With around 2,000 delegates, the 55th annual Scientific Congress of the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) is one of the largest in Australasian eye care. And as Alan Saks reports, the Adelaide event was accompanied by an industry exhibition showcasing the latest intraocular lenses (IOLs), drugs, and equipment – including digital operating suites.
Of course, there were the usual posters, talks, and meetings, as well as a film festival and a sustainability initiative that saw the donation of more than 1,100 trees.
RANZCO Congress, held in November 2024, opened with an inspirational presentation by renowned environmentalist and Antarctic adventurer, Tim Jarvis AM, who told the incredible story of his expedition following in the footsteps of Ernest Shackleton across Antarctica.
Mr Jarvis’ messages were clear and pertinent to the audience: Pragmatic solutions to climate change and biodiversity loss, framed by ‘seeing is believing tangibility’ is key to getting people involved.
To succeed, we need a clear understanding of the mission, attention to detail, and we need to focus on the positives. Don’t ask colleagues to do things you wouldn’t. Break tasks down into bite-size chunks.
Pragmatic solutions to climate change and biodiversity loss, framed by ‘seeing is believing tangibility’ is key to getting people involved
The Dame Ida Mann Lecture
Professor Robyn Jamieson (Sydney) delivered the Dame Ida Mann memorial lecture. She and her team at the Sydney Eye Genetics Research Unit have studied novel genes, variants, disease mechanisms and the interplay between clinical phenotyping, the human genome project, and functional genomics. The resultant clinical trials and therapies now benefit patients and families: 12 patients have received gene therapy with improved vision and outcomes. Prof Jamieson detailed CRISPR gene editing and complex genetics relating to these cases.
Strategic Roadmap
Vision 2030 and beyond is RANZCO’s strategic roadmap for improving eye health outcomes.
Dr Kristin Bell (Hobart) explained that huge gaps exist in rural eye care. RANZCO’s strategic pillars to address this include collaborative care, paediatrics, diabetes, cataract, training, service, preventative care, sustainability, and digital and global eye health.
Dr Justin Mora (Auckland) covered the New Zealand (NZ) program, Te Kitenga Vision 2030 – Aotearoa. Twenty-three new retinal cameras are aiding detection of retinopathy of prematurity. With the higher incidence of keratoconus (KC) among Māori and Pacific Islanders, there’s a focus on treating younger people with corneal cross linking (CXL) to stabilise KC. Speeding up cataract surgery for drivers whose licences are under threat, is another goal.
Dr John Kennedy (Sydney) provided the Australia and New Zealand Eye Foundation (ANZEF) update. Three main objectives embrace growing the First Nations ophthalmology workforce, annual grants and specific projects – including covering central Australia and growing a Pacific education fund.
ANZEF is providing AU$141,000 and aims for 100 scholarships over three years for First Nations, Māori, and Pasifika ophthalmology scholarships.
Paediatric Imaging
Imaging in paediatrics provides accuracy, education, and confidence. It also augments diagnostic/prognostic acumen and streamlines referrals.
Orthoptist Katie Geering (Sydney) provided practical advice. The keys are to relax the child while demonstrating and explaining noises or light flashes. Relate the technology to a child’s interests. Holding a young child helps position them for ultra-widefield and general retinal imaging. They can come back another day if it’s too overwhelming.
Dr Caroline Catt (Sydney) shared tips on performing optical coherence tomography (OCT) in children. It can be tricky getting children to cooperate during binocular indirect ophthalmoscopy. OCT is fast and useful in detecting and monitoring retinoschisis, Stargardt disease, and differentiating optic nerve elevation. It can also be helpful in diagnosing disc drusen, optic neuritis, and paediatric glaucoma. She presented excellent cases and images, as did Dr Deepa Taranath (Adelaide) in her talk on fundus photography in children, illustrating colobomas, morning glory disc anomaly, and optic disc hamartoma. Imaging is invaluable when diagnosing and documenting cases of abusive head trauma where, Dr Taranath said, retinal haemorrhages are seen in 85% of cases.
She added that ultra-widefield fundus autofluorescence is most sensitive in detecting disease and shows 76% more abnormal peripheral findings than standard examination. It’s a precious resource in inherited retinal disease (IRD) and gene therapy.
Imaging refines many aspects of retinal disorders in children, reducing examination under general anaesthetic, and helps avoid local anaesthetics and dilating drops that can traumatise a child.
Professor Elise Héon, (Canada) also presented a variety of excellent cases and delivered the paediatrics update lecture. She was instrumental in implementing voretigene neparvovec, the first gene replacement therapy for retinal degeneration (RPE65 gene). By the end of 2024, 26 patients had been treated in their clinic in Toronto. Gene replacement therapy is a wonderful new era of medicine.
Imaging refines many aspects of retinal disorders in children, reducing examination under general anaesthetic, and helps avoid local anaesthetics and dilating drops that can traumatise a child.
Cataract Update
Professor Rosa Braga-Mele (Canada) delivered one of the most dynamic talks, highlighting one survey that found 51% of ophthalmologists reported neck or back pain. She suggested tilting traditional operating microscopes, rather than your head/neck. Evolving digital surgical platforms can greatly improve surgeons’ posture.
She detailed trifocal, small aperture, and extended depth of focus IOLs, as well as enhanced monofocals and blended vision. True accommodating IOLs could revolutionise outcomes. IOLs using a Galilean telescopic design can help low vision patients.
Fluidic control systems in phacoemulsification target 50% reduction in intraocular pressure (IOP) – to around 28 mmHg. Robotic operating systems show potential to be steadier than human hands.
Professor Rosa Braga-Mele (Canada) delivered one of the most dynamic talks, highlighting one survey that found 51% of ophthalmologists reported neck or back pain.
Thyroid Eye Disease
Dr Raymond Douglas (USA) presented on new therapeutic options for thyroid eye disease (TED). Teprotumumab is approved by the US Food and Drug Administration (FDA) and is awaiting local approval by the Therapeutic Goods Administration (TGA). High cost remains a barrier.
The audience was advised that TED is the most common cause of proptosis with a 6 to 8:1 female-to-male ratio. Ninety per cent of cases are hyperthyroid. Two-thirds of Graves’ disease patients develop TED within one year. Patients experience poor clinical outcomes and suffer fibrosis, proptosis, strabismus, and permanent facial disfigurement.
Dr Douglas detailed TED’s complex pathophysiology and showed how teprotumumab – a fully human monoclonal antibody – acts as an inhibitor of IGF-1R, blocking autoantibodies from attacking orbital cells at the disease source, reducing inflammation, and preventing excessive cell growth and hyaluronan buildup behind the eye. Long-term hearing loss in patients with normal baseline hearing following treatment with teprotumumab is 3%, but patients with baseline hearing dysfunction are at greater risk of hearing loss (20%). Audiology screening is essential in the work up and for monitoring.
Teprotumumab is effective initially in 80% of patients, and most dramatic in inflammatory muscle-predominant disease. In just a few years it has typically replaced surgical therapies,
Other TED sessions reinforced and expanded on the above. Professor Dinesh Selva (Adelaide) presented on augmented endonasal apical decompression and Professor Timothy Sullivan (Brisbane) discussed external orbital decompression. They showed dramatic videos of intricate surgical cases.
Biologic drug and decompression surgery provide similar levels of around 3–3.5 mm reduction in proptosis.
This is just the first wave. The therapeutic landscape has evolved dramatically.
Corneal Transplantation 100 Years On
Professor Charles McGhee noted that penetrating keratoplasty (PKP) is trending down as a variety of lamellar grafting techniques have evolved. A NZ study showed the ratio of PKP to lamellar grafts was approximately 50:50 by 2018. NZ National Eye Bank data revealed keratoconus as the leading indication for grafts (around 41%).
PKP accounts for around one third of transplants in the USA. Australian corneal graft registry data shows keratoconus penetrating grafts have around 90% long-term survival rates. Other conditions show significantly greater risk of rejection/failure.
CXL means less need for grafts with fewer severe cases. Population growth and increasing cataract surgery also influence graft trends.
Artificial endothelial keratoplasty utilises a 6.5 mm diameter, 50-micron thick, hydrophilic acrylic plate, and results in up to several lines improvement in visual acuity.
Dr Peter Beckingsale (Brisbane) noted that Fuchs’ dystrophy and endothelial failure were the most common reasons for endothelial grafts. He also discussed alternatives, such as rho kinase inhibitor for endothelial cell protection/division and the introduction of cultured human corneal endothelial cells.
Dr Mo Ziaei (Auckland) covered cataract surgery in post-keratoplasty eyes, which remains challenging.
Any degree of pre-op oedema is reason to pause. Central corneal thickness over 600 microns is worrisome. With less than 800 endothelial cells/mm, graft failure is probable, and inevitable if under 500 cells/mm.
He advised against IOL designs that induce aberrations/lower contrast sensitivity and to maximise treatment of myopia/hyperopia/astigmatism. Multifocal and extended depth of focus IOLs are not advisable for most keratoplasty patients. Pinhole and light adjustable IOLs have their place. Approximately one third of eyes have 5D or more corneal astigmatism. Realistic expectations, desired improved distance acuity, stable grafts, low levels of irregular astigmatism and those wishing to avoid rigid gas permeable lenses postop are potentially suitable candidates for toric IOLs.
He suggested aggressive management of inflammation with steroids, at least four to six times daily for several weeks, until all inflammation subsides, with frequent monitoring of IOP and graft clarity.
In the developing arena of cellular therapies for the cornea, Dr Jie Zhang (Auckland) explained the various sources of cells and techniques, including conventional limbal transplant of deceased donor tissue (requiring systemic immunosuppression), and conjunctival limbal autograft, which has risk for the donor’s healthy eye.
Cultivated limbal epithelial transplantation is the first stem cell-based therapy approved in the Western world. There’s momentum for mesenchymal stromal cell-based therapies, with tissue derived from adipose tissue, limbus, umbilical cord, and bone marrow. These can be differentiated into keratocytes, which can reduce/suppress inflammation and inhibit neovascularisation. There’s a bright future ahead.
Professor Gerard Sutton provided updates on the synthetic cornea, noting the need as 4.9 million people are bilaterally corneal blind, with 23 million unilaterally. Almost 13 million are on waiting lists for a transplant but only one in 70 will get one. Fifty-three per cent of the world’s inhabitants have no access.
Regenerative medicine and cell therapy are a future direction of healthcare, with the global cell therapy market projected at around US$36 billion in the near future. Cell therapy and 3D cornea printing remain in the limelight.
Prof Sutton sequenced the development pathway of cell therapy into five main areas, including single layer topical epithelia and endothelia, partial and full thickness bioengineered cornea implants, and purified human collagen. He described some of the challenges and complex processes required to create these different corneal tissues and multilayered structures.
Graduation Celebration
At the graduation ceremony at the Adelaide Oval, RANZCO President Professor Peter McCluskey recognised the many years of commitment college graduates had made saying, “you stand at the threshold of an extraordinary career…a specialist in the most intricate and essential senses… a discipline where the intricate dance of precision, skill, and compassion merge to impact the most fundamental human sense: sight”.
Thirty-nine doctors were proudly admitted as RANZCO fellows, and five trainers of excellence were recognised. Ten deserving leaders received college awards and medals in recognition of their distinguished and meritorious service.
Council Lecture
Sunday kicked off with the Council Lecture, ‘The wide world of uveitis’, delivered by Professor Justine Smith (Adelaide). She detailed three main types of uveitis, including infectious and non-infectious; the many causes, related conditions, and masqueraders, while dispelling a few myths. She detailed first-line conventional immunomodulatory drugs like prednisone as well as other options like methotrexate, mycophenolate, azathioprine, and ciclosporin, and biologics such as adalimumab, infliximab, and rituximab. Prof Smith cited a study group, where 78.2% supported uveitis inactivity of “three to four months” before cataract surgery.
Macular oedema and related retinal scarring are the major causes of vision loss in non-infective uveitis.
Focussing on infectious uveitis, she noted an alarming increase in ocular syphilis in men and women. Delayed antibiotic treatment may result in worse VA. Although syphilis is ‘the great masquerader’, 100% of 54 studied eyes had at least one retinal finding.
In the glaucoma update, Professor Jeffrey Goldberg (USA) covered developments including neuroprotection and neuroenhancement. Although reducing IOP remains core, neuroprotectors and enhancers play a role.
There’s a double-edged sword of detrimental reactive astrocytes (pro-inflammatory cytokines, oxidative stress, neurotoxicity) versus beneficial reactive astrocytes, (neurotrophic factors, proliferation, neuroprotection). He detailed the pathophysiology of optic neuropathies and the “canary in the coal mine”, where ‘off’ retinal ganglion cell (RGC) dendrites decay before ‘on’ RGC dendrites. A sensitive measure of change. Prof Goldberg mentioned a variety of trials, including neurotrophic factor eye drops and implants, synapse and cell death protectants, and visual and electrical activity promoters.
In the retina update lecture, Dr SriniVas Sadda (USA) detailed emerging functional/metabolic imaging such as multi- and hyper-spectral imaging, flavoprotein fluorescence imaging, fluorescence-life-time imaging ophthalmoscopy (FLIO), and optoretinography. He delved into dysfunctional mitochondria in the high metabolism retina and noted the value of FLIO in Alzheimer’s and plaquenil toxicity.
In management of complications relating to intravitreal injections (IVI) Professor Stephanie Watson (Sydney) detailed ocular surface issues and allergy in IVI and reactions to antiseptics like chlorhexidine and betadine.
She provided valuable tips on managing conditions and interactions. Topical steroids are great at reducing inflammation but use those that have the least effect on IOP. True iodine allergy is rare and is confused with contact dermatitis from anaesthetics and chlorhexidine. A skin prick test quickly provides answers. We should switch agents to avoid toxicity and use unpreserved eye drops, where possible.
Other presenters covered various aspects of IVI complications, noting that it’s the number one procedure in ophthalmology. Talks covered IVI-related posterior capsular tears, IOP issues, immune reaction side effects to specific anti-VEGF drugs, safer techniques for intravitreal dexamethasone injection, infective endophthalmitis, sterile inflammation, and macular complications.
Best Papers
The best paper presentations included the impact of baseline IOP on treatment response in the laser in glaucoma and ocular hypertension (LiGHT) trial comparing selective laser trabeculoplasty (SLT) versus medication. Dr Eamonn Fahy (Sydney) noted that prostaglandin analogue eye drops were more effective for baseline pressures under 22 mmHg, but SLT was more effective in higher pressures.
Dr Gareth Lingham (Perth) reported that basal cell and squamous cell carcinoma account for more cancer diagnoses annually than all other cancers combined, with a cost to Medicare of AU$127 million (in 2014). Cutaneous melanoma is the third most commonly diagnosed cancer in Australia where it has the highest incidence in the world. Ultraviolet (UV) exposure, male sex, increasing age, and fair complexion increase risk of all skin cancers, while melanoma risk factors include high numbers of atypical naevi, family history, and immunosuppression.
Nepal is self-sufficient in IOLs and corneas, with 25% of corneas provided to other countries.
The Final Countdown
The final day began with a moving talk from Dr Reeta Gurung (Nepal) who delivered the Fred Hollows Lecture. She had worked with Professor Hollows, and the Foundation helped set up the Tilganga Institute of Ophthalmology (TIO), where she is now the CEO. It has become a major centre for eye health in the region – with 40 ophthalmologists at the main centre and three secondary hospitals covering a wide range of services. Its IOL manufacturing plant produces top quality, low cost IOLs, increasing IOL use in Nepal from 25% in 1994 to almost 99.5% in 2008. Melbourne’s Royal Victorian Eye and Ear Hospital had been a great help in training ophthalmologists, but today 50–60 ophthalmologists are trained annually in Nepal, as well as nurses, assistants and optometrists. Nepal’s prevalence of blindness has reduced from 0.81% in 1980/81 – where cataract was the cause of 72% of blindness – to 0.3% in 2010.
Nepal’s eye bank harvests over 1,500 corneas yearly, supplying tissue to corneal surgeons throughout the country, to address what is the second major cause of blindness in the nation. Nepal is self-sufficient in IOLs and corneas, with 25% of corneas provided to other countries. Solar power provides environmental sustainability, saving money and 28 tons of CO2.
In the Australian Vision Research plenary sessions, optometrist Dr Carla Abbott (Melbourne), discussed electrical stimulation to improve gene therapy efficiency via adeno-associated virus therapy, where an adenovirus is used as a vector to deliver the gene therapy via IVI. Research findings showed that electrical stimulation can improve efficacy.
In preventing misdiagnosis of inherited retinal diseases (IRD), Associate Professor Heather Mack (Melbourne) showed how IRD mimics geographic atrophy (GA), with a similar appearance. Gene analysis is needed to confirm, so arrange genetic testing if seeing “atypical” age-related macular degeneration (AMD). In practice, there’s a low rate of missed IRD among GA patients of around 1%, but if you miss the IRD you also miss the syndrome with potential medicolegal issues.
Prof Sadda delved into vitelliform lesions and when to suspect an IRD, noting the need to differentiate from toxic retinopathy and other conditions.
Several conditions that can be mimickers of IRD present with similar lesions, such as AMD, pachychoroid disease, vitreomacular traction, and drug toxicities. He illustrated the differentials with superb imaging.
Young onset, bilateral cases and family history are indicators that it’s an IRD. Genetic testing is the best strategy.
RANZCO featured dozens of other lectures in a variety of rooms covering the full gamut of ophthalmology from strabismus to AMD/GA, vitreoretinal, refractive surgery, oncology, infections, neuroophthalmology, controversies, coaching, performance, cybersecurity, cashflow, borrowing, continued professional development, cardiopulmonary resuscitation, and more.
Delegates can view selected recordings of plenary talks missed when attending other sessions or as a refresher at ranzco2024.com.
Congratulations to the organisers for a well-run event.
Alan Saks is a retired optometrist. He is the Chief Executive Officer of the Cornea and Contact Lens Society of Australia, and a regular contributor to mivision.
