Hosted by Optometry NSW/ACT, Super Sunday attracted 310 delegates, who came from every state of Australia as well as New Zealand.
The full day of conferencing kicked off with optometrist Lisa Jansen (Perth) who spoke about the foundations for building a sustainable career in optometry at a time when the profession faces an acknowledged over-supply. Ms Jansen covered off skill diversification, networking, financial planning, and the potential to embed artificial intelligence (AI) in day-to-day clinical work.
Visual Disturbances
The focus quickly turned to visual snow syndrome with clinician-researcher and optometrist Dr Bao Nguyen (Melbourne) “drumming in” the diagnostic criteria for this disturbing neurological condition, which was only formally included in the International Classification of Diseases in January last year. A review of cases of visual snow seen by neurologists found that ~40% of people reported either an inciting (‘triggering’) event or contributing comorbidity for their visual snow symptoms (e.g. epilepsy, psychiatric disorder, hormonal change, head injury), so it is important to ask questions that help identify whether there was one.1 Treating the inciting event/underlying cause may – or may not – resolve visual snow symptoms.
Given the visual nature of symptoms, and the long history of this condition being misunderstood and dismissed, optometrists have an important role in ensuring comprehensive eye examinations are conducted with appropriate referral to ophthalmology and neurology, providing reassurance and validation of the patient’s experience, and helping people understand when difficulties might arise or what might worsen their symptoms (e.g. driving at night, fluorescent or harsh lighting, poor sleep). Resources for patients and clinicians can be found at visualsnowinitiative.org.
Dr Nguyen returned to the stage later in the day to discuss visual disturbances associated with episodic migraine attacks, cerebrospinal fluid leak, and visual hallucinations in Charles Bonnet syndrome.
The burden of migraine is rising, with around 15% of the global population with the condition.2 The most common subtype is migraine without aura.3 For those who have migraines with aura, over 90% experience visual symptoms, normally before the headache phase3 – “almost like giving people advanced notice”.
Dr Nguyen said that people do not necessarily follow the ‘textbook’ descriptions of migraine visual aura, often described or depicted as ‘scintillating scotomas’ or ‘fortification spectra’. There are many more symptoms experienced by people with migraine with aura, including bright lights, fracturing, mosaic vision, tunnel vision, one or multiple scotomas, and tiny flickering dots like visual snow.4 If patients describe total vision loss in one eye only, this is not expected of a migraine and further work-up is required.
Even those who do not typically experience a migraine visual aura describe transient visual disturbances; e.g. phosphenes, scintillating scotomas, and general blurring of vision lasting from less than one minute to the entire duration of the migraine.
Vitreous Floaters
Retinal surgeon Dr Christopher Go (Sydney) spoke about managing “the uninvited guests in the vitreous” – i.e. vitreous floaters commonly seen in the clinic. Causes can be physiological, related to posterior vitreous detachment (PVD), or pathological; they are subjectively measured and tend to get worse with age.
Red flags for early referral for intervention include visual loss, a curtain or shadow over their vision, tobacco dust, and a retinal tear. Flashes of light may indicate progression of the condition, and patients should be educated to seek attention if their vision changes.
He focused his presentation on physiological and PVD-related floaters; “the annoying ones that you could leave – but could do something more about” to improve quality of life.
Benign floaters are non-sight threatening but they can affect quality of life – work, driving etc. Surgical intervention is available in these cases, and the strategy is determined by impact assessment: the number of floaters, their position, how often they are bothered by them and how quickly they go away, and how they affect work/driving.
The treatment options are A) conservative: reassure, monitor, and talk about oral supplements or B) interventional with laser or vitrectomy surgery. It’s a matter of weighing up risk vs benefit for the patient sitting in front of you.
YAG vitreolysis breaks floaters into smaller fragments away from the central field but does not get rid of them altogether. It is ideal for a patient with a central isolated identifiable floater. YAG could become part of a staged procedure with vitrectomy needed if the fragmented floaters still cause concern for the patient. Vitrectomy is the definitive treatment because it removes all the vitreous. Post-procedure, patients may still have floaters, they just won’t affect them as much. Vitrectomy does come with some risks, such as a retinal tear causing detachment and endophthalmitis; it is not suitable for patients who have ocular co-morbidities such as glaucoma or age-related macular degeneration. Setting expectations is key.
Novel Approaches to Ocular Surface Disease
Cataract and refractive laser surgeon Dr Kenneth Ooi (Sydney) spoke about novel anti-inflammatories and nanotherapeutics for the treatment of ocular surface disease.
Recent advancements in nanotechnology, biologic proteins, and targeted immunomodulators have initiated a shift from palliative lubrication toward disease modifying therapies that improve drug durability and effect.
He spoke about the barriers to topical drops: tear washout, enzymatic degradation and the epithelial wall, which mean <5% bioavailability of traditional drugs. Stinging, burning, and blurred vision are side effects, regimen complexity impacts compliance, and toxicity creates the need to “do better”.
Discussing current and emerging formulations, Dr Ooi said lipid nanoparticle technology offers a transformative approach to circumventing ocular barriers by stabilising the drug, extending residence time, and improving tissue penetration.
Prescribing Anti-Virals
Refractive surgeon Associate Professor Smita Agarwal (Illawarra) spoke about viral infections of the eye, differential diagnoses, and optometrists’ role in treatment. Common viral diseases of the eye include herpes simplex, herpes zoster ophthalmicus, keratitis, adenovirus, molluscum, and cytomegalovirus.
While patients will often visit a GP with an ocular infection/ red eye, she said optometrists are better equipped – with slit lamps, fluorescein dye, and the ability to perform ocular examination – to diagnose these conditions. Education is needed to ensure the public and GPs understand this.
While most herpetic viral infections resolve spontaneously, without treatment many can linger, causing corneal scarring or complications, and leading to visual disturbances. Timely management and appropriate treatment of viral infections, by an optometrist, if necessary in collaboration with an ophthalmologist, can prevent the unnecessary over-prescribing of antibiotics and long-term complications of the eye.
Associate Professor Smita Agarwal
The Emergence of Artificial Intelligence
A panel discussion on AI, chaired by optometrist Mark Koszek, with ophthalmologist Dr Simon Chen, CEO of Optometry Australia Mark Nevin, and optometrist/academic Judy Nam, all from Sydney, sparked the audience’s imagination.
Dr Chen spoke about his use of AI and AI scribes, specifically a system called i-scribe – not for diagnosis but rather for drafting clinical letters and patient records. He said using an AI scribe to manage this documentation has freed him to spend more face-to-face time with patients. While he keeps clinical and personal workflows separate, he noted that he also uses AI to draft his personal emails. “Eighty per cent of them are good enough to send without any editing,” he said, though he maintains oversight of the outputs. He added that patients “really like” to receive the summaries and advice he sends them immediately following a consultation.
Mr Nevin said optometrists have a dual responsibility to understand the fundamentals of AI technology, and duty of care for patient safety. He stressed the need to protect patient confidentiality by anonymising images and records and only using secure subscriber-based AI platforms, reminding optometrists of their duty of care to do so. Emphasising this, Dr Chen said “theoretically, if you upload a patient letter into ChatGPT, it could be reverse engineered and the patient identified”. And Ms Nam stressed the need to have written consent from a patient before you use artificial intelligence, including AI scribes.
Dr Nam said AI is proving instrumental in optimising practice management. “It can help you understand patient behaviour and manage that with, for example, reminders sent to those who are often late to appointments and administration associated with lens orders. It is also a useful clinical decision support for diagnosis, providing differentials, and patient communication/education.”
Mr Nevin said the “real challenge” with AI is not to get left behind. “AI can blur the boundaries between different healthcare professions – e.g. in dry eye care between optometrists, GPs, and pharmacists. We need to think about using AI to excel in service delivery – to revolutionissse the way we practise optometry and keep the patient base with us.”
On upskilling teams, he said people are already on the journey in terms of AI adoption. “You’ve got to meet your practice team where they are at – create a vision for what that future will look like – the way their roles will change – we’re a human-centred profession but AI will help and enhance the way you interact with patients.”
Referencing the uptake of technology like optical coherence tomography, Mr Nevin said, “optometrists have a solid history of adopting new technology, and AI will be no different”.
Paediatric Eye Health
Ophthalmologist Dr Craig Donaldson (Sydney) spoke about strabismus in children and when to refer. Describing the direct ophthalmoscope (DO) as “the most useful tool you have for examining children”, he said “it’s your friend – and the best way to assess red reflex, identify leucocoria, and assess pupillary function”.
While childhood strabismus is a topic that is “too enormous to cover”, he said many serious conditions can be identified (or ruled out) “within six minutes” by asking the following questions.
- Is it constant?
- Do they have diplopia?
- Is the child unwell?
- Is the red reflex normal?
- Is pupil function normal?
- Is there nystagmus?
- Is there limitation in eye movement?
Behavioural optometrist Melissa Allen (Sydney) continued the paediatric theme, covering off the importance of examining young children, and providing insights into how to build rapport with 2–5-year-olds, interact with parents, and take an age-appropriate history.
She said a pre-school eye examination is not just about whether the child in front of you has strabismus; it’s about determining how well they are using their eyes together. How a child moves their eyes tells us how they are collecting information about the world around us. Can they look, can they fixate and follow, and do they have full use of their eye movement? If not, “refer to a paediatric optometrist or ophthalmologist for sure”. With vision so integral to development, optimising eyesight is critical.
Her tips for a successful examination included getting a history completed online ahead of the consultation – this gives the clinical clues to look for and ask about.
Once the child is in the practice, time is the essence, concentration is fleeting, and emotions can change everything. Making the child in your room feel comfortable is essential for success. A play area, special place to sit in the consult room, and weighted sensory tools are particularly helpful for all kids and neurodivergent populations. Gamify the tests, match the task to the child’s developmental stage, have options and be flexible. Reschedule if necessary; never force an examination.
While Dr Donaldson put direct ophthalmoscopes on the pedestal, Ms Allen said, “your retinoscope is your power tool” (along with a DO, pen torch and mobile phone for consented photos that you can reflect on later).
“If you don’t use (a retinoscope), pull it out… the more you use it the more confident you’ll become… It will be particularly useful for non-verbal children.”
Christine Craigie Award for Distinguished Service
Optometry NSW/ACT President Tim Grant presented the Christine Craigie Award for Distinguished Service to Kyriacos Mavrolefteros, principal of You and Eye Optometry in Maroubra, Sydney.
Mr Mavrolefteros has spent over two decades providing outreach optometry across remote New South Wales communities, including Lightning Ridge, Walgett, Bourke, Cobar, and Brewarrina. Without his regular visits, residents in these areas would face road trips of four to five hours to reach the nearest optometrist in Dubbo. He and his wife Katerina, also an optometrist, have conducted approximately 150 clinic days annually, seeing around 1,200 patients each year.
Accepting the award, Mr Mavrolefteros paid tribute to the late Christine Craigie, who had been his clinical supervisor nearly 40 years ago, and acknowledged the Brien Holden Vision Foundation program pioneers who drove five to 10 hours to reach outback towns long before fly-in services became practical.
He also highlighted the importance of exposing students to rural and remote practice, having hosted dozens of preceptorship students from the University of New South Wales, Australian National University, and Deakin University over the years – several of whom have since taken up positions in regional practices.
With his children and their partners, and his grandchildren applauding him from the audience, Mr Mavrolefteros encouraged colleagues in the room to also consider volunteering their time to save sight in regional and remote Australia.
Christine Craigie award winner, Kyriacos Mavrolefteros (centre), with his family.
Dry Eye and IPL
Scientia Professor Fiona Stapleton (Sydney) outlined the mechanisms by which intense pulsed light (IPL) may benefit patients with meibomian gland dysfunction, including closure of abnormal telangiectasias, photobiomodulation, Demodex eradication, and meibum softening. She noted that while evidence supports improvement in tear break-up time, symptom outcomes remain more equivocal.
On patient selection, she advised that moderate rather than severe meibomian gland dysfunction, younger patients, those with lower initial break-up times and higher Schirmer readings tend to respond best. Around 20–30% of patients will not respond.
A standard protocol of four treatments fortnightly, followed by retreatment at six months, was recommended, with meibomian gland expression performed after each session. Treating beyond the lower lid improves outcomes, and combining IPL with low-level light therapy may offer a further 20% improvement across key measures.
Eye protection is mandatory for both patient and practitioner, with scleral shields preferred when treating closer to the lid margins.
Closing Out
Optometrist Michael Yapp (Sydney) had the tough job of bringing Super Sunday to a close. Equipped with dad jokes, competitions, and prizes, he spoke about the use of multimodal imaging and referral approaches when confronted with difficult cases, including optic nerve atrophy and epiretinal membranes.
On epiretinal membranes, he said architects, engineers, and tradies are often early to notice a change because “they’re always looking at straight lines”.
The majority of epiretinal membranes are idiopathic and initiated by posterior vitreous detachment. However, they can also occur secondary to other ocular pathologies, so it’s important to consider the cause. Carefully dilate the patient to ensure you’re not missing something. Contrast sensitivity may also provide more information on functional effects of the membrane and optical coherence tomography is critical to assessment. While a watch-and-wait approach can be taken, if the membrane causes significant blurring or visual distortion, surgery will be required. Ectopic inner fovea layers and disorganisation of the inner retinal layers indicate worse outcomes post-surgery.
Mr Yapp, who recently co-founded Access Eye Centre, a new collaborative practice in the inner Sydney suburb of Woolloomooloo, kept the audience’s attention right to the end with a series of interactive case studies.
Throughout the day, Audrey Molloy, Paula Katalinic, and Rebecca Tobias from Optometry NSW/ACT presented ‘Medicare Bites’. These short but punchy segments on claiming Medicare optometry items were well received by the audience.
Super Sunday was sponsored by Bausch and Lomb, Vision Eye Institute and the Australasian College of Optical Dispensing. There were 233 delegates from New South Wales, 14 from Australian Capital Territory, one from Northern Territory, 13 from Queensland, 10 from South Australia, seven from Tasmania, five from Western Australia, 24 from Victoria, and three from New Zealand.
References
- Mehta DG, Garza I, Robertson CE. Two hundred and forty-eight cases of visual snow: A review of potential inciting events and contributing comorbidities. Cephalalgia. 2021 Aug;41(9):1015-1026. doi: 10.1177/0333102421996355.
- Steiner T, Stovner LJ. Global epidemiology of migraine and its implications for public health and health policy. Nat Rev Neurol. 2023;19:109-117. doi: 10.1038/s41582-022-00763-1.
- Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211. doi: 10.1177/0333102417738202.
- Viana M, Hougaard A, Zecca C, et al. Visual migraine aura iconography: A multicentre, cross-sectional study of individuals with migraine with aura. Cephalalgia. 2024 Feb;44(2):3331024241234809. doi: 10.1177/03331024241234809.
