Nov 2016

The final Grand Round of 2016
Wednesday 21 September saw the last in
the Eye Doctor’s series of Grand Rounds
for 2016, held at Novotel Ellerslie. There
was a great turnout of 41 people, a reminder of
the enduring popularity of these Bausch + Lombsponsored
educational talks. Eye Doctor’s are also
celebrating their 10-year anniversary and thanked
the audience for being part of their success story.
From baby rashes to strabismus surgery
Dr Shuan Dai opened the evening with an interesting
case of a six-week old baby presenting with skin
rashes and watering eyes since she was two
weeks old. There was no family history of any eye
conditions. The child was irritable and crying with
a swollen right eye, poor red reflex, and an IOP
of 34mmHg. There was hyphema with no other
causes and this led to the diagnosis of Juvenile
Xanthogranuloma – the most common condition
causing spontaneous hyphema in children.
The condition is characterised by benign cutaneous
histiocyte granulomatous inflammation with 10%
involvement of eye and adnexa. It usually presents in
the first 12 months, and the rash looks like yellowish
slightly raised skin lesions that take a few months to
disappear once treatment begins. It’s a self-limiting
disease though raised intraocular pressure can cause
permanent visual damage unless treated. After two
months using a topical steroid and eye pressure
lowering drops, the IOP came down to 17mmHg.
Signs of amblyopia will need ongoing treatment.
Dr Dai also showed some slides from his ‘working
holiday’ to China, and talked about the new
strabismus surgery techniques he was invited
to present at the ophthalmology conference he
attended in China. He showed excellent surgical
outcome with transposition of superior rectus muscle
to lateral rectus for correcting esotropia in patients
with chronic 6th nerve palsy. The most amazing part
is the restoration of nearly full-range movement
to the eye, he said. Dr Dai showed some video of
pre and post-op patients who had a full range of
movement just a few weeks after surgery.
Scleral thining
Dr Penny McAllum opened with the topic of the
blue/grey tinge to a patient’s eye caused by scleral
thinning. This can be congenital or acquired. If
congenital, it could be Ehlers Danlos Syndrome,
an inherited collagen disorder – ask your patient
to bend back their fingers to see if they have
hyper extendable joints, she said. If their joints are
normal, it could be osteogenesis imperfecta (brittle
bone disease), another collagen defect – check
your patient’s teeth, as people with this condition
often have teeth abnormalities. Another condition
causing the problem could be Marfan syndrome,
a fibrillin disorder resulting in the patient being
unusually tall, with long limbs, fingers and neck,
some heart defects. Lens subluxation is present in
75% due to weak zonules.
Acquired scleral thinning could be the result
of necrotising scleritis/scleromalacia due to
rheumatoid arthritis. The main treatment is oral
Prednisone or other oral immunosuppressant
agents for active disease. Another uncommon
acquired cause is radiation from pterygium
surgery, which can cause scleral melting many
years later. Fortunately, it’s no longer used in New
Zealand. It can also be caused by eye whitening
surgery using mitomycin C, particularly popular
in Korea. Other causes of thin sclera include large
eyes, such as in high myopes or buphthalmos
from congenital glaucoma. A blue or grey scleral
appearance can also result from staining with
some drugs, like tetracyclines, after many years
of regular use. Look for grey, brown or even green
staining of their teeth, skin and nails as well.
Dr McAllum then talked about the interesting
case of a three-year-old Indian boy with yellow
eyes, a sore throat, cough and a fever. He was
diagnosed with jaundice and strep throat – but
what was causing the jaundice? It’s not usual with
strep throat.
She explained that Jaundice is caused by high
levels of bilirubin in the blood stream, a yellow
breakdown product from haemoglobin. There are
three types of jaundice – haemolytic
(increased red blood cell breakdown),
hepatocellular (when the liver is not
functioning properly), and obstructive
(when there is a blockage in the bile
ducts, between liver and intestines),
which is the most common but usually
in adults. Dr McAllum’s patient had
a condition called G6PD deficiency, a
common genetic condition in African,
South Asian and Middle Eastern people,
triggered by some sort of stress on the
body. The patient was in haemolytic
crisis due to his G6PD deficiency,
triggered by the strep throat. It can also
be triggered by aspirin, antimalarial
drugs, some antibiotics and fava
(broad) beans. Once the cause of the
crisis has been removed, the condition
settles on its own.
Dr McAllum said this example served
as a reminder that sometimes you see
things in the eyes that reflect what is
happening elsewhere in the body.
Retinal vasculitis
Retinal vasculitis was the topic
presented by Dr Mark Donaldson.
Clinical signs include perivascular
whitening, haemorrhage in the retina,
a few cells in vitreous, and leakage. Systemic signs
include diabetes, IBS, and smoking.
Dr Donaldson talked us through the case of a fit
asymptomatic 60-year-old woman referred with
retinal haemorrhages. Ultra-wide fluorescein
angiography demonstrated ischemic retina, a
complication that could lead to neovascularisation
and blindness. All possible systemic causes of
vasculitis eliminated the diagnosis defaults
to Eale’s disease with photocoagulation
being recommended. The case succinctly
demonstrated the diagnostic pathways followed in
understanding patients with vasculitis.
Cirrus OCT angiography
Dr Andrew Riley reviewed the Cirrus OCT
angiography, which Eye Doctors purchased after
assessing its potential.
Dr Riley talked about the machines capabilities.
With advancements of live-tracking and faster
Dr Andrew Riley, Stephen Hill, Hue Bullen and Gary Filer
Dr Mark Donaldson, Cindy Tse, Lily Chang, Elkie Wong, and Dr Shuan Dai
acquisition time we can now see the doppler
effect of movement, he said. We actually see the
erythrocyte movement so can map the vessels.
However, he said it does not directly show
leakage. Dr Riley said he is excited about what
this technology provides. Abnormal vessels in
diabetic macular oedema and vein occlusion were
presented and definitions of macular ischaemia
explored. Choroidal neovascularisation from
myopic, trauma and age-related changes can
be identified and mature nets highlighted. The
cases highlighted how OCT angiography has a
bright future not just in diagnosis but also in
improved treatment decisions. This is likely to
reduce considerably the need for fluorescein
angiography, said Dr Riley, adding he envisaged
wider scanning areas with time. Other conditions
are being explored with this technology and optic
nerve vasculature and choroidal circulation are two
where we are just learning, he said. ▀
Bradley Pillay, Dr Penny McCallum and Sonia Swan
Chris Earnshaw and Stuart Campbell
VSP wearables study
Introduced
November 2014
“OptiMed NZ have now sold over 50 Takagi
700GL Slit Lamps”
Slitlamp Microscope
700GL
See your patients’ eyes
in a new light.
VSP Global announced it is
launching a major academic study
and consumer pilot test with the
latest version of the company’s techembedded
eyewear, called Level. The
study is in partnership with University of
Southern California (USC) Center for Body
Computing (CBC),
VSP Global’s innovation lab, The Shop,
debuted an early version of the prototype
in 2015 as Project Genesis— touted as
the first wearable to seamlessly integrate
health-tracking technology into the
temple of an optical frame. A partnership
with USC CBC followed soon after.
“Our partnership with VSP Global will
accelerate research and discovery as to how to
create digital health products and experiences
that will elevate, enhance and expand the lives
of users,” said USC CBC founder and executive
director Dr Leslie Saxon. “This study is the first
of its kind and will provide a crucial roadmap
for validating future products and platforms
and for understanding overall consumer health
engagement.”
The pilot study, launched in September
with USC employees, is being managed by
USC CBC in partnership with USC Roski Eye
Institute. Participants receive a Level frame
and accompanying smartphone app that
allows them to track their activity. The app
also syncs with the VSP Global’s Eyes of Hope
initiative, allowing participants to accrue points
for reaching daily step goals. Once a certain
number of points are achieved, that user
will automatically trigger the donation of a
comprehensive eye exam and a pair of glasses to
someone in need.
VSP’s tech-embedded eyewear Level
“As a community-based not-for-profit, we’re
curious not only about the technology and how
it can benefit the individual utilising it, but
also about the motivations that drive certain
behavior,” said Jay Sales, co-lead of The Shop.
“Connecting Level to our Eyes of Hope initiative
was a perfect way to explore how technology
within a platform as common as eyewear could
increase health and wellness as well as empathy
and opportunity for someone in need.”
Though still in prototype mode, the technology
embedded within the Level frames—including a
gyroscope, accelerometer and magnetometer—
will track a wearer’s steps, calories burned,
and activity time. Users will be able to locate
misplaced frames through the app’s “Find My
Glasses” feature.
It is hoped the study will provide useful feedback
on how individuals interact with the device, which
will inform future strategies for the prototype.
Select eye care providers within the VSP network
will also have an opportunity to test and provide
feedback about the Level experience. ▀
Optional Extras
• Camera Adapter With Yellow Filter
• Adjustable Inclined Eye Piece
• Inclined Eye Piece Adapter
• Yellow Filter
For further information or to order a Takagi Slit Lamp today
Ph: 0800 657 720 info@optimed.co.nz
Craig 0275 657 200 or Robert 0275 657 720
t 012 3456 7890
f 012 3456 7890 e user@yoursite.com
November 2016
NEW ZEALAND OPTICS
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