Sharpening Your Focus Australian Vision Convention 2024

The hybrid event, attended by 160 in person delegates and a further 200 virtual registrations, enabled industry colleagues and delegates to hear the latest on a diverse range of topics, explore new technologies in the large exhibition area, and catch up over breaks and cocktails.

Broad ranging, interesting plenary talks, and workshops – as well as breakfast sessions by platinum sponsors Bausch and Lomb and Johnson and Johnson, took place during the two-day weekend conference. Numerous, additional pre-recorded talks were also made accessible to all delegates.

The plenary talks were divided into themed sessions covering systemic conditions, paediatrics, anterior eye, therapeutics, retina, neuro-optometry, glaucoma, and ocular oncology – with useful information, groundbreaking developments, and many take-home tips and techniques discussed. The concurrent interactive Saturday workshops were well attended, covering subjects ranging from traumatic brain injury assessments and managing vision loss, through to wavefronts, diplopia red flags, swabbing for ocular pathology, and dry eye.

STROKE MANAGEMENT

In the opening plenary session covering systemic conditions, ophthalmologist Dr Anthony Fong (Southside Eye Centre, Brisbane), delivered a talk titled ‘Identifying the stroke patient – red flags and management’. He elaborated on the differentials between a stroke, otherwise known as a cerebrovascular accident (CVA) and a transient ischaemic attack (TIA). Stroke is the fifth leading cause of death in the United States, affecting 25% of the population by age 80. Without specific treatment, there’s a 10% mortality rate.

Fifty per cent suffer moderate-to-severe disability, with 25% dependent on others for daily activities. Acute therapy reduces disability by 7–13%, while 30% are more likely to have minimal or no disability at three months. Recurrent stroke rates are 2.5 to 4%.

There’s a difference between CVAs of the anterior and posterior circulation. The former affect memory, the face, upper and lower limbs (causing weakness/numbness), and cause aphasia and hemianopias. CVAs in the posterior circulation result in vertigo, nausea, vomiting, gaze disorders (nystagmus/horizontal gaze palsy), cranial nerve palsies, and ataxia.

Timing is critical. A stroke ideally needs medical intervention within four and a half hours, but there’s a range of timing for different issues, which he detailed via a treatment/timing flow chart.

We should remember the B.E.F.A.S.T acronym.

• B: Balance/’thunderclap’ headache/ dizziness.
• E: Eyes/vision.
• F: Facial weakness affecting lower facial symmetry.
• A: Arm weakness affecting ability to raise both arms.
• S: Speech problems.
• T: Time is of the essence – call an ambulance.

Dr Fong noted that central retinal artery occlusion (CRAO) is an ocular stroke, and elaborated on visual signs, vision loss, rehabilitation, TIAs, and other retinal branch occlusions.

DIABETES EYE CARE

In their talk ‘The diabetes lens: How to optimise your consults for people with diabetes’, Linda Karlsson and Neeta Oakley from Diabetes Australia, together with optometrist Jacinta Lok (Specsavers, Queensland), provided valuable insights into diabetes eye care. Like many, they stressed using considerate and inclusive terminology, so as not to define a person by their condition e.g. ‘a diabetic’, but as a person or patient with diabetes. Diabetes Australia sees optometrists as key members of the diabetes team, as they are accessible, knowledgeable, affordable, and have clinical skills to help prevent complications like vision loss. They emphasise to patients the need to see an optometrist.

Diabetes causes significant stress for sufferers: One in four feel overwhelmed, with difficulty keeping up with tasks, best treatment, blood sugar monitoring, eating correctly/ timing, managing medication, and insulin injections. Fatigue and finding time off work or in daily schedules to attend health checks, general practitioners, podiatrists, audiologists, optometrists, ophthalmologists, endocrinologists, educators, psychologists, dieticians, physiotherapists, dentists, and so on is also daunting. They are often lost to follow-up and can be non-compliant with treatment plans and medication. Significant expense in paying for all this care, as well as medication, special food, and supplies adds to the burden. Money worries can be an unspoken barrier to proper care. If unchecked, diabetes stress can lead to burnout and stopping glucose monitoring.

Ms Lok mentioned patient interaction issues, loss to follow-up and the importance of communication, understanding and compassion. Using our tools – like retinal images – to demonstrate the issues, and stressing, for example, attending ophthalmology referrals, is important. She mentioned that diabetes control can be “all over the place” over Christmas, Easter etc., and supporting patients to get back on track is helpful. Denial is also an issue to be addressed.

Keep the ‘three As’ in your frame of reference:

• Awareness,
• Ask, and
• Assist.

PAEDIATRIC CARE

In the paediatrics session, Sarah Coudrey (Clarity Optometrists, Brisbane) presented a valuable talk titled, ‘Contact lens fitting for all ages: paediatric tips and tricks’, with an overview of aspects of paediatric contact lenses including myopia and aphakia. She provided many useful tips for managing these patients – from a very young age until adulthood – as well as insertion and removal of contact lenses. Ms Coudrey recommended viewing rigid gas permeable contact lenses with sodium fluorescein, using a handheld blue light magnifier/Burton Lamp to visualise the fit in a natural posture, with the child sitting on their parent’s lap. A handheld autorefractor and fun fixation targets for retinoscopy are useful. She went on to present some interesting cases with ideal lens selection, to illustrate some of the points.

In ‘Paediatric presentations and management in optometry’, Elspeth Wrigley (also Clarity Optometrists, Brisbane) presented various tips for managing children, by age group and what we can achieve. She differentiated the potential pathways in managing congenital and acquired causes of oculomotor issues and reinforced the need to differentiate wide epicanthus from frank esotropia, or a Duane’s retraction syndrome from a tumour, and so on. Assessing the retinal red reflex is a simple but effective tool: leukocoria (a white pupil) may indicate retinoblastoma.

Courtenay Lind (Gerry and Johnson Optometrists, Brisbane) detailed ‘The optometrist’s role in the multidisciplinary assessment of a child with a learning disability’. Red flags include issues with listening, speaking, learning, writing, concentration, and cognitive function.

We need to determine if there’s an identifiable barrier, like an intellectual disability or other issues. A learning disability can be a diagnosis by exclusion. Autism spectrum disorder (ASD) diagnosis is increasing and is now as common as 1:100, with four times greater prevalence in males. It remains a lifelong condition. Early intervention is essential.

She covered various testing procedures including visual information processing, presented some interesting cases, and detailed Medicare codes for complex neurodevelopmental disorders.

ANTERIOR EYE

In the anterior eye session, ophthalmologist Dr Frank Howes (Eye and Laser Centre Gold Coast), delivered ‘The presentation, management and treatment of inflammatory disorders involving the anterior eye’. He elaborated on a classificational approach, and recommended avoiding preservatives where possible. He noted a trend toward using low dose eluting agents. In treating the uveal tract, systemic drugs or slow-release depot injections can be beneficial. In managing complex conditions, a practitioners’ comfort level, experience and scope are considerations. Refer when necessary!

Among interesting case presentations, he stressed the differentials in preseptal vs orbital cellulitis, which is much more dangerous and can potentially lead to meningitis and septicaemia, requiring rapid action. Scleritis can be linked to autoimmune conditions and needs in-depth investigation.

In ‘One size doesn’t fit all: choosing the correct refractive procedure for your patients’, Brisbane ophthalmologist Dr Cameron McLintock reviewed various refractive procedures illustrating a simple low myopia case where photorefractive keratectomy was ideal, while very high myopic astigmatism was best managed by an implantable collamer lens.

THERAPEUTICS

In the therapeutic session, Andrew Robinson (ICU Optometrists, Brisbane) delivered an informative and surprisingly humorous talk on ‘Maintaining your concentration: what strength atropine for myopia control?’, which can be a confusing and dull subject. His slide (Figure 1), shows some of the confusion surrounding atropine concentrations and results.

In summary he noted that atropine does work, however the effect is dose dependent, is likely age dependent, and probably does ‘boost’ other myopia controlling techniques. Side effects are dose dependent.

RETINAL CONDITIONS

Sunday kicked off with a retina session where ophthalmologist Dr Tom Moloney (The Eye Health Centre, Brisbane) presented ‘Inflammatory retinal conditions – unique diagnosis and treatment’. He covered various inflammatory conditions, discussing signs, referrals, testing, and treatment.

Sarcoid responds well to steroids. Behcet’s disease seems to be most prevalent in the Silk Road region of Asia, presenting with widespread retinal vasculitis. In rheumatology and immunology, steroids, and immunosuppression are the preferred treatments. In Vogt-Koyanagi-Harada (VKH) disease, anterior uveitis with mutton-fat keratic precipitates, granulomatous iris thickening, pupil block, and retinitis, are issues to be considered and dealt with.

Fluorescein angiography is a useful tool in many of these conditions. An indocyanine green (ICG) view of the retina helps define specific conditions, including VHK and Behcet’s.

Like Behcet’s, VHK needs steroids and immunosuppression, and management is complex.

Fortunately, these conditions are rare, but we need to know about them, as they’re not rare when they’re in your chair.

Associate Professor Abhishek Sharma (Brisbane Retina, Queensland Eye Institute) presented an engaging talk on ‘Macula matters: Insights into retina-vations – Retina update over the past 12–18 months.’ A drug that ‘controls’ geographic atrophy (GA) doesn’t usually improve visual acuity and can unfortunately induce wet/neovascular age-related macular degeneration (nAMD) in 10% of cases. He discussed disease progression, magnifying intraocular lenses, and photobiomodulation.

He provided a refresher and update on nAMD drugs and treatment regimens, noting that new drugs and higher doses may increase intervals between injections. A trial of an implantable ‘port delivery system’ with 36-week refills of an nAMD drug seems promising. These interesting developments surrounding implants – that deliver controlled, slow-release drugs – can also be useful for steroids and a variety of other drugs/conditions, hopefully leading to improved outcomes.

A diabetes patient with disc/macular oedema and haemorrhages – who started taking the antidiabetic drug semaglutide – appeared to undergo stabilisation of the retina. Will such drugs reduce diabetes-related retinal damage? Assoc Prof Sharma suggested referral to an endocrinologist if general practitioners are not proactive in diabetes care.

NEURO-OPTOMETRY

In the neuro-optometry session Dr Bao Nguyen (University of Melbourne) – one of only two interstate presenters – delivered an interesting talk on ‘What optometrists should know about visual snow’.

Visual snow has had very little exposure in the past. Patients were ignored and considered to be suffering from an imaginary condition. Interest in the subject has increased dramatically over the past decade. It’s now an accepted condition, is increasingly addressed, and no longer stigmatised. Around two per cent of people are affected. Ten to 50% report having visual snow ‘as long as they can remember’. It has varying severity, from ‘merely annoying’ to disabling.

She showed examples of how people describe it and likened it to the ‘snow’ seen on an untuned TV set in the old days. Dr Bao also differentiated and discussed entopic phenomena, psychoactive drug flash backs, and migraines. During a break, an animated optometrist told Dr Bao she at last understood that what she’s suffered from most of her life was in fact visual snow. It was a revelation.

Dr Bao also delivered the closing plenary talk, ‘A dementia-friendly future of eye care’, noting that 55 million people currently suffer from dementia. It’s likely to triple in incidence and is regarded as a terminal disease. Dementia is a collection of symptoms, which include cognitive, psychological, behavioural, and physical changes, caused by the degeneration of brain cells, leading to a progressive decline in function. Becoming more ‘dementiafriendly’ means recognising the impact, understanding its effect on a person’s needs, and developing a basic support plan. It ties in with optometry’s patient-centred, individualised approach, and values of inclusive, respectful, empathetic care.

After a busy lunch in the exhibition hall, the final sessions covered glaucoma and ocular oncology.

GLAUCOMA

Professor Graham Lee (University of Queensland) delved into ‘Glaucoma: simple or complex? When do I call for help?’. He presented some cases, including a primary angle closure glaucoma suspect, the relevance of shallow anterior chambers and narrow angles, and how to investigate and manage such cases, that can quickly turn bad. Prof Lee also showed correlation between field defects and nerve fibre thinning. He stressed, with supporting data, the importance of the water drinking test and its significant effect on intraocular pressure (IOP).

Michael Yapp (Centre for Eye Health Australia), the other interstate presenter, followed with ‘Xalatan is not working. What do I do next?’. He explained a step-by-step process on how to manage latanoprost cases if target IOPs are not attained, or if adverse reactions or progression is noted. With his usual animated approach, he detailed combination treatments, management of hyperaemia, and when to refer for selective laser trabeculoplasty. He suggested asking all patients on brimonidine about itching, and to evert their lids.

Ophthalmologist Dr Judy Ku (OKKO Eye Specialist Centre, Brisbane) joined Prof Lee and Mr Yapp virtually, for an in-depth panel discussion/Q&A. Dr Ku also presented ‘Secondary glaucoma 101 – tips on diagnosis and management’. She included a beneficial overview and a handy flow chart for classifying secondary glaucoma and went on to discuss pseudoexfoliation and pigment dispersion syndrome differentials, uveitis, diagnosis, and treatments (Figure 2).

It’s good to see that ‘preperimetric glaucoma’ is now being proactively treated, to prevent field loss and development of primary open angle glaucoma.

OCULAR ONCOLOGY

Ophthalmologist Dr Lindsay McGrath (Brisbane) presented the ocular oncology talk ‘Treatment of ocular tumours and effects of cancer treatment on the eye’.

Having provided an overview of immune therapy for cancer, she detailed her involvement in immunotherapy clinical trials for ocular melanoma, noting that 27% of trial patients were alive at three years, versus 18% in a control group.

Ocular side effects of immune therapy cancer treatments include uveitis, VKH-like serous detachment, papillitis, and diplopia/motility defects. In radiation therapy, side effects include blepharoconjunctivitis, telangiectasia, dry eye, madarosis, ectropion/entropion, nerve damage, cataract, retinopathy, and optic neuropathy. With topical chemotherapy we might see conjunctival hyperaemia, ocular irritation, corneal epithelial defects/ haze, keratoconjunctivitis, limbal stem cell deficiency, tearing, and pannus.

All things considered, AVC was a well-run and valuable conference, with thanks to the sponsors and exhibitors whose support makes these great conferences possible.

Alan Saks is a retired optometrist. He is the Chief Executive Officer of the Cornea and Contact Lens Society and a regular contributor to mivision.