Another year on, another Super Sunday, and this year did not fail to impress. Held again at the Big Top at Luna Park Sydney, 2019 saw 465 optometrists turn up early on a Sunday morning for a day of learning, mingling and lots of eating! Being pregnant and with a two year old at home, these three rare opportunities brought a level of excitement that would rarely be attributed to a 10 hour optometry conference.
Once again Super Sunday covered diverse and fascinating topics, commencing with a presentation by GP Dr Kate Kalloniatis who spoke about vascular disease – one of Australia’s leading causes of death. Dr Kalloniatis highlighted the negative effects of smoking on the body and emphasised the importance of optometrists re-enforcing the ‘quit smoking’ message. She suggested optometrists’ ability to use digital retinal imaging to physically show patients their retinal vasculature, provided an excellent lead into having conversations about health.
Dr Kalloniatis summarised the signs of a hypertensive crisis and noted the benefits of having a blood pressure monitor in practice. One of her take home messages was that if a pregnant woman presents after 25 weeks gestation with sensations of flashing lights, auras, light sensitivity or blurred vision or spots, this may be a sign of pre-eclampsia, a serious complication in pregnancy. If possible, measure the patient’s blood pressure to check for hypertension. Even if blood pressure is not raised, urgent referral to their GP is indicated. Pre-eclampsia, in the absence of raised blood pressure, can subsequently be diagnosed by a urine test.
DRY EYE DISEASE MANAGEMENT
Associate Professor Jennifer Craig presented an update on dry eye disease (DED) management. Along with female gender and age, she noted that Asian ethnicity is now a more clearly recognised risk factor for dry eye. Describing the vicious circle of DED, she explained that our task is to try to break the selfperpetuating cycle, focusing on the source of the dry eye. To that end, she suggested using steroids to suppress the inflammatory response in dry eye will most likely be only temporarily effective if the source of the inflammation has not been identified. Non-penetrating steroids (such as fluorometholone) are the best option in temporarily suppressing the inflammatory component of DED if required initially, but identifying and treating the source of the dry eye is critical in the longer term management of the patient. Establishing whether the inflammation is intrinsic, such as in the case of autoimmune disease, as opposed to extrinsic where it may be a downstream effect, secondary to lid disease for example, is essential in selecting the most appropriate course of therapy. Intrinsic inflammation is more likely to require ongoing anti-inflammatory therapy, while downstream inflammation can often be resolved by controlling the source problem, e.g. MGD.
Beyond artificial tear supplementation, that remains the mainstay therapy for dry eye, current options for management of aqueous deficient dry eye (ADDE) include punctal occlusion, topical cyclosporin and tacrolimus, as well as lifitegrast, nasal neurostimulation and secretagogues, where available (not currently in Australia or NZ).
A wider range of management options is available to optometrists for evaporative dry eye (EDE), including lid margin management (debridement and topical antibiotics), doxycycline, azithromycin, IPL and thermal pulsation. The latest evidence suggests a potential role for Manuka honey in maintaining and restoring eyelid health, without application of topical antibiotics or tea tree oil.
MEIBOMIAN GLAND DYSFUNCTION
Professor Craig then returned to the stage to update the audience on the latest in meibomian gland dysfunction (MGD) research and how it can translate into clinical practice. She recommended a staged approach to managing MGD.
Step 1: Lid Margin Management
- Lid margin debridement with a golf club spud helps remove any excess keratinisation blocking the gland orifices. Use topical anaesthesia to soften the tissue and lissamine green to stain. Lid debridement has been shown to increase the number of functional glands. This can be supplemented by lid and lash cleansing with the BlephEx, which has been shown to contribute to improved comfort in contact lens wearers.
- Prescribe commercial lid cleansers. While cleaning lid margins with baby shampoo may remove crusts, research shows baby shampoo can be less kind to the tissues than dedicated eyelid cleansers, and can result in poorer outcomes with respect to patient symptoms and lipid layer quality.
- Bacterial overload on the eyelids is typically managed with topical antibiotics, and demodex infestation with tea tree oil lid cleansers. Recent research shows promise for Manuka honey as a natural alternative to improving eyelid health and patient symptoms.
Step 2: Encourage Meibum Flow:
- Daily warm compresses (with products such as the MGDRx Eyebag or Bruder mask have been found to be more effective at maintaining adequate temperatures than warm face washers), Blephasteam can be performed in office, or purchased for at-home use by patients.
- A single treatment of the Lipiflow, a thermal pulsation device, is reported in the literature to be effective up to nine to 12 months and has been found to be at least as successful as warm compresses performed with regular therapeutic gland expression.
- Studies into IPL, applied to four locations inferior to the lower eyelid, conducted at day one, day 15 and day 45 have been shown to improve lipid layer thickness and stability as well as patient symptoms.
- Gland expression is considered a fundamental component of MGD therapy and heat treatments tend to show the greatest benefit if combined with therapeutic manual lid expression.
Step 3: Improve Meibum Quality
Improved meibum quality can be achieved with a course of tetracyclines (for example, doxycycline 50mg daily for two to three months) or with azithromycin (systemic, or topical, where available outside Australia and NZ), resulting in improvements in patients signs and symptoms.
Meibum quality can also be improved for some, by increasing consumption of essential fatty acids within the diet, or by taking essential fatty acid supplements.
Liposomal sprays or lipid containing drops such Systane Balance may also be beneficial in supplementing the natural meibomian gland oils to improve tear film stability.
President of O NSW/ACT, Luke Cahill presented Professor Stephen Dain with the Josef Lederer Award for 2018 and Professor Barry Collin presented Professor Fiona Stapleton with the H Barry Collin Research Medal. Professor Collin made special mention that Professor Stapleton was the first female to ever receive this honour. I have to admit, as a member of the audience I felt incredibly privileged to be in the presence of three optometry greats.
As the H Barry Collin Research Medallist, Professor Stapleton presented the keynote address, Why does corneal infection remain a problem for contact lens wearers? She explained that contact lens (CL) related keratitis is the largest single cause of corneal infection (making up about one third of all corneal infections). However, it is less severe and has better visual outcomes than non-CL related keratitis.
Interestingly, silicone hydrogel materials have not appreciably changed the rate of infection in extended wear. Furthermore, the overall rates of infection in daily wear and daily disposables (DD) are similar, however disease has been found to be less severe in DD wearers.
Pseudomonas auruginosa remains the most common causative organism, followed by gram positive bacteria. Disease severity is least for environmental causative organisms, worse for endogenous organisms and the worst for culturenegative organisms.
She discussed the association between water and CL complications. Encouraging patients to not wear their lenses while showering and swimming, as well as ensuring clean dry hands is recommended. Case contamination remains a major contributor to CL related keratitis. Many patients still use tap water to clean their cases which can lead to major complications. With respect to cleaning cases, best practice for patients is to suggest they rub and rinse their case with their disinfectant solution, then wipe it out with a clean tissue and leave it to air dry. Interestingly, if you are concerned about compliance, wiping the case out with a tissue and leaving it to air dry is actually more effective than rubbing and rinsing then leaving it to air dry! Monthly case replacement is also recommended.
PRACTICE MANAGER UPDATE AND NETWORKING
For the first time, Super Sunday provided practice staff with education about eye anatomy, common ocular diseases, triaging at the front desk, retinal photography, visual fields and intraocular pressure (IOP) measurement. Grant Hannaford delivered talks on best dispensing practice and Audrey Molloy spoke on issuing prescriptions.
This year, many optometrists were grateful to Provision who put on drinks from 4.30pm – this was a much appreciated gesture to conclude a very successful day of learning and CPD point accrual. A big thank you to O NSW/ACT for another successful Super Sunday. I will be back next year.
Amy Fortescue graduated in optometry from the University of New South Wales in 2010. She practices at EyeQ Optometrists in Ramsgate NSW, and has special interests in behavioural optometry, ocular health and orthokeratology.