson said. Clinical observations are important in testing children, as this determines the priority and sequence of testing. Completing more active components of testing at the start of the consult will usually yield better subjective responses from paediatric patients, and testing efficiency can be increased by doing a series of tests with a piece of equipment before moving to the next.

In addition to testing sight, Dr Simonson presented on visual processing, an integral part of functional vision. Visual performance not only involves the ability to see but also involves relating what has been seen to all senses and past experiences. Seventy per cent of children with learning difficulties have some form of visual impairment such as ocular motor, perceptual or binocular dysfunction. For example, words moving on page could be a fixation stability or diplopia issue. Thus, it is important to remediate visual problems with lenses, prisms, and vision therapy where appropriate. Compensatory accommodations such as enlarging print and increasing text spacing can also help children with vision difficulties.

MYOPIA

Dr SooJin Nam, Director of Eyecare Kids and Eyecare Plus, delivered a practical guide to paediatrics and myopia management. Dr Nam shared case studies of myopic patients with varying presentations and worked through patient management via an interactive session with the audience. Previous progression does not indicate future progression, Dr Nam said, and it is important to assess progression risk factors for individual patients such as age, binocular vision, ethnicity, family history, near work, and outdoor exposure when deciding suitable management options.

Dr Samantha Lee, Research Fellow at the Lions Eye Institute and the University of Western Australia, expanded on myopia further during her presentation on atropine for myopia control. She compared the populations and results of landmark trials including ATOM, LAMP, CHAMP, PEDIG and ATLAS studies.1 Speaking on the topic of weighing up risk of progression with risk of adverse effects, Dr Lee said “it’s very important to manage patient expectations”. Thinning choroidal thickness could precede myopia progression in children, which could be a sign to watch for in practice. There are a number of clinical trials on low-dose atropine that we can expect to see in coming years.

Mr Yapp returned to present on retinal complications of myopia. Pathological myopia refers to excessive axial elongation that leads to structural changes in the posterior eye that can lead to loss of best corrected visual acuity, of which posterior staphyloma is a hallmark feature. Mr Yapp acknowledged that imaging high myopes can be difficult, and mirror artefacts can frequently be seen on OCT. Reducing scan length or changing scan direction from horizontal to vertical can be helpful for capturing a better image.

The ATN classification system for myopic maculopathy, proposed by Ruiz-Medrano et al. (2018), has a high degree of agreeability between observers and considers atrophic (A), tractional (T), and neovascular (N) components of the disease. Atrophic can be seen as tesselated fundus, where there is increased visibility of choroidal vessels, diffuse chorioretinal atrophy, patchy, or complete macular atrophy. For tractional changes, Mr Yapp explained that the majority of myopic macular schisis, splitting within retinal layers, can be monitored. Referral should be considered for those with more severe macular involvement or progressive visual acuity reduction. In the ATN grading scale, foveoschisis can progress to foveal detachment, to a full thickness macular hole, and ultimately macular hole and retinal detachment. In additional to macular scans, Mr Yapp explained that OCT wide scans and scans around disc and vessel branches are useful to detect other myopic tractional changes not located at the fovea.

Neovascularisation in myopia commonly arises from patchy chorioretinal atrophy and lacquer cracks, which represent breaks in Bruch’s membrane. OCT shows Type 2 or classic CNV appearing as dome shaped hyperreflective elevations above RPE.

Regression of CNV can lead to pigmented scars called Fuch’s spots. One delegate described the series of myopia presentations as a good reminder of how optometrists can play an integral role in public health and reducing avoidable blindness through early intervention and prevention.

CONTACT LENS AND ANTERIOR EYE

Heidi Hunter, Principal Optometrist and owner at Custom Eyecare, delivered a presentation on contact lens drop out which she described as “like a leaky bucket”. Patients drop out for a variety of reasons, but ocular dryness, discomfort, and vision are commonly reported. Ms Hunter recommended taking a proactive approach in the consult room by asking patients about contact lens comfort and vision at the beginning and end of the day, to manage symptoms early and avoid patients ceasing lens wear altogether.

For distance- and near-centred multifocal lenses, Ms Hunter recommended advising patients to wear sunglasses when outside to increase pupil size for a larger distance zone and use bright task lighting, which causes pupil constriction, when reading to achieve better vision.

Ms Hunter presented a range of case studies to delegates, sharing her experiences working in an anterior eye ophthalmology practice, building trusted relationships with ophthalmologists, and instances where patients were referred back to optometry for further care. She shared cases where cosmetic contact lenses, high plus-powered soft contact lenses for aphakia, and bandage contact lens use for bullous keratopathy, have been life changing for patients. The cases highlighted the importance of collaborative care between optometry and ophthalmology to facilitate referrals, learnings, and better patient outcomes.

Dr Pav Gounder, consultant ophthalmologist, oculoplastic and orbit surgeon, presented on dermatochalasis and ptosis, two conditions that can affect the superior visual field. Patients with both tend to describe a heavy sensation, a forehead or brow ache that is worse at the end of the day. The margin to reflex distance is commonly used in the measurement of ptosis. As the onset of involutional or age-related ptosis is generally not acute, conditions such as Horner syndrome, myasthenia gravis, and third nerve palsy are important to exclude in acute presentations. Eyelid eversion is also important as ptosis may be caused by a foreign body or tumour. Dr Gounder shared various surgical videos of ptosis and dermatochalasis.

TRADE SHOW

The exhibitor trade show was popular with delegates and provided a wide array of suppliers and sponsors the opportunity to showcase their latest products and services. A competition boosted visits to trade show stands during breaks, and exhibitors were pleased with the engagement from both optometrists and dispensers.

WAVE is scheduled to return to the Fremantle Esplanade Hotel in 2025.

Jingyi Chen is an optometrist and a lecturer at the University of Western Australia’s Doctor of Optometry program. She is currently undertaking a PhD on rural and remote access to eye care.

Linden Sawyers has worked in the eye health industry for almost 20 years across both independent and corporate practices. She has been employed in the industry in both the United Kingdom and Australia and in 2015 became a dispensing partner in her current practice in Baldvis Western Australia.

Reference

1. Atropine for myopia control in children (ATOM); Lowconcentration atropine for myopia progression (LAMP) study; Childhood atropine for myopia progression (CHAMP) study; Paediatric Eye Disease Investigator Group (PEDIG); and the atropine treatment long-term assessment study (ATLAS).