As the rain fell on Sydney on a very dreary Sunday morning in March, 425 optometrists and 20 practice staff made their way into the Big Top at Luna Park for another information-packed Super Sunday. This year saw a secondary afternoon stream, run by the Optometry NSW/ACT early career optometrists. We were lucky to get together as just eight days later, the day would have been cancelled due to the emerging COVID-19.
Super Sunday is renowned for its impressive clinical education program presented by high calibre optometrists, ophthalmologists and other health care speakers. Inevitably, the program covers mainstream ocular conditions and diseases that optometrists encounter and discuss most days of the week, along with a sprinkling of topics that are less comfortable to talk about, though equally important. 2020 was no different.
EMERGING TECHNOLOGIES IN EYECARE
Super Sunday commenced with a presentation by leading researcher Dr Lauren Ayton outlining the latest information on bionic eyes, gene therapy, stem cells and artificial intelligence.
There are currently 50 active vision prosthesis groups undertaking research worldwide. While there are three regulatory approved retinal prostheses available, at this stage, they have been deemed not commercially viable. Retinal prostheses can enable patients who have no vision (equivalent to seeing the world with one’s eyes closed) to see hand movements and light perception. However, because they require an intact inner retina and optic nerve, there are limited conditions for which they are useful e.g. retinitis pigmentosa or choroidemia.
Interest is now being focused on cortical prostheses which would be suitable for a far wider patient population as these prostheses don’t need an intact anterior visual pathway. Currently there are no regulatory approved devices available.
GENE AND STEM CELL THERAPIES
Gene therapy has shown promising results. The first direct- to-human gene therapy procedure was conducted in 2017 for Leber’s congenital amaurosis using Luxturna. Delivered via a subretinal injection, Luxturna introduces a virus carrying the correct version of the mutated RPE-65 gene into the eye. The eye is an excellent location for gene therapy as it has favourable immunologic properties. Firstly, its lack of a direct blood supply to the outer retina and lack of lymphatics means that the risk of the virus being spread to the rest of the body is low. Furthermore, retinal cells do not divide after birth, meaning that transgene expression may persist indefinitely and not be diluted by cell division.
Gene therapy relies on at least 63% of the photoreceptors being present. It has the potential to halt disease progression and, in some cases, even restore visual function. It will target patients before they become blind. Currently most gene therapy trials are targeting patients with monogenic inherited retinal diseases. This includes Leber’s congenital amaurosis, choroidemia, achromatopsia, X-linked retinoschisis, retinitis pigmentosa, Stargardt disease and Leber hereditary optic neuropathy.
Patients are currently in clinical trials for corneal stem cell therapies and retinal stem cell therapies.
Research is currently being conducted into whether artificial intelligence (AI) can be used for retinal image analysis for the diagnosis of diabetic retinopathy, late neovascular age-related macular degeneration (AMD) and for the identification of glaucoma suspects and possible cataract.
One of the take home messages from this talk was that as optometrists, it is worth keeping a database of patients with diseases of interest, so that you can refer them for new therapies or as recruits for clinical trials when they become available. Clinical trials are currently underway at University of New South Wales, The University of Melbourne, Save Sight Institute, Centre for Eye Research Australia and the Centre for Eye Health.
Associate Professor Vivek Thakkar, a rheumatologist in South Western Sydney, provided a contemporary update on autoimmunity and inflammatory immune diseases.
He stressed that while a family history often confers a higher risk of an autoimmune disease, this does not mean a patient is destined to inherit the disease and yet it can cause unnecessary worry. He explained that instead, disease onset is likely due to the interaction of genes and the environment.
A/Prof Thakkar discussed a selection of autoimmune diseases which can directly or indirectly impact eye health, one of which was systemic lupus erythematosus. In relation to this, he spoke about the benefits of hydroxychloroquine (Plaquenil) for mild cases, explaining that Plaquenil controls mild disease manifestations, reduces flares, reduces clotting and improves pregnancy outcomes. Importantly for the audience, he stressed that the incidence of toxicity and eye problems is very low. The fear of plaquenil toxicity however, has a major impact on compliance, so he cautioned, be positive and supportive when discussing Plaquenil with your patients.
Dr Susan Heward-Belle, a Senior Lecturer at the University of Sydney and recognised leader in domestic and family violence research, outlined what optometrists need to know about domestic violence in order to promote safety and wellbeing for survivors. The statistics were alarming:
- One in four Australian women have experienced physical or sexual violence by an intimate partner since age 15.
- One in three Australian women have experienced physical or sexual violence and/or emotional abuse by an intimate partner since age 15.
- Intimate partner violence (IPV) is the leading cause of homelessness for women and children in Australia, with 40,000 women in NSW on the housing waiting list at any given time.
- Sadly, one in two women seeking refuge are turned away.
- From a medical standpoint, almost half of women who are murdered by their partner present to an emergency department within two years of their death.
Dr Heward-Belle discussed trauma informed healthcare and how, as optometrists, we can be helpful in this context. Using the acronym LIVES, she recommended:
L- listen with your eyes and ears,
I- Inquire about needs,
V- validate her experience,
E- enhance safety, and
S- ensure support.
If we have concerns, she recommended consulting in a de-identified manner; reporting any concerns about a child or young person; documenting in a confidential manner using a separate file if required; and referring, either to the police, the child protection helpline or 1800 RESPECT.
Ophthalmologist Dr Brighu Swamy then presented on ocular manifestations of domestic violence. He explained that IPV is pervasive and underappreciated, with a large discrepancy between physician awareness and actual prevalence (one study found that the perceived prevalence was 1% when in actual fact it was 32%.)
Of most interest, was that women who talked to their health care provider about IPV were 3.9 times more likely to use an intervention and 2.6 times more likely to exit the abusive relationship. In situations where IPV is suspected, he recommended conducting an IPV screening:
Introduce the topic of IPV by saying:
“Because IPV is so common, there are some standard questions I ask my patients..”
Then ask direct questions such as, “Have you been physically, sexually, or emotionally abused by an intimate partner?” and, “Are your current injuries as a result of this kind of abuse?”
Respond to positive screening with phrases such as, “I am glad you shared this with me and I am so sorry this happened to you”, ”This is not your fault”, “You are not alone” and “Help is available”.
Do not say things like, “You need to leave your partner”, “You are definitely in an abusive relationship”, “You should call the police and make a report” or, ”So what happened next and then what happened?”
Dr Swamy stressed the importance of doing no harm, reminding us that assessing for IPV can put a patient in danger. He advised us to always disclose the limits of confidentiality before beginning any assessment and recommended always assessing patients alone, and out of earshot of any partner or family member. Further to that, he advised to never use a family member or friend as an interpreter – only use medically trained interpreters. Additionally, he said it is essential to always ensure patient safety by asking questions such as, “Do you feel safe going home?”.
In summary, the key message from this talk was that as an optometrist, if you suspect IPV, you should not be afraid to conduct an IPV screening – you may be the catalyst for change for that victim.
EARLY CAREER OPTOMETRISTS’ STREAM
The first early career optometrist program for Optometry NSW/ACT was launched during the afternoon of Super Sunday. Being just on the cut-off for this group (it is open to optometrists who have graduated in the past 10 years), I was able to attend. The first lecture, given by Dr Alex Koutsokeras, provided beginners’ fitting tips for specialty contact lenses for keratoconus. It was really refreshing to be guided by an optometrist who has a similar level of experience to myself – Alex made lens fitting seem a lot more achievable.
Presentations continued into the afternoon on AMD, glaucoma, myopia control, rural and regional optometry, and paediatrics.
ProVision again generously provided drinks at 5.00pm, much to the delight of many delegates.
I would like to congratulate the team at Optometry NSW/ACT for another very successful and engaging Super Sunday. After so many years, their ability to provide new and different programs each year is highly impressive. I will be back again next year!
Amy Fortescue graduated in optometry from the University of New South Wales in 2010. She practises at EyeQ Optometrists in Ramsgate NSW, and has special interests in behavioural optometry, ocular health and orthokeratology.