Southern Regional Congress in Melbourne attracted over 700 delegates – record numbers for Australia’s biggest optometric CPD event – and evidence that optometrists value the opportunity to acquire education in a live environment, explore new technologies and network with colleagues.
The 2018 Southern Regional Congress didn’t showcase as many emerging areas of interest as it has in previous years, however, its furtherance this year lay in its structure and delivery: a third stream was introduced to focus on business acumen, strategy, and support, and there was greater input from female speakers, some of whom presented several times.
Of note this year were guest speakers Dr. Kelly Malloy from the Pennsylvania College of Optometry of Salus University, who presented a whopping six different lectures, and Dr. Nate Lighthizer who presented on a variety of topics including diagnostic devices, removal of lumps and bumps and next level antibiotic prescribing.
evidence that optometrists value the opportunity to acquire education in a live environment
Although our understanding of binocular vision (BV) is plateauing compared to our expanding knowledge of ocular pathology/ neurological advancements, we must acknowledge that the amount of near tasks and visual stress insidiously saturating our lifestyles is making BV issues more relevant. According to a study back in 2015, near vision and computer tasks took up 58 per cent of class time, and this could only have risen, especially as students increasingly record work on digital devices as opposed to using pen and paper. This results in increasing periods of near fixation and more frequent need to change focus from distance to near.
Kate Gifford gave some time to discuss the consideration of contact lenses to manage children with BV issues. In her presentation, she said, fitting a decompensating exophoric hyperope with corrective plus glasses will induce a base-out prismatic effect, by moving the image in and increasing vergence (and accommodative) demand. Switching to contact lenses will mean there is less baseout vergence demand, and it can decrease the manifest of exophoria (since there will be greater positive fusional vergence reserves (BO), as well as improving accommodative lag. This means rather than simply approaching paediatric contact lens prescribing from a sporting perspective, we also need to consider school and binocular vision demand.
DIAGNOSTIC PROCESSES AND DEVICES
An eminent and recurring clinical motif at this year’s congress was the role of diagnostic processes and devices; which was thoroughly explored over a number of sessions. This included spotlights on visual field; optical coherence tomography-angiography (OCT-A); the Optos; visual evoked potential (VEP) and electroretinogram (ERG) scans; as well as computed tomography (CT) and magnetic resonance imaging (MRI) scan specificity.
Dr. Nate Lighthizer’s presentation on electrodiagnostics was a personal highlight as it challenged my assumption that the commercial availability of optical coherence tomography (OCT) made the use of electrodiagnostics redundant. The ideal measure of care involves mapping structure against function, and what better functional measure than an objective one? Increased pattern VEP latency was found to be significantly correlated with both the severity and location of visual field defects and the degree of cupping and pallor of the optic disc. This, in turn with the finding of abnormally long VEP latencies in some patients with ocular hypertension (OCT), hints at future application of assessment/ monitoring of subclinical lesions that have not been possible with other imaging techniques, such as the OCT.
Other electrodiagnostic food for thought was the application of comparing VEP, a measure of visual pathway, to pattern electroretinogram (pERG), a measure of electrophysiological activity at the retina, to help differential diagnosis of retinal disorders from optic nerve head disorders. One that can realistically become clinically relevant is the use of full-field electroretinogram (ffERG) measurements of outer retinal functioning to monitor/predict ischaemia (e.g. for the effect of Lucentis injections in DME treatment). It has been clinically demonstrated that ffERG has a higher predictive value of vascularisation in central and branch venous occlusions than fluorescein angiography.
Although the role of the optometrist in the US is more embedded in neurology than is the case in Australia, I still found Dr. Kelly Malloy’s lecture on neuroimaging relevant. As clinicians recommending CT or MRI scans, we should be conscious of the contraindications and relevance of each scan. For example, a sagittal section of the brain can be assessed with MRI scans, which is useful for viewing the pituitary gland, pineal region, corpus callosum, and cervico-medullary junction. As a generalisation, MRI scans are useful for assessing anatomy and soft tissue, whereas CT scans are good for looking at bones and blood (such as for the detection of nerve sheath meningioma, fractures, sinus assessment, and subdural or subarachnoid haemorrhages). MRI T1 weighted images are useful for viewing anatomy, whereas T2 weighted images are useful for pathology assessment (such as edema). Familiarity with these scans could put us in a position similar to Dr. Kelly Malloy in the future, whose review of films helped her find an internal carotid artery aneurysm misdiagnosed as a meningioma. I know this seems like a long way away for us, but look how far our role with the OCT has evolved. At the very least, we can take home the practise relevant clinical pearl of MRI contraindications: patients with pacemakers, cochlear implants, metallic foreign bodies in their orbit, patients with recent stents/metallic implants (unless titanium is used), patients with claustrophobia, weight limitations, previous allergies, and medical patches.
One pertinent advancement discussed by Allison McKendrick was OCT-A, a nondye alternative to fluorescein angiography. OCT-A provides motion contrast from perfused blood vessels by comparing differences in rapidly collected b-scans. Though it has limitations, such as motion artefacts from eye movements during image acquisition; protection artefacts from the motion of shadows cast by superficial retinal vasculature; and inability to capture extravascular flow (preventing imaging of late stage hyperfluorescent fluorescein angiography patterns such as leakage, which helps identify the source of breakdown of the blood retinal barrier); it also has great strengths. For one, it enables delineation of neovascular complexes (since it is not obscured by overlying areas of hyperfluorescence). It is also noninvasive and able to be performed multiple times within a sitting, which is useful for monitoring restoration of blood flow, eg. central retinal artery occlusion. Additionally, OCT-A allows superimposition on structural OCT data, and in doing so exactly localises vascular lesions, eg. correlating a choroidal neovascularisation complex to a shallow pigment epithelial detachment.
BUILDING ON PRACTICE BUSINESS
Another aspect to our profession that is becoming increasingly contextually relevant is the business aspect of optometry. Whether it be through existing chains, or an independent pathway, we have to find that confluence between our own ethical intrinsic measures of performance, and commercial ones. SRC helped disarm the high pressure aspect of retail, and instead, empower us, as optometrists to successfully build our practices by upskilling, and increasing our knowledge of finance, funding, marketing (from recalls to social media), recruitment, and feedback mechanisms. As discussed by Paul McKinley, when armed with this knowledge, we can make more educated decisions and build sustainable practices ethically – whether ours is a greenfield, chain or existing independent.
Overall, the 2018 SRC gave a well rounded snap shot of optometry: revisiting the old but relevant, introducing the new, and expanding in both directions of commercial and clinical practice.
Layal Naji graduated as an optometrist from University of New South Wales (UNSW) in 2014 with her honours research project focusing on asylum seekers’ access to eye care in NSW. She currently divides her time between locum work, the Asylum Seeker Centre in Newtown, working as a visiting clinical supervisor at UNSW and with low vision patients at UNSW and Chatswood Low Vision Clinic. Ms. Naji is passionate about optometry’s role in public health, and ocular manifestations of chronic lifestyle related disease.