In November 2018, Optometry South Australia’s annual SA Blue Sky Congress rolled into town, bringing with it a very laid back ‘western’ theme. But unlike most western towns, delegates to Blue Sky were made to feel very welcome – there were no pistols to be seen at high noon… no nodded greetings of “Stranger” or “This town’s not big enough for the both of us” remarks. The food was ‘lip smack’n’ good, and the presenters ‘pumped you full of lead’, or was that knowledge!
The 2018 SA Blue Sky Congress, in the beautiful Adelaide Hills, was a seriously good conference, with a solid line up of local and international speakers, among them the ever popular Dr Blair Lonsberry, Dr Simon Chen, Dr Dania Qatarneh, and lens expert Nicola Peaper.
Dr Chen demonstrated the need for clinicians to be adaptable and alter management plans in the event of clinical surprises
GLAUCOMA AND OPTICAL COHERENCE TOMOGRAPHY
Over the two day conference, US optometrist and keynote speaker, Dr Blair Lonsberry, presented several informative, interactive sessions covering an array of topics, including the use of optical coherence tomography (OCT) imaging in clinical practice.
Using clinical cases, Dr Lonsberry outlined the application of OCT to diagnose and manage glaucoma. He discussed the value of OCT assessment of the neuroretinal rim, and perhaps more importantly the retinal nerve fibre layer (RNFL), particularly in glaucoma suspects and early glaucoma patients. This is due to the fact that significant structural changes often occur prior to functional vision loss detectable with automated perimetry. He showed how the use of guided progression analysis technology can be implemented to detect glaucomatous change once a baseline has been established for a patient, which requires two scans with Cirrus OCT software.
When interpreting OCTs, Dr Lonsberry warned not to fall into the mindset of ‘red is disease’ or ‘green is clean’ – that is, not to rely on the colour coded classifications to assess patient scans. The raw data must also be considered when interpreting OCT imaging because what is anatomically normal for a specific patient may fall outside the range of what is considered normal for someone their age. This is especially relevant for patients of different ethnicities or those who have other comorbidities, for example high myopes who are predisposed to a thinner than average RNFL and are not considered in the database population.
Dr Lonsberry also mentioned the potential future use of OCT-Angiography in the analysis of optic nerve head perfusion and vessel density around the disc, which has been shown to reduce with glaucoma progression.
Importantly, Dr Lonsberry tied the technology back to clinical practice, saying that although data may be statistically significant, it is imperative to ensure all decision making is still clinically relevant for the patient. That is, all factors must be considered when evaluating structural and/or functional change in glaucoma and implementing management, such as a patient’s life expectancy.
Interactive polling throughout the presentation highlighted the fact that there isn’t always an explicit answer in glaucoma management and treatment.
The use of OCT in combination with 10-2 visual fields in Plaquenil toxicity screening was also discussed, as well as an overview on the new macular hole classification and staging system that is now based purely on OCT appearance.
In an engaging presentation, ophthalmologist Dr Simon Chen presented an array of interesting (but somewhat gruesome) ocular trauma cases. These ranged from a harpoon assault to the head leading to enucleation and facial reconstruction surgery, to a butter knife injury to the eye that was successfully removed, against doctors’ recommendations, by the patient while waiting for surgery. He illustrated that ocular trauma can cause a diverse range of anterior and posterior segment eye injuries, and that treatment must be tailored to specific cases. By showing a series of videos of intraocular surgeries, Dr Chen demonstrated the need for clinicians to be adaptable and alter management plans in the event of clinical surprises.
Dr Chen also highlighted the importance of holistic patient care, and the need to always consider life-threatening diagnoses before those that are sight threatening. Many of the cases demonstrated the remarkable resilience of the eye, and the ability that ophthalmologists have, in some cases, to preserve vision even after severe trauma.
LIGHT TRANSMISSION, REFLECTION, AND ABSORPTION
Nicola Peaper presented on the topic of Controlling light – transmission, reflection, and absorption. This lecture covered basic lens properties that can be used to reduce glare, such as antireflective coatings, tints, photochromatic coatings, and polarised lenses. Then she delved into how we can best match the right lens properties to suit each patient and optimise their visual needs. Ms Peaper illustrated the need to carefully match lens properties with examples that included the case of a patient who was having difficulty playing outdoor sports having been prescribed a photochromatic lens. The lens had an antireflective coating (back and front) with a 45 per cent transmission in its deactivated state and an 85 per cent transmission when fully activated. She also reminded us that some occupations have strict colour vision standards – grey tints and polarised lenses can be prescribed for these patients because they will help with glare symptoms without impacting colour perception.
The session also included discussion about the role of short wavelength blue light blocking lens coatings and tints and the considerations that need to be made concerning our patients. Considerations included glare and contrast management, circadian rhythm, myopia development, and retinal damage. We were encouraged to consider the literature and evidence base when prescribing options for our patients.
AGE RELATED MACULAR DEGENERATION
Dr Dania Qatarneh presented on Keeping up with age related macular degeneration (AMD) – an update on treatment and new strategies to reduce risk of advanced disease. This was an excellent lecture which covered interpreting OCT scans of macular degeneration, current treatment options, the evidence behind current treatments, and a look at future treatments. An interesting discussion point during the lecture was the results that have been released so far from the ongoing 2RT study. The study is using the Ellex ultrashort nanosecond laser coupled with Ellex Nanopix Technology to promote retinal rejuvenation. The laser used in this study uses 500 times less energy than standard photocoagulation, which eliminates the incidence of thermal damage. The treatment aims to induce the orderly replacement of retinal pigmented epithelium and the removal of metabolic waste products. The results so far from this study are promising for patients with early and intermediate AMD without reticular drusen. This may prove to be a game changer in preventing the progression of early and intermediate AMD to the end stage disease that results in significant visual impairment.
SA Blue Sky Congress included a trade exhibition area, enabling delegates to familiarise themselves with the latest eye health technology to aid disease diagnosis and management.
Luke Higgins is the principal optometrist at Luke Higgins Optometry in Mount Compass, South Australia. He also provides outreach optometry services and practices for the Royal Society for the Blind as a low vision and rehabilitation optometrist. Mr Higgins is part of the teaching team at Flinders University School of Optometry and a board member of Optometry South Australia.
Hannah Stanley is an optometrist who works at independent practice, Eyre Eye Centre, based in Port Lincoln, South Australia. She also works at branches located in Ceduna and Whyalla, in addition to providing outreach services to Streaky Bay and running clinics at Port Lincoln Aboriginal Health. She is a member of the Early Careers Optometry Board of South Australia.