Super Sunday A Standout Event

The Optometry Australia NSW/ACT Super Sunday conference has long been a platform that brings together individuals in the industry to discuss cutting-edge research, latest advancements in technology, and updates on best practices and emerging trends.

This year’s event, held at Doltone House against the glistening backdrop of Sydney’s sunny Pyrmont Bay in May, did not disappoint. From groundbreaking presentations to thought-provoking panels, and interactive Slido polls, the conference was a testament to the dynamic and collaborative spirit of the optometry community.

In this article, we delve into the key takeaways and highlights that defined this year’s conference, capturing the essence of clinically-relevant topics discussed by a stellar line-up of Australian and international presenters who continue to inspire and elevate the practice of optometry.

THERAPEUTICS UPDATE

Foods, Fads, and Supplements for Dry Eye

Kicking off the day’s discussions with a dive into dietary impacts on eye health, optometrist Adele Jefferies (Auckland, New Zealand) presented her insightful talk on ‘Foods, fads and supplements: What really helps your dry eye patients?’ Dry eye is an ocular surface disease, so topical treatment is essential, but nutrition can support underlying inflammation, with the emphasis being on omega-3 sources, fruit and vegetables, and a Mediterranean diet.

Ms Jefferies discussed metabolic deficiency in omega-3 fatty acids also known as “the good oil”, which can be a cause of chronic ocular surface inflammation. She recommended 1,500–3,000 mg EPA/DHA per day for a sustained period of at least three months in triglyceride form over ethyl ester forms as it is better tolerated with less gastrointestinal side effects.

Gamma linolenic acid – “the other good oil” – has anti-inflammatory properties, leading to improved tear film stability when combined with omega-3.

Ms Jefferies said it has been statistically proven that 15 mg/ day for 45 days showed improvements in symptoms, lissamine green staining, and ocular surface inflammation. Some reputable brands that offer third-party testing for purity and consistency include Lacritec and DryEye Forte. Ms Jefferies also took us through her experience in New Zealand of building confidence with oral therapeutics. She emphasised the importance of taking a comprehensive patient history before initiating oral therapies, which includes:

• Medical history: pregnancy/breastfeeding, alcohol, antidepressants, haematological disease, kidney/liver failure,
• Medications (including supplements and vitamins),
• Allergies and drug reactions,
• Review of systems, and
• Drug interactions.

Uveitis

Ophthalmologist Dr Richard Symes (Sydney) then offered vital insights into navigating ocular comorbidities in patients with a history of uveitis. He outlined the basic rules in uveitis. For acute anterior uveitis, if the patient cannot be controlled on three drops or fewer per day, then consider immunomodulatory therapy. Secondly, for uveitis requiring steroid therapy, aim to discontinue oral steroid altogether or at least lower the dosage down to <7.5 mg per day.

The Dry Eye Wheel

In a World Council of Optometry (WCO) initiative undertaken in partnership with Alcon and global dry eye experts, the TFOS DEWS II approach to dry eye diagnosis and management is presented in the form of the dry eye wheel. Professor Jennifer Craig (University of Auckland) used the dry eye wheel to explain how mitigation, measurement and management of dry eye disease can be achieved across a spectrum of simple and complex cases.

Simple treatment, starting at the bronze outer ring, entails mitigation or triaging for symptoms of dry eye and identifying risk factors. Measurement involves the ocular surface disease index (OSDI) survey and the blink test, which measures the time taken for a patient’s eyes to be uncomfortable between blinks. The mainstay treatment in this ring is artificial tears, along with blinking exercises, warm compresses, and lid hygiene. The inner silver ring for moderate treatment involves more careful differential diagnosis, measurement of osmolarity and slit lamp examination including tear breakup time (TBUT) and tear meniscus height. Management can involve in-office treatments such as intense pulsed light (IPL), low level light therapy (LLT), and thermal pulsation. Mitigation in the gold ring entails prophylaxis and review of the patient’s medications. Lissamine green and meibography can be included in measurement, along with considerations for punctal plugging in management.

Protocols for Prescribing Ciclosporin

Professor Stephanie Watson OAM’s (Sydney) talk on protocols for prescribing ciclosporin was insightful, encapsulating clinical trial evidence on topical ciclosporin in dry eye disease (DED) indicated through improvements in OSDI, Schirmer’s test, TBUT, and corneal staining. Currently, topical ciclosporin in Australia is available as Ikervis (PBS-listed), Cequa (PBS-listed), Restasis (special access scheme and authorised prescriber), and compounded ciclosporin (in concentrations of 0.02%, 0.05%, 0.2%, 0.5%, occasionally 1%, and rarely 2%).

Prof Watson reiterated the need to counsel patients that results may take one month to work and further improvements can be seen up to one year. Patients should be reassessed at least every six months and practitioners can communicate this to patients using the treatment graph available in the Save Sight Dry Eye Registry. Carol Nguyen (co-writer of this article) is fortunate to be working on this project alongside Prof Watson, collecting and analysing dry eye data as part of her final year optometry research project. The Save Sight Dry Eye Registry serves as a platform, delivering real-world evidence for tracking eye disease, interventions and patient outcomes. Clinicians can enter anonymised data on treatments and outcomes wherein the software generates graphs and reports illustrating individual patient journeys.

THE OPTOMETRIST’S JOURNEY: ALTERNATIVE PATHWAYS

Dr Daisy Shu (University of New South Wales, Sydney) began this session by sharing her journey on how a ‘cold email’ changed her pathway from being an optometrist in Australia to a Harvard researcher. Dr Shu addressed how she overcame challenges and learned new skills, redefining her career path as a researcher. During her PhD she had a supportive team and made lifelong memories on retreats playing beach cricket and bonding over a warm bonfire. In the final year of her PhD she reached out via email to a lab at Harvard that was similarly researching transforming growth factor beta receptors, asking if she could contribute to the research. To her surprise the answer was ‘yes’. Dr Shu discussed how her international career allowed for global perspectives on education and healthcare systems. Her experience debunked myths such as ‘you have to have prior research experience’ and ‘you have to be smart’ to do a PhD. Dr Shu showcased different pathways in optometry and encouraged us all to step outside our comfort zone and seize new opportunities.

Dr Matthew Wells (Sydney) then provided an insightful presentation on the importance of communication in improving collaboration between optometry and ophthalmology. Due to Australia’s ageing population, there is an increasing demand for optometrists and ophthalmologists and thus collaborative care. When referring a patient to the nearest public hospital, check there is an available ophthalmology unit. Dr Wells advised, “Don’t be afraid to make the phone call yourself ”. This ensures that the patient will be seen urgently, will be accurately diagnosed, and on the correct treatment pathway. Another key piece of advice from Dr Wells was to become familiar with the local ophthalmologists around you and their specialties so you know who to refer your patient to. Getting to know your local ophthalmologists by attending educational events in your local area or asking to sit in on a clinic will not only improve your knowledge and confidence when referring but also help to build a healthy relationship with someone you can easily turn to for advice.

Associate Professor Kris Rallah-Baker (Sunshine Coast) joined Super Sunday online to discuss how optometrists and ophthalmologists can work together to improve the delivery of eye care to Indigenous patients. He addressed the key barriers to accessibility of eye care and optometry services in rural, remote, and urban Indigenous populations. The four major causes of blindness in Indigenous people, in which optometrists play a vital role in screening for, are refractive error, cataracts, diabetic retinopathy, and trachoma. Optometrists who screen for these conditions relieve some of the ophthalmologists’ workload, enable patients to better understand their diagnosis, and help prepare the patient to travel to the hospital for surgical care. There has been great success in reducing the rate of blindness in Indigenous Australians. Prior to the Close the Gap campaign, the rate of Indigenous blindness was 10 times the rate of non-Indigenous however, this number is down to three times. Assoc Prof Rallah-Baker emphasised the key to successful delivery of Indigenous healthcare is collaborative care, relationship building, and trust.

CLARIFYING CONDITIONAL DRIVING LICENCES

Audrey Molloy from ONSW/ACT hosted a panel with Dr Sharon Oberstein (University of New South Wales) and Paula Katalinic (ONSW/ACT) to address common confusions when it comes to prescribing a conditional licence. To have an unconditional private licence in NSW, the patient must have:

• Uncorrected Visual acuity of 6/12 in the better eye or in both eyes,
• Binocular visual field which extends at least 110 degrees horizontally and 10 degrees above and below the horizontal midline,
• Cannot be functionally monocular (light perception or worse in the poorer eye), and
• No significant scotoma or non-physiological diplopia within a central radius of 20 degrees.

For a patient to be considered for a conditional licence, the patient must have a visual acuity of 6/24 in the better eye. When prescribing a conditional licence, Dr Oberstein discussed the importance of assessing contrast sensitivity. The Mars contrast sensitivity test is great because it is quick to perform and easy to interpret the results. Understanding a patient’s contrast sensitivity will tell you about their quality of vision rather than quantity, which is important when assessing their ability to drive at night. “Everyone’s vision is worse at night,” she said, so when it comes to a conditional licence the most common restriction is nighttime driving.

NEURO-OPHTHALMOLOGY

Facing the challenge of diagnosing headaches can be overwhelming, but neuroophthalmologist Dr Kate Reid (Canberra) led the afternoon session by offering valuable tips to recognise the red flags in dangerous headaches. Using timing, location and tells, Prof Reid distinguished life-threatening headaches from common headaches. She differentiated the headaches into four main categories:

• Lethal headaches: subarachnoid haemorrhage, stroke, traumatic brain injury, meningitis.
• Vision threatening headaches: papilloedema (fulminant idiopathic intracranial hypertension (IIH), tumour, thrombosis), optic nerve stroke, malignant hypertension, angle closure.
• Severe headaches: migraine, cluster headache, trigeminal neuralgia, ice pick pain.
• Common headaches: refractive, tension, referred (cervicogenic/sinus/ temporomandibular joint (TMJ)).

Dr Reid emphasised that life threatening and vision threatening headaches should be referred to emergency immediately. Severe and common headaches can wait to see the GP in a few weeks.

Dr Reid also delved into IIH. The most common cause of papilloedema is IIH, which is often accompanied by a ‘whooshing’ headache. When looking at a swollen disc, it is important to consider if it is actually papilloedema or if it is pseudopapilloedema, optic disc drusen or another type of optic neuropathy. Using multimodal assessment, such as detailed history and examination, optical coherence tomography (OCT) and visual field testing will facilitate the diagnosis of these conditions. Eighty per cent of IIH cases are not visually threatening and can be treated with medication and weight loss. Eighteen per cent of cases don’t respond to maximal medical treatment and require a procedure where a stent is placed. This leaves 2% of cases that are at risk of permanent vision loss, needing immediate intervention. Dr Reid highlighted the importance of visual fields to triage the different subtypes and identify visually threatening cases. A 30-2 visual field is the preferred visual field because for these patients, visual loss usually begins peripherally. “You can have a bad looking OCT and a bad looking disc clinically, but if the visual field is holding up then it is not a crisis,” she said.

GLAUCOMA: WHEN TO INITIATE TREATMENT?

Michael Yapp (Sydney) led an entertaining panel discussion filled with humorous jokes and playful puns for his session on ‘Initiating treatment in your glaucoma patients’. Accompanied by Sydney ophthalmologist Dr Katherine Masselos, and optometrists Siri Tang (Broken Hill) and Heidi Hunter (Newcastle), the panel gave insight on different approaches to managing glaucoma patients and addressed common questions such as setting target pressures, how to manage dry eye with glaucoma, and when to consider selective laser trabeculoplasty (SLT) as first line treatment. Dr Masselos explained that when it comes to setting target pressures in an advanced case, 30% may not be enough. “You should look at the age of the patient, severity of the disease and starting pressures”. All members of the panel agreed that the first choice of treatment is usually a prostaglandin as it is the most efficacious with minimal side effects and only one drop is required. However, it is important to consider if the glaucoma is unilateral or if there is any history of uveitis or macular oedema because in these cases you want to consider a beta blocker instead. The panel recommended that SLT is more suited to patients with a higher pressure who have not been on treatment for their open angle glaucoma.

CONTACT LENS SIDE EFFECTS

Returning for the final interactive session, Adele Jefferies tackled the challenges of ‘Managing the side effects of contact lenses’. She presented a series of case studies about contact lenses in children, focussing on myopia control lenses such as orthokeratology, before moving on to dispel the common misconception that allergies necessitate avoiding contact lenses given the association between seasonal allergies and giant papillary conjunctivitis.

Interestingly, daily disposables can play a role in the management of allergy-related eye irritation by reducing symptoms in allergy prone patients due to the barrier function. The importance of compliance with replacement should be stressed to the patient, and they should be advised to wait 15 minutes before lens insertion when co-currently using therapeutic agents. She also hinted that antihistamine-releasing contact lenses may soon become a part of our professional toolbox.

OCULAR ONCOLOGY MASQUERADES

Finally, the conference culminated in a dynamic interactive session with Professor Adrian Fung (Sydney) unravelling the mysteries of ‘Ocular oncology masquerades: it’s not melanoma!’. Peripheral exudative haemorrhagic chorioretinopathy (PEHCR), also known as peripheral choroidal neovascularisation (CNV)/age-related macular degeneration (AMD), is commonly seen in elderly patients and can be distinguished from choroidal melanoma as most melanomas do not bleed. Most cases can be monitored and treatment with anti-vascular endothelial growth factor may be needed if the macula is threatened.

Different presentations of congenital hypertrophy of the retinal pigment epithelium (CHRPE) were also investigated, including CHRPEs with hypopigmented areas of retinal pigment epithelium (RPE) atrophy within the lesion known as lacunae, and RPE hamartomas in familial adenomatous polyposis: ‘A typical CHRPE’ that presents as round or oval shaped with a ‘fishtail’ hypopigmented area at one or both ends. These entail a high risk for colon cancer and require referral for colonoscopy.

A SUPER SUNDAY

Following a jam-packed day of engaging presentations, panels and discussions, the curtains drew on another illuminating Super Sunday conference, leaving attendees to depart equipped with newfound and refreshed insights into the advancing field of optometry.

We would like to congratulate the team at Optometry NSW/ACT for another successful Super Sunday and are looking forward to being back again next year!

Carol Nguyen and Jennifer Doeur are in the final year of their Bachelor of Vision Science/Master’s of Clinical Optometry degree at the University of New South Wales. Ms Nguyen is currently working as an optical dispenser at 1001 Optometry in Bondi Junction NSW, and has special interests in myopia control interventions including orthokeratology, and also the management of dry eye disease. Ms Doeur is currently working as an optical dispenser at HCF Eyecare. She is particularly interested in contact lenses and ocular pathology.