Jul 2016

The wider world of
medicine and optometry
If quick-fire presentations, good food and great
wine are your thing, then the Eye Institute’s
education seminar on 24 May certainly
delivered. With more than 145 attendees and eight
speakers, the evening was a lively start to the Eye
Institute’s annual seminar series. The focus of the
first meeting was on applying evidence-based
medicine to everyday optometry practice.
Optometry and GPs
Dr Shanu Subbiah, who recently welcomed
his second child into the world, took the stage
first with a look at the relationship between
optometry and general practice. Does your
patient’s GP need to be involved in their eye
care? When is it prudent to get them involved?
And what role should they take? These were all
questions Dr Subbiah addressed, reassuring the
audience that patient care is teamwork, and the
GP often plays a central role as the conductor,
curating the flow of information. “Many
ophthalmic diseases can have underlying systemic
pathology,” he said. “Often these conditions can
be treated more effectively by the GP.”
His presentation provided a summary of systemic
conditions to watch out for, such as macular
degeneration, when early referral to the GP is
essential to optimise patient care within the
multidisciplinary team.
Five scary things and the optic nerve
Professor Helen Danesh-Meyer stepped up next
to talk us through “five scary things” in relation to
the optic nerve. Using a series of images, Professor
Danesh-Meyer challenged the audience to identify
the nerve problem. She focused on signs of optic
nerve head morphology to assist in determining
the underlying cause of the optic nerve disease
and the appropriate management strategy. Key
takeaways included the need to run visual field
tests, to take care to focus on the rim and to
remember that all patients will have different size
eyes naturally.
Zika virus update
Dr Peter Ring gave us an interesting update on the
Zika virus, which was first identified in 1947 in the
Zika forest in Uganda. Since 2007, Zika has become
a common word in our language as outbreaks
of the once rare virus continue to occur globally.
Symptoms include rash, fever, achy joints and nonpurulent
conjunctivitis. They can often be mistaken
for other, more benign illnesses and the symptoms
resolve within seven days but can lead to Guillain–
Barré syndrome (in rare cases) and microcephaly
in infants when a mother becomes infected
during pregnancy. There is a third complication for
optometrists and ophthalmologists to be aware
of and that is chorioretinal atrophy and optic
nerve abnormalities. Studies are currently being
undertaken, using blood extracted from infants
with microcephaly and chorioretinal atrophy, to
establish the link.
Cross-linking shared care
Dr Adam Watson’s topic was cross-linking (CXL),
which usually involves removal of a broad area
of corneal epithelium followed by application of
riboflavin and ultraviolet light energy. “Shared care
of patients following CXL is common,” he said. “It
is important that the optometrist is aware of the
normal course of healing, what topical medications
are typically used and why, and potential
complications including microbial keratitis and
atypical inflammatory responses requiring specific
treatment.”
Dr Watson also talked us through post-treatment
care and atypical outcomes to be aware of.
Lens regeneration research
After the break, Dr Trevor Gray welcomed us back
and reviewed recent amazing research published
in Nature around lens stem cell regeneration of
the phakic lens in paediatric cataract patients. The
research team in China removed the lens of several
infants born with cataracts and demonstrated
how over a matter of weeks the eye began to bring
forward lens epithelial stem cells. By five months,
post op, the infants had generated a new, clear,
biconvex lens (see story on p3 and column
this page.)
Retina condition quiz
In a fun, high-speed session Dr Peter Hadden
presented the audience with a series of slides and
asked them to identify the condition. He then
talked about the treatment, care and management
Drs Peter Hadden and Trevor Gray
Speakers Dr Simon Dean and Dr Shanu Subbiah
Dr Peter Hadden and Michael Holmes
Kevin Wong and Shelly Brannigan
of each vitreoretinal disease that was identified.
Laser eye surgery post-op management
As iLASIK laser eye surgery becomes increasingly
more common, Dr Nick Mantell used his talk to
address what is normal post-surgery and what
changes/symptoms need to be addressed. “Comanagement
optometrists for our out-of-town
patients play a vital role in monitoring iLASIK
patients. We are not only interested in the refractive
outcome but also the appearance of the LASIK flap.
The appearance of the flap post-operatively can be
quite variable and it can be difficult to differentiate
what is normal and what is abnormal.”
Dr Mantell explained how the flap should look,
when to refer back and when abnormal findings
are clinically insignificant.
Pterygia and pingueculae
The evening was rounded up nicely by Dr Simon
Dean, who looked at the conditions pterygia and
pingueculae, their therapeutic management and
when surgical intervention is necessary. “The
assessment of how to intervene in management
of these ocular surface irregularities takes into
account a number of factors,” he said. “A simple
framework of whether they are vision threatening,
significantly uncomfortable, cosmetically
unacceptable (or frequently a combination of the
above) will help to decide the best management.”
Dr Dean noted continued assessment at regular
intervals can also help alter the management over
time. “These masses can change and grow requiring
an escalation of intervention and there is always
an index of suspicion regarding ocular surface
squamous neoplasia making follow-up prudent.”
The next Eye Institute evening education seminar
will be held on 16 August. ▀
Focus on
Eye Research
Retinopathy, stem cell
regeneration and myopia in
Europeans
MORIN, J. ET AL. NEURODEVELOPMENTAL
OUTCOMES FOLLOWING BEVACIZUMAB
INJECTIONS FOR RETINOPATHY OF PREMATURITY.
Pediatrics 2016;137(4)
Review: The appeal of intravitreal bevacizumab for
the treatment of ROP is obvious – to use a small
injection of intraocular anti-VEGF agent to treat a
baby-blinding disease explicitly caused by VEGF.
The BEAT-ROP study, among others, has shown the
effectiveness of intravitreal bevacizumab in treating
ROP with ‘plus’-disease. However, concerns about
the long-term sequalae of anti-VEGF treatment in a
developing child abound, but relevant high-quality
evidence has been lacking.
This study utilised data collected for the Canadian
Neonatal Network (CNN) and the Canadian
Neonatal Follow-Up Network (CNFUN) over a 21
month period and found 27 babies born 3 dioptres, >1
dioptre progression per year) aged under 18 years
to receive atropine 0.5% drops and followed them
for 12 months. The mean age was 10.3 years (range
2.7-16.8 years), the mean baseline myopia -6.6
dioptres and 70% were European, 8% African with
the remainder Asian. Only 60 (78%) adhered to the
treatment for the whole 12 months.
The 12 month results showed the mean myopic
progression had decreased from 1 dioptre per
year pre-treatment, to 0.1 dioptre per year during
treatment. Of note over 70% reported photophobia
and 37% experienced reading problems.
Comment: Although the description of the
authors’ in treating a predominantly non-Asian
population with atropine drops to prevent myopic
progression is appreciated, unfortunately this
study began enrollment just before the ATOM2
study was published, and thus a higher 0.5% dose
was used with inherent side-effect limitations. It
is also unfortunate axial length progression before
and during treatment was not assessed, as this
underpins the supposed mechanism of action of
atropine in myopia. Another limitation is the lack
of a control group, especially when the authors
state that the ‘treatment effect’ was greatest in
teenage subjects – as of course older teens will have
a slower rate of axial elongation anyway. However,
there is now evidence to support the use of atropine
to prevent myopic progression in a non-Asian
population, and we can look forward to further
studies investigating the currently favoured 0.01%
dose to compare to the ATOM2 study results.
ABOUT THE AUTHOR
* Dr Logan Mitchell is a
consultant ophthalmologist
specialising in strabismus,
cornea/external eye disease
and general ophthalmology
at Dunedin Hospital and
Marinoto Clinic, Dunedin. He
is also clinical senior lecturer
at the University of Otago
Dunedin School of Medicine.
July 2016
NEW ZEALAND OPTICS
13