CAKE & PIE POST (52nd RANZCO 2022 Edition) - Issue 1

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ISSUE

02 | 27 | 22

HIGHLIGHTS Dawn of Gene Editing 05 The Is Asia-Pacific ready for precision ophthalmology?

Help with 06 Need Glaucoma Management?

Here are tips from experts Cancer Gets in 14 When Your Eyes Highlights from an ocular oncology session

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RANZCO 2022 virtual presents a bold 10-year plan to eradicate blindness in Australia

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by Hazlin Hassan

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mid gloomy reports from Eastern Europe over the increasingly complicated RussiaUkraine crisis, uplifting news from Australia and New Zealand is more than a welcome respite — at least in ophthalmology.

opening ceremony. “It feels very strange to address you without being able to be with you in person, but this is what the current situation demands. And to this, we must all adapt and adjust as we move forward,” he said.

The 52nd Annual Scientific Congress of The Royal Australian and New Zealand College of Ophthalmologists (RANZCO Brisbane 2022) opened yesterday, optimistically laying out its 10-year goal to eliminate blindness in Australia with its Vision 2030 plan.

RANZCO’s Annual Scientific Congress brings together ophthalmologists from across Australia and overseas to share and discuss the latest innovations, techniques and advances in eye care. This year, virtual meetings take place from February 26 to March 1.

RANZCO President, Prof. Nitin Verma, gave a warm welcome to all delegates during the

With topics such as glaucoma, cataract, cornea, Cont. on Page 3 >>

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27 February 2022 | Issue #1

An innovative vision for ophthalmology begins with using our ears At Roche, we believe in order to transform vision outcomes in Australia, our innovation must extend beyond the science that underpins our novel medicines and drug delivery solutions.

Fundamental to our approach is personalised healthcare, harnessing digital solutions and artificial intelligence to improve diagnosis, identify biomarkers, enhance prevention and guide treatment.

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In order to keep you informed, we need your contact information and consent. Scan or click on the QR code to access our online consent form.

Roche Products Pty Limited, ABN 70 000 132 865, Level 8, 30-34 Hickson Road, Sydney NSW 2000.

Medical Information: www.medinfo.roche.com/australia or 1800 233 950. EMVOPH0012 M-AU-00001382 PreparedFeb22

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CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

>> Cont. from Page 1

uveitis and surgical retina featured in its packed scientific program, delegates can be sure to take away with them not only enjoyable memories but a wealth of knowledge.

One focus of discussion was inequity in the access to and delivery of health care across Australia, which is often cited as the cause of visual loss among patients, which in many cases is irreversible yet preventable.

Axis of hope A 10-year plan being developed by RANZCO, called Vision 2030, aims to ensure that equitable health care is available to Australians, eliminating avoidable visual impairment and blindness in the country.

Dr. Kristin Bell, the Vision 2030 and Beyond clinical lead and RANZCO Regional QEC chair, shared the needs of public ophthalmology service in Australia.

“Most adult and pediatric services are overwhelmed,” Dr. Bell said, adding that more than 50% of existing services don’t offer comprehensive care.

There also exists a maldistribution of outpatient services between and within local hospital networks, with longer waits for public inpatient services in inner and outer regional Australia.

Dr. Justin Mora, RANZCO Qualification and Education Committee censor-inchief, who presented his talk on Focus on Workforce and Training, said: “The ophthalmology workforce of the future

is under threat.” He added that a 2018 report on the sector warned of a lack of funded training positions in the public sector and an impending critical shortage of pediatric ophthalmologists.

There are no existing National Health Reform Agreement (NHRA) governance measures to ensure growth to meet capability, while insufficient and maldistributed training posts will likely result in an impending, overall workforce shortage by 2030.

“There is a regional workforce maldistribution,” added Dr. Mora, “with 29% of Australia’s population living regionally but only 16% of ophthalmologists based in regional locations.”

Meanwhile, 90% of the 107 ophthalmologists trained under RANZCO’s Vocational Training Program (VTP) are residents in urban areas.

“Solutions to the problem of impending overall workforce shortage and public workforce maldistribution need to recognize that overall workforce distribution and sustainability are inextricably linked with equitable public hospital service delivery,” shared Dr. Mora.

The number of trainees with a regional background and the number of regional training positions should be increased.

A promising ally Prof. Alex Hewitt presented this year’s Dame Ida Mann Memorial Lecture, titled The Dawn of Precision Ophthalmology in the Asia-Pacific, where he talked about

the adaptation of the clustered regularly interspaced short palindromic repeats or CRISPR system to the mammalian cells — a development that is set to revolutionize treatments for inherited diseases.

“With the increasing availability of genetic testing, we’re now rapidly reaching a point whereby it’s possible to diagnose disease earlier and earlier,” said Prof.

Hewitt.

The CRISPR-Cas9 is a genome-editing tool that is said to be faster, cheaper and more accurate than previous techniques of editing DNA and has a wide range of potential applications.

Heralded as the most significant breakthrough in biology since polymerase chain reaction (PCR), the system is used by bacteria to counter viral intrusion and can cut or edit DNA at specific sites. The clinical application of this technology opens the very real prospect of anticipatory cures to well-defined inherited diseases.

While ocular blinding conditions will be at the forefront of these, a transformative shift in the Australian biotechnology and health care delivery sectors must occur to ensure this becomes reality.

Many of the steps for a safe therapeutic pipeline for the in vivo CRISPR-Cas9 therapy, such as accredited mutation detection and patient-specific profiling, are well-established and a clear pathway of how this technology would be incorporated into clinical care has been developed.

With ongoing advances and enhanced manufacturing capabilities, the end of blinding monogenic retinal diseases is finally in sight.

Editor’s Note: Prof. Ida Mann was a distinguished ophthalmologist recognized for her inspiring work on embryology and development of the eye, as well as genetic and social influences on eye diseases.

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27 February 2022 | Issue #1

RANZCO 2022 Bausch + Lomb Hosted Morning Symposium IOL Formulas – The short and long of it!

Formulas for calculation of IOL power have been evolving since their inception.

Our panel of experts will discuss how formulas calculate the optimum lens power to help maximise outcomes.

Sunday, February 27th 2022 6.45am - 7.45am AEST 7.45am - 8.45am AEDT

Open to all RANZCO registered delegates To join the symposium select this session from the RANZCO Virtual Attendee Hub

RANZCO recognises this CPD activity for 1 point/ hour in the Clinical Expertise Category, Level 1

Moderator Professor Gerard Sutton (Australia)

How to develop an IOL power calculation formula Dr Damien Gatinel (France)

Development and outcomes of the EVO formula

IOL Formulae: Assessing accuracy for short eyes

Dr Tun Kuan Yeo (Singapore)

Dr Nishant Gupta (Australia)

Please note this event is by invitation only. In order to comply with company policies, we request that you forward this invitation to your employer’s administrative department (unless you are the practice principal or employer). Furthermore, we request that you make all necessary disclosures to any relevant professional associations or institutions regarding your attendance at this event. By accepting this invitation, you warrant that these requirements have been met. © 2022 Bausch & Lomb Incorporated. ®/TM denote trademarks of Bausch & Lomb Incorporated and its affiliates.

Bausch & Lomb (Australia) Pty Ltd. ABN 88 000 222 408. Level 2, 12 Help Street, Chatswood NSW 2067 Australia. (Ph 1800 251 150) New Zealand Distributor: Toomac Ophthalmic. 32D Poland Road, Glenfield 0627 Auckland New Zealand (Ph 0508 443 5347) BHC.0001.AU.22

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

The Dawn of Gene Editing Is Asia-Pacific ready for precision ophthalmology? by Tan Sher Lynn

effectively correcting genetic defects.

Prof. Hewitt gave examples of recent advances in correcting disease-causing variants using gene editing, such as the programmable editing of a target base in genomic DNA without doublestranded DNA cleavage, as well as the programmable base editing of AT to GC in genomic DNA without DNA cleavage by notable chemist David Liu’s team the following year.

“Combining CRISPR-Cas9 with base editors not only allows the ‘spelling mistake’ in the genome to be corrected but also causes other ‘letters’ to be corrected as well. Thankfully, researchers have found where to hide the base editor in the Cas9 protein in order to eliminate this issue,” he added.

All about the patient The next step is production. “The solution is to have a distributed manufacturing process,” Prof. Hewitt noted. “The Tasmanian Eye Institute has recently refurbished a water tank in Hobart into a laboratory, which can fully function as a GMP production facility. The aim is to link this approach with all active clinicians across Australia and New Zealand.”

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ustralia is at the forefront of genetic discoveries, foremost of which is identifying genetic eye disorders early on using the CRISPR-Cas9 system, a technology that can cut or edit DNA at specific sites.

“On this front, Australia has led the way in many genetic discoveries by dissecting many of the genotype and phenotype correlation,” noted Tasmanian clinicianscientist Prof. Alex Hewitt, who presented the Dame Ida Mann Memorial Lecture during the opening plenary of the 52nd Annual Scientific Congress of The Royal Australian and New Zealand College of Ophthalmologists (RANZCO Brisbane 2022) yesterday.

Among the highlights of his presentation were the recent developments in gene-editing technology, which holds tremendous promise in treating hereditary eye diseases.

Genetic eye disorders are typically

hard to treat due to the complexity of the genome. “But thanks to the rapid advancement of science and technology, we can now diagnose disease earlier and earlier, and identify the genetic cause in seven out of 10 unselected patients,” enthused Prof. Hewitt.

Finally, the last and pressing issue to address is the patient. “There are two major things to consider,” he explained.

“First is the clinical trial framework, which needs to be redesigned for rare orphan diseases. For example, the phase 1 and 2 in the clinical trial framework can be condensed and a greater focus be placed on the post-licensing surveillance.”

Prof. Hewitt’s team was the first to demonstrate the adaptation of the clustered, regularly interspersed, short palindromic repeats (CRISPR) system in adult mammalian cells using mice vectors, which resulted in an 84% reduction of gene expression.

The second is to ensure that the patient would want to do it. To address this issue, an online questionnaire was set up and completed by 12,000 participants with a median age of 24. The questionnaire found that overall, there is firm support for gene editing. “Interestingly, those who did not agree to it said that they did not understand the technology. Hence, education can potentially address this issue,” Prof. Hewitt said.

The CRISPR-Cas9 system, used by bacteria to counter viral intrusion, can cut or edit DNA at specific sites. Applied in inherited disease, this technology can make changes in a person’s DNA by replacing an existing segment with a customized DNA sequence, thereby

“In conclusion, the full clinical route in the translation of gene-editing technology is almost complete,” he noted. “We are almost set to transform the care of patients with a well-defined genetically characterized disease if diagnosed early.”

Front and center

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27 February 2022 | Issue #1

Need Help with Glaucoma Management?

Here are tips from experts at RANZCO 2022

by Hazlin Hassan

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laucoma management can be a minefield of hidden problems and dangers. However, with better treatments and earlier detection, the impact of this so called “silent thief of sight” can be reduced — helping sufferers lead a normal, independent life with their vision preserved.

In the Australian and New Zealand Glaucoma Society (ANZGS) Symposium 2022 - Survival Tips from the Glaucoma Experts, challenges in managing glaucoma, including patient adherence to medication, were discussed.

Patients can be prescribed the best medications available, but if they fail to take them the proper way, the treatment simply won’t work. Even with the best

diagnostic tools available, it still requires interpretation to make a diagnosis.

Here are some tips from glaucoma experts to help you and your patients manage glaucoma better.

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Identify the reasons of adherence problems

Prof. Ivan Goldberg from the University of Sydney and Sydney Eye Hospital, Australia, shared tips on how to try to optimize medication adherence.

“The average adherence among eye disorders is ranked as high as 73%,” said Prof. Goldberg, adding that the rate has been reported as being anywhere

between 5% and 85%.

According to him, some four billion prescriptions are given out in the United States each year, based on statistics from the Centers for Disease Control and Prevention (CDC).

“One in five is never filled at all and for half of those that are filled, the medications are taken incorrectly with respect to timing, dosing frequency, or duration,” he said.

The costs of non-adherence include higher rates of hospital admissions, sub-optimal health outcomes, higher morbidity and mortality for chronic conditions like glaucoma.

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

Skipping doses may lead to increased IOP fluctuations. Data has also shown that over an eight-year period, there is a four-fold increase in loss of visual field sensitivity in patients who admit to not following their prescription.

Factors that undermine OCT accuracy include OCT “red disease” where the nonexistent disease is incorrectly indicated by instrumentation, signal quality, scan alignment, scan centration, opacities and segmentation error.

trabeculoplasties and stents that need supplementation and medication.

However, they don’t work if the angle is closed, or if stents are not working. “The laser energy must be applied with optimal fluence and positioning,” he added.

“In conclusion, patients generally do not do what they are ‘supposed’ to do,” Prof. Goldberg said. “Patients will also not tell doctors reliably that they are not doing what they are supposed to be doing, partly because they don’t want to disappoint them, and also because ‘how can you expect me to remember what I have forgotten to do?’”

She said it is important to look for focal change.

Patients should not be sent home without a 45-minute post-SLT pressure check or sent home with steroids.

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To conclude, she noted that the OCT is a powerful tool that requires a systematic approach and is an essential part of glaucoma management.

Customize your adherence strategy

The barriers to adherence can be divided into financial as well as human resources, and the patient’s level of education and understanding about the disease, the goals of treatment and the pitfalls of treatments.

The chronicity and asymptomatic nature of glaucoma generally tends to be progressive if it is not well controlled, and patients need to be made aware of this.

In summary, strategies must be individualized, and there is no “one size fits all” approach, Prof. Goldberg shared.

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Know your OCT

Prof. Helen Danesh-Meyer, Sir William Professor of Ophthalmology from the Department of Ophthalmology, University of Auckland, New Zealand, shared how to avoid the pitfalls of optical coherence tomography (OCT).

“OCT has revolutionized glaucoma care.

It is the most important tool for early diagnosis and management of glaucoma,” she said. She pointed out that the reason for this is that glaucoma is an optic neuropathy.

“The damage to the retinal ganglion cells, which form the inner layers of the retina, and the axons from the retinal nerve fiber layer, converge at the optic nerve head as the neuroretinal rim. So, a device such as the OCT, which allows us to objectively measure these various parameters, is helpful in identifying the state of glaucoma,” she added.

The three most common retinal nerve fiber layer (RNFL) progression patterns include a new RNFL defect, widening of an existing defect, and deepening of an existing RNFL defect without widening.

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Make SLT work

Dr. Frank Howes from the Eye and Laser Centre, Gold Coast, spoke about how to make selective laser trabeculoplasty (SLT) work.

“The great thing about SLT is that it works between 80% and 90% of the time. We need to know the laser, the anatomy, the gonioscope and the application routine,” shared Dr. Howes.

Choosing the right patient and the correct laser setting is also crucial.

SLTs work best as a primary treatment and appear to work in all forms of openangle glaucoma and ocular hypertension (OHT), whether treated or untreated.

They also work on previous

Further, he cautioned that a significant number of patients can have an intraocular pressure (IOP) rise post-SLT, particularly in heavily-pigmented angles and in the presence of 360-delivered SLT. It is, therefore, particularly useful to pretreat patients with Iopidine in a busy laser clinic to avoid post-laser congestion.

“Do not give up on success until three months after SLT delivery. Success may still be defined as a reduction in the total number of drugs required to reach target IOP,” Dr. Howes concluded.

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Minimize side effects and provide support

Other suggestions from experts include minimizing drug administrations, costs and side effects, encouraging communication, providing support and being non-judgmental.

Session chair Prof. Graham Lee of the University of Queensland, Australia, suggested advising the patient to take their eye drops together with an activity they do every day around the same time, such as brushing their teeth.

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27 February 2022 | Issue #1

The Parr and Crock Awards A tribute to ‘papers par excellence’

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he Royal Australian and New Zealand College of Ophthalmologists 52nd Annual Scientific Congress (RANZCO Brisbane 2022) virtual recognized several papers that were up for two awards: the John Parr and Gerard Crock awards.

by Sam McCommon

was one of New Zealand’s titans of ophthalmology, with the classic 1976 textbook Introduction to Ophthalmology to his credit.

The Parr award: AI at the forefront

Two of the three papers focused on deep learning or artificial intelligence (AI) systems. One of those, presented by Mr. Finley Breeze, described a system that predicted ophthalmic clinic attendance with machine learning. In short, an algorithm can be created to determine which patients might be at risk of skipping sessions and give doctors something to chew on with regard to encouraging patients to get to the clinic when they need to.

The first part of the discussion featured pre-vocational medical students who have been nominated to win the John Parr award. For those unaware, Dr. Parr

The third, presented by Dr. Jason Daley, covered the development of a deep learning algorithm for diabetes retinal screening in South Western Sydney.

Logically, then, this segment was split into two parts. So, first, we shall discuss the Parr award — which gave us papers par excellence.

Let’s dive right in!

We’d love to get into more detail on those, but delving into these includes as much computer science as it does ophthalmology. That’s the way many trends are going, indeed, but much of data science is its own field.

So, instead, we shall move to the second paper, which examined a 21-year retrospective study of ocular melanoma in New Zealand, and raised plenty of questions. This discussion was led by Dr. Joevy Lim, a Ph.D. candidate at the University of Auckland.

First, let’s establish some basics: Ocular melanoma most commonly occurs in the uvea. North of 50% of patients with uveal melanoma develop metastases, with fatalities commonly occurring in less than a year as the cancer spreads to the liver, lungs and bones.

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

Uveal melanoma is far higher in western and northern Europe, with Sweden topping the list at 11 cases per million per year. By comparison, South Korea only experiences 0.4 cases per million per year, so something is up here.

In New Zealand, 1.64% of melanomas reviewed over the 20-year period were ocular melanomas — 771 out of 46,975 total melanomas. The majority of those ocular melanomas — 94.9%, to be exact — were of European descent, with a nearly even breakdown between male and female, and an average age of 63.9. For reference, the next closest demographic was Maori at 3.6%. No survival difference was found between Maori and Europeans.

Also for reference, Maori populations experienced an earlier onset of ocular melanoma.

But do you want to know something weird? While ocular melanoma made up only 1.6% of melanomas in New Zealand, it made up 3.7% to 5.1% of melanomas in the US. However, the incidence of cutaneous melanoma in NZ was twice that in the US. If that makes you ask, “why?” then you’re not alone.

While latitude was weakly correlated with an increase in melanoma rates, it doesn’t explain the differences in ocular melanoma rates between NZ and the US. NZ counts iris and ciliary melanoma as the same thing, but it still doesn’t get to the root of the difference.

Long story short? Something is up here, but we don’t know what yet. This is the largest incidence and mortality study on ocular melanoma so far in NZ, so it’s a great start. This is one of those threads that might unravel if the ophthalmic community keeps pulling on it.

The Crock award: Women and myopia Gerard Crock was the founding professor of ophthalmology at the University of Melbourne and was an outstanding pioneer in the field.

There were three nominees for the award this year: Dr. David Squirrell, who presented a multi-center retrospective trial of THEIA to detect diabetic retinopathy and diabetic macular edema in NZ; Dr. Samantha Sy Lee,

who discussed myopia incidence and progression between 20 and 28 years of age; and Dr. George Kong, who shared his research on home monitoring of the visual field for glaucoma patients using a tablet.

We applaud all of these doctors for their presentations since there’s a lot to chew on here. But there’s one particular bone we need to pick — and that’s the progression of myopia, which is becoming an alarming problem worldwide.

As Dr. Lee explained, myopia generally develops and progresses fastest during childhood and stabilizes when a patient is around 15 to 16 years old. However, several resorts of myopia onset or continued progression in university students and young adults have been released over the past 20 years or so.

Dr. Lee suggested that one cause of increased myopia during this time could be due to essentially indoor work. As most university students go from school to an office or otherwise indoor job, they spend lots of time looking at screens or other near-vision objects, which could contribute to myopia. We have little data on just how refractive error develops during this period and how it relates to indoor work.

Dr. Lee drew data from the Raine study, which followed 813 young adults between the ages of 20 and 28. Among these young people, the eight-year incidence of myopia was 14% — roughly one in seven.

Of these, women, those of East Asian ethnicity, those with parental myopia, or those with less self-reported sun exposure were most at risk. Education level was not significantly associated, by the by.

Oddly enough, women’s myopia progressed faster than men’s. At age 20, there was no sex difference in myopia rates. So what happened during age 20 to 28?

Dr. Lee suggested that there might be several factors at play here, notably a higher tendency for women to work indoor-based jobs and a broader push for women to achieve higher education than before. Still, though, since the study corrected for education levels, it shouldn’t be the determining factor.

Lifestyle and habits, as well as biological and hormonal factors may be at play. This disparity is something that will need to be tested out in future studies.

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27 February 2022 | Issue #1

VERITAS: A True Partner for Cataract Surgeons

by Brooke Herron

occlusion sensing, pressure in the aspiration channels is continuously monitored and proactively adjusted for further chamber stability.

The VERITAS system also includes surgeon-centric features to increase efficiency during phaco — even in challenging cases. Its dual pump system (including both peristaltic and venturi pumps) allows surgeons to select their preferred approach, or to adapt case-bycase. And to further increase efficiency — and use less energy — VERITAS comes with Johnson & Johnson’s proven WHITESTAR technology.

Dr. Jonathan Goh is an ophthalmologist at The Royal Victorian Eye and Ear Hospital in Melbourne, Australia. He shared that the main advantages of VERITAS are its fluidics and excellent venturi pump system.

“I think the key improvements in the VERITAS over the previous Signature PRO are its fluidics and anterior chamber stability — although good previously, it is now rock solid,” he said. “Post-occlusion surge also seems to be much reduced in denser nuclei. Overall, this makes cataract surgery even safer, more efficient and more predictable.”

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orldwide, cataract remains a leading cause of preventable visual impairment and loss. To narrow it down to the RANZCO region: Approximately 700,000 Australians have cataract,1 while 370,000 Kiwis are affected.2 And each year 250,000 and 30,000 cataract surgeries are performed in Australia and New Zealand, respectively.1,3

system, VERITAS was designed with three critical areas in mind: patient safety, surgeon efficiency and comfort.

Today, phacoemulsification (or phaco) is the most common method of cataract removal and is preferred among surgeons for its safety.4 However, it is a delicate procedure and therefore, surgeons need to be able to rely on the equipment used during surgery to optimize results.

Fluidics play an important role during phaco: Balancing the inflow and outflow maintains the working space and prevents the chamber from collapsing.

As such, fluidics optimization is crucial to both safety and efficiency.

With an aging population, the number of patients already awaiting cataract surgery is sure to rise, adding more burden to an already backlogged system. Recognizing this unmet need, Johnson & Johnson Vision (Santa Ana, California, USA) developed the VERITAS™ Vision System.

Described as a next generation phaco

For a safer, more efficient surgery…

The VERITAS addresses this vital area via its proprietary Hybrid Fluidics Technology. The system utilizes a series of capabilities designed to enhance performance throughout the procedure, including an advanced tubing system to minimize post-occlusion surge and advanced infusion to protect intraocular structures. In addition, using intelligent

Dr. Goh continued: “Although I prefer the venturi pump, the option of having both a true venturi and a true peristaltic pump at the switch of a button — which transitions seamlessly — is also very handy. In addition, it’s a good platform to show trainees the real-world difference between the two pump types.”

Further, adding to the ease and efficiency of cataract removal, the phaco tip moves in an elliptical pattern for ultra-smooth cutting and lens extraction — resulting in less stress for the surgeon and better outcomes. Together, the sum of these features help preserve a calm, stable chamber while offering surgeons more control — even in dense cataracts.

…and a more comfortable one, too Surgeons often perform multiple cataract procedures daily. This can take a toll on the body: Between 52-80% of ophthalmologists report back and neck pain as a result of their work — causing a

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

significant number to either take breaks or reduce their surgical workload.5

provides optimal range of motion for extra comfort and control.

The increasing importance of ergonomics to surgeons’ health — and thus, career longevity — was recognized by R&D over at Johnson & Johnson Vision during the development of the VERITAS, which was designed to not only optimize comfort — but to also reduce fatigue.

The swivel handpiece (with up to 220° rotation) enhances maneuverability and precision, while the lightweight body minimizes hand and wrist fatigue. Plus, the ergonomically designed foot pedal

Enhanced safety, exceptional efficiency and the added focus on surgeon comfort makes the VERITAS a triple threat when it comes to improving outcomes in cataract surgery. And as Dr. Goh concluded: “Overall, the VERITAS is a nice complete package with excellent fluidics.”

The VERITAS Vision System will be available soon to ophthalmologists in Australia and New Zealand.

REFERENCES 1.

700,000 Australians now living with cataracts. Medibank. 8 March 2018. Available at https://www.medibank. com.au/livebetter/health-brief/health-insights/700000-australians-now-living-with-cataracts. Accessed on 16 Feb 2022.

2.

New standard to improve care for Australians with cataract. Australian Commission on Safety and Equality in Health Care. 17 Aug 2021. Available at: https://www.safetyandquality.gov.au/about-us/latest-news/mediareleases/new-standard-improve-care-australians-cataract#_edn2. Accessed on 16 Feb 2022.

3.

Statistics and Research. Blind Low Vision NZ. 2021. Available at https://blindlowvision.org.nz/information/ statistics-and-research/. Accessed on 16 Feb 2022.

4.

Davis G. The Evolution of Cataract Surgery. Mo Med. 2016; 113(1): 58–62.

5.

Honavar SG. Head up, heels down, posture perfect: Ergonomics for an ophthalmologist. Indian J Ophthalmol.

2017;65(8):647-650.

Fire It Up!

Hot topics from an exciting session on epidemiology and genetics by Tan Sher Lynn

Contributing Doctor Dr. Jonathan Goh is a fellowship trained comprehensive ophthalmologist. He obtained his medical degree from the University of Melbourne (MBBS, BMedSci). He was later awarded his Postgraduate Diploma of Surgical Anatomy (PGDipSurgAnat) and Master of Surgery (MS) from the University of Melbourne for his research in age-related macular degeneration (ARMD). He completed his ophthalmology training at The Royal Victorian Eye and Ear Hospital with further subspecialty training in medical retina and ocular inflammatory diseases.

He continues to be involved in ophthalmic research and has published and presented his findings nationally and internationally in ARMD, diabetic retinopathy, and dry eye disease. He is actively involved in teaching and held the position of Registrar of the Court (2020). dr.jksgoh@gmail.com

were conflicting, with most of the data being outdated and reporting about Type 1 (T1) DR. By performing a prospective cohort study involving 147 pregnant women with T1DR or Type 2 (T2) DR from two obstetrics hospitals in Melbourne (2017-2019), Dr. Felicia Widyaputri from the Centre for Eye Research Australia (CERA) aimed to find out the prevalence of DR and sight-threatening diabetic retinopathy (STDR) during pregnancy. In addition, she aimed to identify the risk factors that play a role in its progression.

Diabetic eye screening was scheduled in the first, second and third trimester, and at three months after delivery.

From the risk of diabetic retinopathy in pregnant women to sibling discordance in Stargardt disease, experts presented hot topics from their respective fields during yet another rapid-fire session at The Royal Australian and New Zealand College of Ophthalmologists 52nd Annual Congress (RANZCO Brisbane 2022).

Hot off the press, here are a few of them…

Risk and progression of DR in pregnant women Prior studies about diabetic retinopathy (DR) in pregnant women

“Overall, the prevalence of any DR was 20.8 per 100 eyes, and the prevalence of STDR was 6.6 per 100 eyes — which is similar in the non-pregnant diabetic population in Australia,” said Dr. Widyaputri. “Elevated systolic blood pressure and pre-existing DR in either eye in early pregnancy increased the Cont. to Page 13 >>

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27 February 2022 | Issue #1

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>> Cont. from Page 11

risk of progression. We identified that T1DR, high HbA1C in early pregnancy and longer duration of diabetes are associated with the presence of DR in pregnancy but not associated with its progression. Instead, pre-existing DR and higher systolic blood pressure (>120 mmHg) in early pregnancy were associated with increased risk of DR progression,” she added.

The disparities of ophthalmic workforce provision in New Zealand The increasing prevalence of chronic ophthalmic diseases and an expanding range of treatment options have led to increased demand for ophthalmology services and specialist care.

Dr. Ruhella Hossain from New Zealand and colleagues evaluated the disparities in the distribution of publicfunded ophthalmic workforce provision and clinic appointment attendances in New Zealand through an analysis of 3,015,623 clinic appointments from 2009 to 2018.

Using national and regional datasets from the New Zealand Ministry of Health, national full-time equivalent employment data for the ophthalmic workforce was obtained from every ophthalmology department in 2017.

Rates of first-specialist assessments (FSA) and follow-up appointment attendances per 100,000-population per year were calculated.

“From 2009 to 2018, there were more than 2,803,350 public-funded clinic attendances across New Zealand with a 31.4% increase in all clinic appointment attendances,” shared

Dr. Hossain. “The majority of clinical appointments were follow-up at 62.5% and FSA at 18.9%. Followup attendances outnumbered FSA attendances, suggesting a large proportion of patients with chronic pathology requiring ongoing care,” she noted.

Understanding ADAMTSL4-associated ectopia lentis According to orthoptist Lachlan Knight from Flinders University, ADAMTSL4-associated ectopia lentis is a rare childhood autosomal recessive condition associated with biallelic pathogenic variants in the ADAMTSL4 gene. Recent reports have suggested that these are the presence of anterior segment abnormalities, including iris transillumination.

Knight and his team set out to summarize the ocular and systemic phenotype of the condition by performing a cross-section case series with a literature review last conducted in September 2021. All 92 individuals studied have biallelic pathogenic variants in ADAMTSL4.

They found that 100% of the individuals had ectopia lentis, 19% had ectopia lentis et pupillae, 14% had iris transillumination, 13% had iridodonesis, 13% had persistent pupillary membrane, 13% had earlyonset cataract or lens opacity, 12% had spherophakia, and 12% had poor pupillary dilatation. In terms of systemic disease, 73% had no systemic features, ruling out that systemic disease is part of the disease spectrum, although this is not conclusive due to the low number of cases.

“ADAMTSL4-associated ectopia lentis is most commonly an isolated ocular condition

with relatively low complications.

Genetic testing is recommended in children with ectopia lentis and this would allow for appropriate referrals to investigate and manage any associated systemic features, as well as genetic counseling,” Knight concluded.

Sibling discordance in Stargardt disease According to Dr. Rachael Jeffery from Perth, a quarter of families with Stargardt disease have more than one affected member. Using ultra-widefield fundus autofluorescence (UWF-FAF), she and colleagues investigated the concordance in age at symptom onset, atrophy size and growth rate between sibling pairs with Stargardt disease due to identical ABCA4 variants.

Of the 39 patients from 19 unrelated families studied, 32 patients from 16 families had age-matched best corrected visual acuity (BCVA) and decreased autofluorescence (DDAF), and 16 patients from eight families had age-matched DDAF growth rates.

“No families had inter-sibling discordance in growth rates that exceeded the 95% interocular limits of agreement in both eyes. We hypothesized that processes which lead to the formation of atrophy are more susceptible to genetic and environmental modifiers while lesion growth is mostly dependent on the baseline DDAF area and genotype,” noted Dr. Jeffery.

She concluded: “Despite asymmetry in disease severity at age-matched time points, there were no significant differences between siblings in their DDAF lesion growth rate. Lack of significant inter-sibling differences in GR warrants further investigation.”

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27 February 2022 | Issue #1

When Cancer Gets in Your Eyes Highlights from an ocular oncology session

by Sam McCommon

P

ew-pew, pow pow, bang bang, ratatat-tat! That’s what the rapid fire session on Day 1 of The Royal Australian and New Zealand College of Ophthalmologists 52nd Annual Scientific Congress (RANZCO Brisbane 2022) virtual meeting sounded like, with oculoplastic and ocular oncology topics flying by at the speed of … well, you get the idea.

bilateral lacrimal gland disease (BLGD) compared to just plain ol’ lacrimal gland disease?

With so many topics to cover in such a short time, a beleaguered writer may be well served by picking topics out of a hat.

So, uh … here we go.

First of all, we need to highlight that BLGD is less common than unilateral lacrimal gland disease. While it may represent a localized orbital disease, like regular LGD, it can also indicate a systemic problem.

In fact, BLGD is a strong indicator of a systemic problem since the two glands are separated in space.

Bilateral lacrimal gland disease: More than meets the eye You know about lacrimal gland disease, naturally. But what do you know about

Fear not: Dr. Sonia Huang, from the South Australian Institute of Ophthalmology at the University of Adelaide, is here to help.

Because, really, there’s more than meets the eye with BLGD.

As of now, there’s not much research available on the topic. That’s a crying shame, and it’s one Dr. Huang would like

to dry the tears of.

So, Dr. Huang organized 25 years (!) of data from practices in three major cities (Melbourne, Los Angeles and Adelaide). Among the patients from whom data was collected, the diagnosis of lacrimal gland disease was made utilizing a combination of clinical findings, laboratory investigations, radiologic studies and biopsy. All patients were required to have either a serological test or biopsy performed to be included in the study. This yielded 115 patients, which is far better than, say, zero. For reference, most patients were female (63.5%) and caucasian (73.9%).

Patients presented with a number of symptoms, including a palpable mass in the lacrimal fossa, mechanical blepharoptosis, periorbital edema, dry

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eye, globe dystopia (the eye kind…) or a conjunctival infection.

the ophthalmic field, and maybe even to some in it, too.

From these multiple symptoms, four specific diagnoses emerged: IgG4related disease and idiopathic orbital inflammatory disease (17.4%), lymphoma (13.9%), lacrimal gland prolapse (11.3%) and sarcoidosis (9.6%).

As Dr. Yinon Shapira with the Royal Adelaide Hospital pointed out, there’s very little information regarding the management approach for orbito-cranial schwannomas (OCS). For reference, a schwannoma is a type of tumor that forms in the nervous system and is quite rare.

They grow on Schwann cells, hence the name. Though they’re often benign, well, sometimes they’re not.

So, what are the takeaways here? First, it’s very difficult to accurately determine the cause of BLGD with clinical findings alone. Most pathologies involved in BLGD are systemic inflammatory conditions or malignancies and may be the first presentation of a multi-organ disease.

In short, when a patient shows up with BLGD, doctors need to look under the hood very carefully, because the real cause may be something much more serious and systemic than initially expected.

The lowdown on orbitocranial schwannomas The term “schwannoma” may sound made up to basically anyone outside of

Dr. Shapira noted that extracapsular total resection — the mainstay for localized lesions — is both challenging and risks significant morbidity. So, he shared data of a case series of 10 patients with OCS, including six orbital services over 22 years, demonstrating alternatives to extracapsular total resection.

OCS can show up fairly early, with the mean age at 41.4 — though ages ranged from 19 to 76 years old. Of the 10 patients, six were female. All tumors in this series involved the orbital apex, the superior orbital fissure, and extended at least to the cavernous sinus.

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In most cases, the orbital approach used was a lateral orbitotomy or superolateral orbitotomy. In three cases, an eyelidsparing exenteration was performed.

Neurosurgical craniotomy approaches included orbitofrontal, orbitozygomatic, frontotemporal and pterional, most often with image guidance. Surgeons utilized an endoscopic transorbital approach for two patients, and adjuvant fractioned stereotactic radiotherapy (SRT) was used in three patients.

In conclusion, Dr. Shapira wants readers to take home the following key messages: First, an orbital-neurosurgical collaborative approach increases the feasibility of complete or subtotal tumor removal. Second, an intracapsular resection may decrease the risk of collateral damage and should be strongly considered, particularly for the intracranial component. And third, postexcision adjuvant stereotactic radiation therapy (SRT) can be considered in the process, as well as for local control of residual tumor progression.

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