Ophthalmology: creating balance

The RANZCO 2021 New Zealand Branch meeting was a much-anticipated affair amid the changing climate of Covid restrictions and unpredictable alert levels. Many of us experienced a renewed sense of freedom, catching a flight after being grounded for many moons, to finally mingle with colleagues at the historic Christchurch Town Hall from 19-20 March.

 

The welcome function was held in the sponsors’ area, detailed with an architectural ambience of crimson carpeting and chandelier lighting, creating the perfect atmosphere for free-flowing conversation over a relaxed glass of wine. Despite travel restrictions, there was a good turnout, with 326 on-site delegates, including sponsors, plus 46 virtual delegates among the specialists’ and nurses’ streams, with international speakers delivering lectures via Zoom.

 

 


The 2021 RANZCO NZ committee, Drs Liz Conner, Logan Robinson and Jo-Anne Pon with conference organiser Karen McLean (second from right)

 

The conference surpassed expectations not only in delivering scientific content but was also one of the foremost New Zealand Branch conferences to shed light on stigmatised topics of incivility, clinician burnout and mental illness. Personal anecdotes were bravely shared by Dr Genevieve Oliver and Dr Malcolm McKellar, clearly striking a chord with the audience. Future planning was also a prominent theme, specifically workforce restructuring in the digital age, climate change and the need to reduce our carbon footprint. Several teams across the country also shared novel, more efficient workplace designs developed in response to the Covid-19 crisis. The scientific programme was well rounded with keynote speakers Professor Bill Morgan from Lions Eye Institute in Perth covering exciting developments in glaucoma and Professor Stephanie Watson, chair of The Ophthalmic Research Institute of Australia, offering clinical pearls of wisdom on examination of the cornea.

 

The future: climate change, pandemics and workforce issues

 

Reflecting this year’s conference theme, Balance, Climate Change Commission chair Dr Rod Carr opened, outlining the real threat of climate change to New Zealand. Importantly he encouraged us to not get too overwhelmed by the task ahead, but to take tiny, practical steps in addressing climate change – something as simple as using the bus one day a week and suggesting the same to a neighbour, or reviewing the carbon footprint required when contracting a business.

 

In ophthalmology, we were told how procurement and supplies in theatre contributes up to 75% of the carbon footprint from cataract surgery. A single cataract surgery produces 150kg CO2, which is equivalent to a return flight from Auckland to Wellington! Dr Jesse Gale from Wellington highlighted the need for district health boards to have sustainability as a key performance indicator.

 

International speaker, Dr Cassandra Thiel, assistant professor at New York University and the Grossman School of Medicine, shared her research comparing carbon emissions from Aravind Eye Hospital in India with its western counterparts. Aravind’s carbon footprint for phacoemulsification was just 5% of the same surgery performed in the UK. This generated much talk on strategies we could develop to reuse, recycle and standardise procedures while maintaining safety.

 

There were more exciting exchanges of information from across the country from the forced restructure of our workplace practices during the pandemic, with some novel adaptations being surprisingly more efficient. Dr Cameron Loveridge-Easther from Nelson discussed the easy adaptability of intravitreal clinics into a virtual format, with clinician access to optical coherence tomography (OCT) and fundal images to decide further treatment – a structure that was also well received by patients. Auckland’s Dr Haya Al-Ani presented the reassuring safety of telephone check-ups for uncomplicated cataract day-one post-op patients, saving the patient from the effort of having to come back in and improving our carbon footprint.

 

Dr Roxanne Crosby-Nwaobi, head of research nursing at the National Institute for Health Research (NIHR) Clinical Research Facility at Moorfields Eye Hospital in London, discussed current research on building a digitally equipped workforce. She introduced audiences to the concept of home monitoring for age-related macular degeneration (AMD) in the form of the Alleye app*, and the exciting role of nurses as future leaders in tech education. In the digital age, emotional intelligence and people skills will be more highly sought-after personnel qualities, given that artificial intelligence may supplant much of our cognitive labour.

 

 


Dr Roxanne Crosby-Nwaobi on building a digitally equipped workforce

 

 

Physician, heal thyself: stress, incivility, self-care

 

A hot topic at this year’s meeting was the necessity of self-care and the impact of our overt and covert behaviours on team performance and patient safety.

 

Dr Genevieve Oliver opened the dialogue on what a stressful day for a surgeon entails, discussing the concept of shame arising from surgical failure and sharing strategies and resources for help. Alarmingly, she revealed that 24.8% of doctors had thought of suicide. Steeped in a culture of silence, she explained, it is easy for doctors to carry a sense of enduring shame rather than learn from a specific event. She highlighted the hidden curriculum of self-sacrifice and competition over collaboration that is ingrained within our personalities, which further contributes to burnout.

 

Seeking help should also be considered a ‘power move’, she explained, encouraging the audience to make use of resources such as the Employee Assistance Programme (EAP) and Doctors’ Health Advisory Service. Dr Oliver also shared personal examples of scheduling time to recharge and de-stress, even if that involves something as simple as hiring a cleaner!

 

The impact of self-neglect and its impact on how we show up to work was hard to miss. Anaesthetist Dr Richard French shone a spotlight on the elephant in the room – incivility, a behaviour that is often dismissed as the norm in medical culture, with personalities driven by performance, competition and poor social skills, under the pretext of ‘not suffering fools’. While bullying and harassment has garnered plenty of general press coverage in our sphere, incivility and rudeness have a real impact on helpfulness of team members and task performance which can affect patient outcomes. Dr French explained that by understanding our own personality and communication style, we can adapt how we exchange information and talk to each other. For example, we can emotionally engage with ‘harmonisers’, while being factual and direct with ‘thinkers’. It was a real wake-up call to think about how we create a culture of safety and assume some personal responsibility for the way we communicate.

 

We were also jolted into action by physiotherapist Emma Ferris who cajoled us into breathing exercises. Many of us, it turns out, are shallow breathers or breath holders, our bodies arrested by the threats and anxieties of the external world. We were left with a simple but effective strategy to check-in on our breathing throughout the day and re-create a sense of internal safety by regulating our breath.

 

Scientific highlights

 

The scientific programme covered a broad range of topics with new insights from uveitis to neurophthalmology.

 

On the uveitis front, herpes zoster ophthalmicus was associated with 2.5 times higher mortality risk from stroke and myocardial infarction, underling the need to raise awareness on stroke prevention and advocate for the funded Zostavax vaccination for patients over 65. Dr Rachael Niederer explained that over one third of paediatric uveitis had an infectious cause, including post-streptococcal uveitis, a bilateral non-granulomatous anterior uveitis which occurs two to four weeks post-strep throat in patients under 40. Idiopathic uveitis may also have higher mortality than HLA-B27 and it pays to repeat investigations at a further date. Sarcoidosis is diagnosed mainly by ophthalmologists. It is important to screen for cardiac sarcoidosis and consider a diagnosis of neurosarcoidosis in patients presenting with a Bell’s palsy and uveitis.

 

 


Drs Ainsley Morris, Rachel Barnes and Rachael Niederer

 

On the retina front, Dr Jim Borthwick discussed exciting research on geographic atrophy in age-related macular degeneration (AMD) with three exciting clinical trials: Apellis phase III, looking at pegacetacoplan which blocks C3; Ionis-FB-LRx phase 2, which has an anti-complement factor administered subcutaneously that blocks factor B; and the ONL phase Ib trial with an anti-apoptosis intravitreal injection. He also explained the exciting use of DARC (detection of apoptosing retinal cells) artificial intelligence which locates dying retinal cells and spatial patterns to interpret images. On a practical note, Dr Nancy Wang highlighted the role of early vitrectomy in endophthalmitis from all causes with improved visual outcomes at nine months.

 

Keynote Prof Morgan explained the importance of pressure difference, gradients and forces that affect nerves in glaucoma and the pathophysiology of papilloedema that results from space travel in astronauts. He also talked about the invention of gelatin-stent technology – a 6mm collagen-derived gelatin tube – and its potential advantages over traditional glaucoma surgery

 

This year the prestigious Dorothy Potter Medal was awarded to Professor Stephanie Watson by RANZCO NZ scientific programme advisor and Auckland University’s head of ophthalmology Professor Charles McGhee. Given Prof Watson’s renowned knowledge of the cornea, her medal lecture and subsequent talks included many simple tips on cornea examination, including wearing a mask during a scrape to reduce contamination. She also urged us to consider cytomegalovirus (CMV) endotheliitis in cases of non-steroid responsive uveitis, which is distinguished by linear keratic precipitates and coin-shaped lesions and is associated with poor outcomes from a delayed diagnosis.

 

Christchurch neurologist Dr Deborah Mason discussed autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy, resulting from improper GFAP regulation and glial scarring which on MRI has characteristic radial enhancing and laminar pattern. In addition, MOG neuritis requires up to six months of immunosuppressive treatment, with 35% often relapsing with optic neuritis, so be wary of early taper.

 

Dr John Dickson simplified the causes of vertical strabismus in adults, cautioning that if the pattern doesn’t fit a nerve palsy to accept it as such. He touched on orbital-sagging syndrome, where the bilateral symmetrical downward displacement of lateral rectus (LR) pulleys may symptomatically reduce supraduction but cause divergence paralysis ‘esotropia’ for distance. While Dr Anne-Marie Yardley shared her pre-operative and post-operative assessment checklist for tackling complex strabismus cases and the benefits of using adjustable sutures.

 

Dr Ken Tarr was awarded the John Parr Medal for his contribution as a clinician, researcher and an esteemed ophthalmic educator. In his talk, To teach is to learn, he paid tribute to clinicians who inspired him, emphasising the understated art of observation that every good clinician must master.

 

The junior registrar presentations were of a high standard, posing a challenge for the judges to pick any winners. Dr Corina Chillibeck received the best poster award for her work on ‘Sub-Tenon's anaesthesia and predictive and associated factors for intraoperative cataract surgery complications’, while Dr Hannah Gill won the best presentation award for her talk on 2020’s vision: ophthalmology workforce planning in Aotearoa.

 

Regarding workforce planning, the ophthalmic nurses programme, which ran parallel to the main scientific meeting and shared many of the plenary sessions, also highlighted the increasing role of nurses as leaders. This included many of them taking the lead in restructuring workflows during the Covid-19 restrictions and the growth of nurse-led clinics across the country and remote injection sites, which have reduced travel time for patients and resulted in a huge increase in patient satisfaction.

 

In summary

 

Even with all this, there was still room for fun and socialising over the two days. Friday evening began with a street art tour, tracing the impressive urban-art landscape in Christchurch which helped to revive and heal the city post-earthquake. The following dinner was a casual affair at Riverside Markets, which included food choices from more than 60 stalls and our own mezzanine to enjoy it all.

 

 


Drs Stephen Ng, Liz Insull and Pragnya Jagadish

 

Overall, I thought RANZCO NZ 2021 was very well-planned, with the organising team facilitating both a virtual hub as well as live attendance, with effortless streaming of international speakers via video. The resulting outlook was both positive and progressive, raising awareness on topics previously swept under the carpet and putting us back in touch with our own, very human vulnerabilities.

 

Next year’s meeting is all set for Blenheim. Symposium submissions are already open and there’s an exciting promise of a wine trail under the blue summer skies. See you there!

 

* https://eyeonoptics.co.nz/articles/archive/positive-results-for-eye-disease-home-monitoring-app/

 

Dr Pragnya Jagadish is an ophthalmology registrar based in Wellington. She enjoyed travelling before racing to relocate from the Amazon jungles in Peru last year when the country went into lockdown! She also has a keen interest in writing and creating uplifting conversations based on the astute art of observation, like her idol, Sherlock Holmes.

 

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