8 months ago

April 2018

Summer Students

Summer Students Symposium 2018 The ninth joint Auckland University Department of Ophthalmology and School of Optometry and Vision Science Summer Student Symposium in March was an upbeat affair. Amusingly chaired by Professor Trevor Sherwin, 17 students from across the departments presented projects and findings from their 10-week studies in rapid, strictly-timed, four-minute sessions. The presentations crossed the gamut of eye disorders and concerns from glaucoma and aging to dry eye and drug delivery mechanisms, each attracting a number of questions and sparking discussion among the 70-strong audience. School of Medicine head, Professor Alan Merry, and Associate Dean (research) Professor Andrew Shelling from the University’s Faculty of Medical and Health Sciences had the tough job of selecting the best presentations on the night. “It’s a challenge to present in four minutes and the standard this evening was uniformly very high,” said Prof Merry. The following is summary of the presentations: • Spheres of Influence, Catherine Tian (Tom Cat Trust) – 1st prize • Influence of high glucose and inflammation on barrier properties of retinal pigment epithelial (ARPE) cells, Charisse Kuo – 2nd prize • Differentiation of transition zone stem cells into corneal endothelial cells, Hannah Ng (Eye Institute) – 3rd prize • Comparison and review of visual field referrals to ADHB glaucoma clinic, Catherine Kwak • Crystallin protein modification and spatial mapping in an aging lens model, Jerry Shen • Evaluating the long-term usability of ex-vivo bovine corneas for drug delivery applications, Darshan Shrestha (Buchanan Charitable Foundation) • The effect of erythropoietin on the vasculature of the premature sheep retina: a cellular and molecular characterisation, Muthana Noori • Nailfold capillary abnormalities in glaucoma, Hilary Goh (Gordon Sanderson Scholarship from Glaucoma New Zealand, see full story p3) • Review of glaucoma referrals to ADHB glaucoma clinic, Tess McCaffrey • Confirmation of UV filter distribution in the aging human lens, Arwa Ibrahim (Molecular Vision Laboratory) • To give or not to give? Should I provide feedback during acuity measurement, Maggie Xu • Monitoring age-related changes of the vitreous of the eye using MRI, Louisa Howse • Evaluating the utility of an eyelid massage device for the management of meibomian gland dysfunction, Jasmine Feng (NZAO Education and Research Fund) • Effect of temperature on the thickness of the human ocular choroid measured with optical coherence tomography, Sungyeon Kim • The effect of virtual reality on the tear film and ocular surface, Joyce Wong • Adaptation of jumping spider behaviour to a modified focal environment, Aimee Aitken (Paul Dunlop Memorial Research Scholarship, NZAO) • Visual impairment in stroke in a New Zealand context: patient characteristics in the CBR Stroke Recovery Clinic, Carla Fasher ▀ The 2017-2018 Summer students Sam Simkin, Chelsea Wood and Dr Hannah Kersten Safal Khanal, Soheil Mohammadpour and Lily Chang PHOTO BY TREVE DROMGOOL Prof Trevor Sherwin, Salim Ismail, Catherine Tian and Jason Xu Jane McGhee, Dr Rachel Barnes and A/Prof Bruce Hadden Dr Andrew Collins, Joanna Black, Monica Acosta and A/Prof Sam Schwarzkopf BOOK REVIEW The Neuro-Ophthalmology Survival Guide, second edition By Anthony Pane, Neil R. Miller and Mike Burdon REVIEWED BY DR STEPHEN BEST* I was delighted to be invited by the NZ Optics’ editorial team to review this book as I had not taken the opportunity to read the previous edition, although I had heard many references to it from colleagues both here, in New Zealand, and in Australia, where the principle author, Dr Anthony Pane is based. I have listened to Anthony’s presentations over the years and appreciate his directness about the potential pitfalls (sometimes known as medico-legal watch cases) of neuro-ophthalmic conditions that might have irreversible sightthreatening sequelae or be life-threatening emergencies seen in routine ophthalmic clinics, but potentially under-diagnosed! Additionally, I have spent time with, and greatly respect, Drs Neil Miller and Michael Burdon, so anticipated this small text book would be a good read and live up to expectations! I was not disappointed; especially after reading the first chapter ‘Staying out of trouble’ which lists 20 neuro “rules” to keep you out of strife. Each rule is illustrated with a case example and cross-referenced to the expanded discussion on that topic in subsequent chapters. This chapter alone should pique interest about common neuro-ophthalmic conditions and, as stated in the introduction, you can’t avoid neuro-ophthalmology – neuro-ophthalmology is special, you want your patients to see well, you want your patients to stay healthy, you want to stay out of trouble, you want to pass your exam (if you still have it ahead of you). This is a short text book designed to be of everyday practical use for ophthalmologists, trainees, optometrists and neurologists, based on clinical symptoms, examination checklists, management flowcharts and referral guidelines. There are 12 chapters (340 pages) that cover blurred vision or field loss, swollen disc(s), double vision, unequal pupils and unexplained eye pain, orbital pain or headaches. The final chapter outlines neurophthalmic history and examination, with particular reference to giant cell arteritis and an excellent table 13.1 titled ‘Localizing value of visual field defects’. This last chapter, in my opinion, should be a must read for all ophthalmic trainees not only to reinforce sound clinical practice but also to help with challenging formal examinations. The chapter on ‘Double vision’ is a wonderful synthesis of an extremely complex topic, but presented in an easily understandable and clinically significant format. While the discussion on cranial mono-neuropathies and localising value flowcharts should guide clinicians to appropriate investigations in particular third nerve disease processes that might have very serious consequences! One of my favourite chapters, however, dealt with ‘Seeing things’. Patients may see things because of eye, optic nerve or brain disease and unusual visual symptoms need to be explained. Visual illusions and hallucinations are explained with excellent cartoons and flow charts, and Anthony reminds the reader that if the patient presents with visual phenomena that are not consistent with visible intraocular disease processes then referral to a neuro-ophthalmologist or a neurologist is appropriate with neuro-imaging to check for serious brain disease. This is a great book to have close to your consulting room and, as with many modern texts, when you purchase the second edition it comes with an eBook version which is downloadable to your electronic screen ensuring great portability and a fantastic set of clinical videos. *Dr Stephen Best is a consultant ophthalmologist, with sub-specialities in glaucoma and neuro-ophthalmology, with Auckland Eye and the Greenlane Clinical Centre. 20 NEW ZEALAND OPTICS April 2018

NZ hosts the world of retina BY DR HANNAH KERSTEN* The biennial Retina International World Congress was held for the first time in Auckland on the 10 and 11 February. With recent host cities including Taipei and Paris, Auckland had a lot to live up to! The Retina International Congress is a unique meeting, bringing together the world’s foremost retinal scientists and clinicians, patients and their families, health professionals and patient advocates. The scientific programme, organised by local retina specialist Associate Professor Andrea Vincent, boasted an incredible line-up of 11 international speakers as well as many local and national presenters. The speakers and delegates were joined by a large group of volunteers, from the Blind Foundation and the University of Auckland, to assist the many low-vision or blind delegates. Speaking to such a diverse audience was always going to be a difficult task, but the speakers more than rose to the challenge. The scientific programme was opened by Professor Elise Héon, from the University and Hospital for Sick Kids in Toronto, who gave a brilliant clinical overview of inherited retinal disease, putting into context much of what was going to be discussed at the meeting. This was followed by a presentation by Professor Eric Pierce, from Harvard Medical School, summarising the genetic causality of inherited retinal diseases and current therapeutic approaches for treating these conditions. Both opening speakers spoke of the difficulties associated with the current inherited retinal disease nomenclature; many disease names (for example, retinitis pigmentosa) cover a range of genetic mutations and phenotypes. The second session of the day covered the somewhat daunting topic of Genetics and Gene Therapy. A/Prof Andrea Vincent, outlined the clinical findings that can provide clues to the genetic diagnosis in inherited retinal disease, while Associate Professor Alex Hewitt (Tasmania) provided an overview of the advances in genetic testing for retinal disease. He included a memorable analogy, where each DNA nucleotide was a matchstick, explaining how changes in the ‘matchstick’ configuration can lead to genetic disease. Professor Jean Bennett, from the University of Pennsylvania, then took to the stage to discuss the enormous amount of work that goes into conducting a clinical trial, and the phenomenal costs involved (up to US$1.8 billion if conducted by a pharmaceutical company!). In the afternoon, the meeting broke off into two parallel sessions, ‘Retinal degenerations’ and ‘AMD and other maculopathies’. I attended the AMD session and one of the highlights was Professor Mark Gillies from Sydney discussing the Australian Fight Retinal Blindness project and the role of big data. He emphasised the importance of natural history disease studies – by understanding the course of disease in individuals, we are able to gather information that cannot be acquired through clinical trials alone. In this session, we also heard from a number of local speakers; Drs Narme Deva, Rachel Barnes, David Squirell and Dianne Sharp covered a range of topics including advances in treating age-related macular degeneration (AMD) and diabetic eye disease, and the latest in retinal imaging for AMD. Claire Fitzgerald, Gary Williamson and Margaret McLeod from the Blind Foundation with volunteer Nancy and Martine Able-Willamson Diego Sonderegger, Drs David Squirrell, Graham Wilson and Angus Hatfield-Smith Part III Optom students and volunteers Linda Zhou, Lusi Yu, Joyce Wong and Kate Lee Speakers Dr Daniel Chung, Prof Elise Héon, A/Prof Andrea Vincent and Dr Thomas Edwards Blind Foundation’s Sue Emirali and Gail Mann (third left) with Jenny and Kyle Dobson The final session of the day included presentations by Associate Professors Alice Pébay, from Melbourne, and Alex Hewitt on using stem cells to model eye disease, and CRISPR gene editing in retinal disease. A/Prof Hewitt explained that although the possibilities for CRISPR gene editing in humans are vast and exciting, it could be many years before they are used in patients with retinal diseases. Dr Kent Small then spoke about his work in North Carolina Macular Dystrophy with patients from across the world. The interesting topics continued on day two of the programme, with ‘Scientific Breaking News’. Professor Bennett, who conducted the first gene therapy treatment trial for patients with inherited retinal disease, spoke about the recent FDA approval of Luxturna (or voretigene neparvovec-rzyl to use its proper name) for the treatment of patients with mutations in the RPE65 gene. Professor Pierce gave an update on the ReNeuron clinical trial of human retinal progenitor cells for patients with advanced retinitis pigmentosa. Dr Sharp discussed treatment difficulties in patients with polypoidal choroidopathy and retinal angiomatous proliferation. Professor Gillies gave an overview of AMD clinical trial results, including brolucizumab as a potentially longer-lasting treatment for neovascular AMD and lampalizumab, trialled for the treatment of geographic atrophy. Finally, Dr Tom Edwards from Melbourne, gave an overview of the safety and efficacy of a robot-assisted retinal surgery system. The robot is able to make very fine movements, particularly important in patients with fragile retinas (including patients with inherited retinal disease). In the video, ‘Robot vs. Surgeon’, the robot was much steadier, with slower, more deliberate movements. The futuristic theme continued, with a session on artificial vision. Dr Edwards discussed the first attempt at artificial vision (back in 1968!) and the considerable progress that has been made since then. Artificial vision requires an intact inner retina, so retinitis pigmentosa is often a good target. Dr Penny Allen from the Royal Victorian Eye and Ear Hospital, talked about Bionic Vision Australia’s suprachoroidal retinal prosthesis, and presented the results of a prototype clinical trial, where all three patients showed improvement in navigational ability following the surgery. Dr Thiran Jayasundera, a New Zealandtrained retinal specialist now working in the USA, was the first to implant the Argus II over a decade ago. Today, there have now been over 350 Argus II implant surgeries. He discussed the Argus II’s surgical procedure and clinical journey. Because the implant only provides very basic vision, pre-operative vision needs to be light perception or worse, he said. The afternoon was again split into parallel sessions, with separate sessions for patients and professionals. I chaired one of the patient sessions, which included an illuminating presentation by ophthalmic nurses Sandy Grant and Olga Brocher on the services offered by the Auckland District Health Board’s low vision clinics. Blindness consultant Jonathan Mosen, blind since birth, talked about why it is the best time in history to be a blind person. Technology was also the focus of the Blind Foundation’s adaptive technology trainer Matthew Rudland, who turned our attention to the Seeing AI app for those with visual impairment, while the Blind Foundation’s Sandra Budd detailed some of the Foundation’s services. Following the parallel sessions, Professor Gerald Chader from the Doheny Institute in the USA, gave the closing keynote presentation, summarising the decades of laboratory and clinical work that have led to clinical trials and better outcomes for patients with retinal disease. Feedback about the conference was positive, with attendees commenting on the high quality of the speakers and the fantastic networking opportunities available. The next Retina International World Congress will be held in Reykjavik, Iceland, in 2020; the perfect excuse to organise a trip to the Northern Hemisphere. ▀ *Dr Hannah Kersten is a lecturer in the School of Optometry and Vision Science at the University of Auckland and a member of the local organising committee for the 2018 Retina International World Congress. Focus on Eye Research Retinal detachment, epiretinal membranes and anti-VEGF for DMO VISUAL RECOVERY AFTER RETINAL DETACHMENT WITH MACULA- OFF: IS SURGERY IN THE FIRST 72H BETTER? Frings A, Markau N, Katz T et al British Journal of Ophthalmology. 2016;100:1466 -1469 Unlike macula-on retinal detachment, which is often treated as an “ophthalmic emergency” and repaired swiftly before the macula detaches, macula-off retinal detachment is usually considered less of an emergency. However, determining the ideal time for repair of maculaoff retinal detachment before compromising the visual prognosis can be difficult. The purpose of this study was to evaluate the influence of lag-time between the onset of central visual acuity loss and surgical intervention of macula-off retinal detachment. A retrospective review of 1727 patients was undertaken, with 89 patients meeting the inclusion criteria. The main outcome measure was final visual acuity as a function of symptom duration of macula-off detachment. Symptom duration was defined as the time from the onset of loss of central vision (macula detachment) to surgical intervention. The results showed there was no clinically significant difference in final visual acuity in those operated within 10 to 30 days of macula-off retinal detachment. But patients with symptom duration of three days or less achieved best final visual acuity (p