CAKE & PIE POST (52nd RANZCO 2022 Edition) - Issue 4

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ISSUE

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HIGHLIGHTS or a Bane 05 Boon Strengths and pitfalls of novel glaucoma testing algorithms

Your Interest 06 Pique Not-to-be-missed neuroophthalmology sessions at RANZCO 2022

Eye Care 07 Accessible for All

Measures for improving eye health among Aboriginal and Torres Strait Islanders

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The Age of Disruptive Innovation RANZCO 2022 wraps up with a key message: adapt and innovate

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Andrew Sweeney Hazlin Hassan Joanna Lee Sam McCommon Tan Sher Lynn Maricel Salvador Graphic Designer

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imply put, disruptive innovation cuts into the bigger and better cycle to bring about a product or service that is more affordable or easier to use, allowing a whole new population of consumers to easily access something that was historically only available to those with more means or greater skills.

In her presentation, she emphasized the need for systems and design thinking, reflecting on the disruptive year of 2020 and the platform of growth for healthcare.

“When we are facing disruption, we need to innovate more than ever,” explained Assoc.

Prof. Catherine Green, head of the Glaucoma Unit at The Royal Victorian Eye and Ear Hospital in Australia, during the Fred Hollows Lecture, which commenced in conjunction with the closing of the 52nd Annual Scientific Congress of The Royal Australian and New Zealand College of Ophthalmologists (RANZCO Brisbane 2022).

This disruptive innovation could be seen in the establishment of the Glaucoma Collaborative Care (GCC) Project, which was organized in 2016. The multidisciplinary effort based at the Australian College of Optometry brought together orthoptists, optometrists and glaucoma specialists to improve the challenge of meeting the capacity of increased patients with their

Novel and cutting-edge projects

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02 March 2022 | Issue #4

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

>> Cont. from Page 1

limited resources of doctors in the system.

They found that a large percentage of patients didn’t need to be in hospitals, so the GCC facilitated a consultant triage for initially low-risk new referrals and later added existing patients onto the waitlist.

One-on-one mentoring and discussions were also conducted during the clinic where they would review patients together. Their collaborative system successfully reduced over 48% of patients on their waiting list — all while being able to prioritize higher-risk patients.

While there was progress and satisfaction by patients and doctors in the GCC project, there still remained a high backlog of patients. Hence, the Glaucoma Community Collaborative Care Project (G3CP) was started. The project engaged community optometrists in areas of high demand. “This was underpinned by educational sessions to promote engagement by the optometrists in a community of practice where they interacted with glaucoma consultants,” Assoc. Prof.

Green said.

The project was a success with high patient satisfaction and reported enjoyable interactions between optometrists and glaucoma consultants. This project had become a proof of concept for the safe monitoring of lower-risk glaucoma patients while establishing a network of optometrists they could collaborate with.

Adapting to a new normal When COVID-19 hit, the barriers to the exchange of information were exacerbated as an issue to which Assoc.

Prof. Green said digital solutions are critical for the long-term sustainability and scalability of ensuring adequate and efficient patient care.

Citing G3CP’s response by creating

See Ya Later at the 53rd RANZCO Congress!

For the closing of the 52nd conference, RANZCO’s President, Prof. Nitin Verma, addressed the 181 participants who joined the virtual session.

“The participation at the 52nd RANZCO virtual conference saw the second-largest congress ever,” he enthused.

On behalf of the congress, he acknowledged the illustrious keynote speakers who have presented their special lectures as well as those who have worked hard behind the scenes, including Chair of the Scientific Program Committee, Dr. Elsie Chan; RANZCO staff; Think Business Events and Gliding Wings Productions; and their sponsors.

Highlighting the successful launch of Vision 2030 and Beyond — a 10-year plan to ensure the availability of equitable eye care — as well as the presentation of three scholarships to upcoming

ophthalmologists under the 2021 Aboriginal, Torres Strait Islander, Māori and Pasifika Scholarships, Prof. Verma rallied for participation at the upcoming May 2022 National Aboriginal and Torres Strait Islander Eye Health Conference.

Several awards were also given out in recognition of recipients’ excellence.

The Best Paper under the Gerard Crock Trophy was won by Dr. George Kong, while the John Parr Trophy award went to Mr. Finley Breeze. The Best CPD Audit prize went to Mr. Joel Mudri. Mr. Edmund Khong won the Best ePoster. And the People’s Choice winner was Dr. Keith Ong. There were also awards for educational films, where Best Overall Film went to Dr. Tabitha Scott’s Filling the Gap - Artificial Iris Intraocular Lenses — which also won the Best Ophthalmic Research Film prize.

As the saying goes, all good things must come to an end. We can’t wait for the 53rd RANZCO, which will be held in Brisbane this year from October 28 to November 1, 2022. See you there!

a system of assessing patients’ risks through their electronic health records by glaucoma consultants to determine the patient’s need for immediate care or recovery, Assoc. Prof. Green emphasized the opportunities for adopting more technologies for health solutions.

Lecture, Assoc. Prof. Green said: “Simulation training is now established as an essential enabler for innovation.”

“The existing health record with adequate clinical information was able to triage the patients in a less labor-intense way than if we had to do it manually,” she said, citing a study* and other digital innovations, such as Peek and Osmosis.org platforms, which were very helpful during the height of the pandemic.

“As a profession, we need to consider how we might be disrupted, especially if we don’t innovate,” Assoc. Prof. Green concluded.

Improvement of surgical training is also another priority. Citing Dr. David Lockington’s earlier Cataract Update

“The elements of disruptive innovation should consist of sophisticated technology that simplifies; low-cost, innovative business models; economically coherent value networks; and regulations and standards that facilitate change,” she added.

* Bommakanti NK, Zhou Y, Ehrlich JR, et al.

Application of the Sight Outcomes Research Collaborative Ophthalmology Data Repository for Triaging Patients With Glaucoma and Clinic Appointments During Pandemics Such as COVID-19.

JAMA Ophthalmol. 2020;138(9):974-980.

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High-Pressure Session RANZCO 2022 presents yet another rapid-fire discussion — this time on glaucoma by Sam McCommon

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efore wrapping up the 52nd Annual Scientific Congress of The Royal Australian and New Zealand College of Ophthalmologists (RANZCO Brisbane 2022), we give you yet another of their bynow-signature Rapid Fire Sessions — each of which provides a veritable treasure trove of ophthalmic goodies on the topics of glaucoma and neuro-ophthalmology.

While we’re far away from Halloween, this grab bag of knowledge goodies is a lot like a bucket of candy and will please the mental palates of eye lovers everywhere.

So, we’ve grabbed two pieces here and will dissect them before digestion.

Childhood glaucoma: QoL impacts in adults In this publication, we discuss glaucoma all the time. After all, it’s one of the most prevalent and pernicious eye diseases worldwide, and its multifactorial basis means there’s no end to what one can learn about it.

One thing that’s a bit new is a discussion of childhood glaucoma and its later effect on the quality of life. This discussion was brought to us by Mr. Lachlan Knight, a Ph.D. candidate at the Orthoptist Flinders University in Australia.

As we know, glaucoma is a chronic condition — but its psychosocial impact is underdiscussed. As Mr. Knight pointed out, there’s limited research regarding quality of life (QoL) in adults with childhood glaucoma. The research there is, however, has suggested lower life satisfaction and lower mental health than those without glaucoma, as well as a limited understanding of the cause of the condition and potential mental health issues. As it stands, there is no childhood glaucoma-specific study to accurately measure QoL from childhood to adulthood.

That’s what Mr. Knight set out to rectify.

This resulted in 47 adults in his study, following a number of recurring themes in QoL. “Coping” and “emotional wellbeing” were the most notable, followed by “ocular health concerns” and “symptoms.”

Issues with coping and emotional well-being far and away dominated the themes, indicating that there are serious long-term psychological impacts of childhood glaucoma. Coping, for example, can include positively adapting to limitations like using visual aids or relying on public transportation. It can also result in maladaptive coping, like ignoring glaucoma care.

Quite notably, the majority — 66% of

patients — were concerned about having children because they didn’t want to pass on the condition. Some 60% of those in Mr. Knight’s study sought genetic counseling before having children to ease their mind, as well as make it up.

The upshot here? Childhood glaucoma can have long-term impacts as far as the next generation, and doctors should be aware of the psychosocial implications of glaucoma as well as the physical, and handle maladaptive coping mechanisms in children and young adults before they inflict long-term damage.

HORIZON study: A five-year follow-up Prof. Graham A. Lee from the University of Queensland, Australia, led us through a discussion of the five-year results of the HORIZON clinical trial. For reference, HORIZON is a randomized, multicenter study of the Hydrus® microstent (Ivantis, Irvine, California), a minimally invasive glaucoma surgery (MIGS) option.

Prof. Lee noted that this continuous five-year follow-up compared combined cataract surgery with Hydrus vs. cataract surgery alone, with 80% of patients from the initial study still onboard after five years. Long-term effectiveness was rated by intraocular pressure (IOP) reduction, dependence on medication, failure rates and safety.

And, drum roll… after five years, a combination of cataract surgery with Hydrus reduces IOP as well as medications. Note the “combination” part — the findings here suggest that the combination is, indeed, the key.

Those with Hydrus and cataract surgery experienced a lower risk of glaucoma surgery.

Dr. Lee pointed out that this is the first reported clinical benefit associated with a MIGS procedure. Essentially, Hydrus reduces medication non-adherence and the surgical procedure reduces diurnal fluctuations in IOP compared to topical eye drops.

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

Boon or a Bane Strengths and pitfalls of novel glaucoma testing algorithms by Tan Sher Lynn

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valuation of visual field (VF) damage remains a mainstay for the clinical diagnosis of glaucoma and assessment of its progression. Recently, new concepts on visual field testing are emerging — to the delight of everyone in the industry.

On Day 4 of the 52nd Annual Scientific Congress of The Royal Australian and New Zealand College of Ophthalmologists (RANZCO Brisbane 2022) during his Glaucoma Update Lecture, Dr. Pradeep Ramulu from the Johns Hopkins Wilmer Eye Institute in the United States presented novel concepts in evaluating functional damage in glaucoma, offering evidencebased insights on how to better integrate visual field reliability data into clinical decision making.

Coming in fast and furious Fast or faster glaucoma testing algorithms are able to complete testing in less time, and real-world data has confirmed the advantage of significant speed by comparing faster versus standard test duration. Nevertheless, Dr. Ramulu noted that there may be some pushback against using faster algorithms, as they are thought to be inherently less accurate, show patterns of damage that are not the same, and won’t detect progression as accurately or quickly.

“One study assessing reliability suggested Swedish Interactive Thresholding Algorithm (SITA) Faster is much less reliable than SITA Standard,” he said. Seed point bias described with prior generations of visual field algorithms is more common with SITA Faster.

“You need to be aware of abnormal test quadrants that tested normal with SITA Standard when switching to SITA Faster,” he noted. “False positives are also more common at value range and stage of the disease where they are least impactful. However, limited evidence suggests that these differences in reliability matter.”

Most importantly, according to a study he found, the variability in StandardFaster VF pairs is similar to StandardStandard VF pairs whether in mild, moderate or advanced glaucoma.

He added that SITA Faster increases the degree of “normal” in the visual field, but the progression of detection is similar between SITA Standard and SITA Faster. Nevertheless, the benefits of 24-2c over SITA Faster 24-2 are unclear. “There is no evidence of better overall sensitivity or specificity or ability to detect progression,” he shared.

Reliability vs. speed Dr. Ramulu thought that the limitations with unreliability need to be weighed against the benefits of faster testing.

“A bottleneck for glaucoma clinics is usually the wait for VF testing — for example, when several patients needing

testing arrive in a cluster,” he said. “In my personal experience, the average patient wait time per clinic drops five to 10 minutes with SITA Faster. Assuming you have one wrong decision due to SITA Faster, in 10 clinic days, there will be 25 to 50 hours saved for every one wrong decision.”

In terms of whether the new SITA test pattern of 24-2c is better than the traditional 24-2 field, Dr. Ramulu said that there is no evidence of better overall sensitivity or specificity, or ability to detect progression.

“It only adds about 30 seconds per test, and it probably does pick up more central defects. However, in one study of 25 glaucoma eyes and 25 normal eyes, it did not diagnose glaucoma better,” he shared.

“VF in glaucoma is only part of the story. Other aspects to consider are the symptomatic worsening of vision, worsening results on testing and whether the IOP is above target.

Based on these points, I make a decision on whether to decrease or continue to the same treatment, use advanced medications, consider laser trabeculoplasty, increase followup frequency or consider/push for surgery,” he concluded.

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02 March 2022 | Issue #4

Pique Your Interest

Not-to-be-missed neuro-ophthalmology sessions at RANZCO 2022 by Andrew Sweeney

His work on the diagnosis of multiple sclerosis (MS) following optic neuritis was particularly insightful, reporting that if a magnetic resonance imaging (MRI) scan demonstrates typical lesions with gadolinium elements, then such a diagnosis can be secured.

Prof. Lee also reported that optic neuritis should be followed for a long time after diagnosis, as there is a 22% risk of MS in patients without lesions over 10 years, and a 70% risk over the same period with patients that have five or more lesions.

All about retinal arterial occlusion Another interesting session was Arterial Occlusion to the Eye - An Ophthalmology Perspective, presented by Dr. Lynn K. Gordon, a professor of ophthalmology and the Vernon O. Underwood Family Chair at the Jules Stein Eye Institute at the University of California Los Angeles (UCLA), USA. Dr. Gordon shared her experience in examining retinal arterial occlusion, reporting that 67% of patients with the disease have at least one cardiovascular risk factor, and up to 30% had magnetic resonance imaging (MRI) evidence for other cerebral ischemia.

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hen a neuro-ophthalmology topic comes up at an ophthalmology conference, you know it’s going to be interesting. So, you gnash your intellectual teeth and brace for an enjoyable session.

Such was this particular symposium that we covered during the 52nd Annual Scientific Congress of The Royal Australian and New Zealand College of Ophthalmologists (RANZCO Brisbane 2022).

The session, titled What Happens After You’ve Diagnosed, didn’t give much away in its title. But it turned out to be a session jam-packed with

interesting presentations about neuroophthalmology from some of Australia and New Zealand’s finest medical minds — covering subjects ranging from optic neuritis to arterial occlusion to the eye.

Diagnosis of MS following optic neuritis One of the first presentations during the symposium was Neurology/NeuroImmunology Perspective by Assoc. Prof.

Andrew Lee, director of the Centre for Neuroscience Innovation at Ashford Hospital, Stanwell, United Kingdom.

She said there was no evidence of efficacy for ocular therapies, and that hyperbaric oxygen treatment is recommended if there is an onset of symptoms in under 24 hours.

When it comes to the long-term treatment of retinal arterial occlusion, Dr. Gordon recommended modification of risk factors and ongoing evaluation for neovascular complications.

If you’re interested in all the nifty, nice, and no doubt fascinating things about neuro-ophthalmology, then make sure to check this symposium out on the RANZCO platform on demand.

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

Accessible Eye Care Measures for improving eye health among for All Aboriginal and Torres Strait Islanders

by Tan Sher Lynn

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ine years after the release of the Roadmap to Close the Gap for Vision policy framework in 2012, eye health access and outcomes for Aboriginal and Torres Strait Islander Australians have improved measurably. Yet, more needs to be done.

On Day 4 of the 52nd Annual Scientific Congress of The Royal Australian and New Zealand College of Ophthalmologists (RANZCO Brisbane 2022), ophthalmologists discussed strategies and approaches to improve eye health outcomes for this particular group of patients.

Expediting access for indigenous patients Dr. Kristin Bell from the Royal Hobart Hospital (RHH) shared how her hospital’s eye department is expediting access to services for Indigenous patients.

“Aboriginal and Torres Strait Islander people make up 4.6% of the Tasmanian population (2016 consensus data) and 5.3% of outpatient appointments at the RHH eye clinic,” shared Dr. Bell. “Areas that we are focusing on in order to expedite access to services for this group of patients include prioritizing new outpatient appointments and access to elective surgery, locating indigenous patients already on the waitlists and expediting their care, and ensuring the RHH Eye Clinic is providing a welcoming and safe space,” she added.

She noted that a huge number of referrals per week (typically faxed and paper referrals) and unwieldy processes are just some of the referral and surgical booking barriers that exist in the hospital.

Patients who identify as Aboriginal and/or Torres Strait Islander are rarely included in referrals, and this information is not visible in the patient’s digital medical record (DMR) details.

Dr. Bell added that solutions are being undertaken to overcome these barriers.

These include educating referral bases — working with general practitioners, optometry and AMS liaisons; having triaging processes in place — ensuring measures to “close the gap” are wellknown by triage staff and providing reception staff to ask questions which identify patients as Aboriginal; and having e-referrals.

Overcoming more challenges Meanwhile, sharing her outreach experience in the Top End (a region encompassing the northernmost section of Australia’s Northern Territory), Dr. Eline

Whist from the Royal Darwin Hospital said that practicing ophthalmology in rural and remote areas comes with its own unique set of challenges and rewards.

“Traveling in the Top End involves vast distances. Due to the tropical weather, many communities are completely inaccessible by road during the wet season,” shared Dr. Whilst. “Hence, trips to these areas tend to be resource and labor-intensive. We (the Outreach Eye Team) work closely with the visiting optometrists, remote doctors, nurses and indigenous health workers. However, the number of ophthalmologists required to service the Northern Territory population is not being met yet. There are currently only five ophthalmologists available, while the number required for the population is more than nine,” she said.

Currently, approximately 100 cataract surgeries are performed a year at the Katherine and Gove hospitals, and the number of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections given during outreach trips continues to rise. In total, the outreach team spent more than 100 days a year in the Top End. Dr. Whilst noted that a change for outreach approach might be needed, as some of the communities that they are visiting have very low attendance rates.

“Non-attendance numbers are observed to be lower in clinics with long-term and enthusiastic staff that know the community well,” she said.

Other ongoing challenges that are to be addressed include inconsistent funding, staff shortage, remoteness and logistics, cultural and language barriers (with no Aboriginal liaison officer positioned in the Top End for the last two years), poor health literacy, and social and financial barriers.

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