With the emphasis on ophthalmology supporting optometry to co-manage patients, Re:Vision partners Drs Trevor Gray and Mo Ziaei pulled together a lineup of speakers from a range of specialties and practices all over Auckland. Shoehorned in between breakfast and lunch were a dozen presentations from eight speakers plus two panel discussions. So we moved along at a rollicking pace, covering a lot of ground with very smooth baton changes.
First up was the University of Auckland’s Dr Hussain Patel, giving us the insider view of the triage of glaucoma referrals, mainly in the public health system. A good referral letter, he said, is one that does not need to be read. A balance of concise and need-to-know information makes it obvious to the triaging person (generally not the consultant) they cannot reject the referral, thereby keeping one more patient out of the public health system. Quick decisions about urgency need to be made (eg angle-closure signs or symptoms or significantly high intraocular pressures (IOP)) to establish who is sent through to the consultant, who should be seen within the next few months, and who can be managed in the community.
A good letter includes the reason for referral, visual fields and optic disc imaging or OCT, and best corrected visual acuity. Corneal thickness can also be helpful, as are significant histories relating to family (parent or sibling), ocular surgery or trauma, and medications such as beta blocker or prednisone use, plus any relevant retinal abnormalities that could affect results.
Dr Hussain encouraged the use of e-referrals for better and faster communication between referring optometrist, patient and hospital clinic, particularly if the referral is declined and the reason given. This enables the optometrist to follow up with the patient and stops people falling through the cracks. Sometimes a referral is declined as it is considered a high-quality referral and the referring optometrist can safely continue to manage the glaucoma, which makes it even more important to follow-up all referrals. Cataract referrals without the ‘Impact on Life’ form are automatically declined.
Unfortunately, a lack of funding has stopped the optometrist-run university clinics in Auckland, so there are huge numbers of patients overdue for follow-up appointments. Some of this may be mitigated by rapid imaging clinics, where consultants don’t see patients but review their results.
Holey macula, Batman! City Eye Specialists’ Dr Clairton de Souza showed us how macular holes occur and can be successfully closed. The retina’s own hydration regulation explains why some early holes do not progress and some early full-thickness holes resolve with good outcomes. However, if there is advanced AMD, the prognosis, even with surgery, is poor.
The critical factors for hole closure are to relieve traction and isolate the hole from the vitreous fluid as soon as possible. The resultant postoperative visual acuity is dependent on the pre-op acuity and the duration of the macula hole, which should ideally be less than a year, though some older ones can still do well.
Dr de Souza also discussed symptomatic vitreous floaters. To operate or not to operate, that is the question! The answer lies in how much the patient is willing to put up with them. This should not be underestimated – in some studies, patients said they were willing to take an 11% risk of death or exchange one out of every 10 years of remaining life to get rid of the distress of vitreous opacities. Previous ocular history – including coexisting conditions such as dry eye, myopia or inflammatory disease – should also be taken into consideration.
The use of small-gauge pars plana vitrectomy has made a huge improvement in reported outcomes, particularly reduced risk of retinal detachment. Sometimes after cataract surgery, the opacities in the phakic eye may become more noticeable, leading to a discussion on advancing combined surgery in that eye.
Re:Vision’s own Dr Mo Ziaei updated our knowledge of pterygia, which mainly occur on the nasal conjunctiva due to its greater UV exposure, the natural flow of tears towards the puncta bringing irritants such as dust towards it, longer temporal lashes shielding temporal conjunctiva, and more anterior ciliary arteries nasally resulting in increased nasal hyperaemia. Interestingly, handedness is also a contributing factor to which side is prone to pterygium growth.
In this part of the world, we are familiar with pterygia and are perhaps a bit blasé about it. Dr Ziaei reminded us that ocular surface squamous neoplasia (OSSN) was present in 5-10% of pterygia samples in Australia. These are found more often in older age groups and inferiorly located pterygia. With greater awareness of OSSN in pterygia, Dr Ziaei now sends all removed tissue to be tested, since there is probably a higher incidence of neoplasm than previously thought.
Considerations for referral include chronic irritation, poor cosmesis, significant astigmatism, contact lens intolerance and progressive pterygia. Urgent referral is warranted with pterygia encroaching on visual axis or diplopia due to traction on extraocular muscles. Suspicious features such as feeder vessels, positive staining with lissamine green or rose bengal, and particularly leukoplakic or gelatinous appearance, should also trigger urgent referral. Cataract surgery should be delayed until the pterygium is removed and heals, so that residual astigmatism can be more accurately measured.
In pursuit of equity
Optometrist Dr Akilesh Gokul’s topical and revealing presentation on improving equity in access and outcomes of post-crosslinking (CXL) patients compared community-based optometry care plus ophthalmology support, to centralised hospital clinic care. A 2020 study using a community-based optometry practice increased the number of appointments available fourfold. It has been well documented that Māori and Pacific peoples are overrepresented in the incidence of keratoconus, so increasing the overall capacity for treatment by a massive eight times should be matched by increased access. However, Dr Gokul said the study showed the number of hospital appointments was not matched, with only a third of patients turning up and 90% of the no-shows being Māori and Pacific patients. Poorer visual outcomes were also reported among this population, with many having no spectacles or contact lenses even after CXL. This appeared to be linked to poorer socio-economic status.
Dr Akilesh Gokul
The study compared attendance and outcomes for a similar population using a community clinic with the data from the centralised hospital clinic. The attendance was markedly improved in the community group and better visual outcomes recorded, endorsing greater investment in community-based health services. While tertiary care does not seem to work for some populations, early referral and treatment leads to cost benefits for the whole community.
The management of intraocular pressure (IOP) issues following cataract surgery was addressed by Dr Trevor Gray. Surprisingly, reducing the height of the irrigation bottle can markedly improve intraoperative IOP. Severe visual loss (wipe-out syndrome) can occur postoperatively, somewhat mitigated by earlier operations for shorter duration surgery, and use of clear corneal incisions, sparing the conjunctiva.
Dr Trevor Gray presents on IOP issues following cataract surgery
Any postoperative effects are seen in the first 24 hours, with the first 4-12 hours being the period of main risk due to possible retention of viscoelastic material. Longer term risk factors more likely to be seen in optometric follow up (five days to six weeks post-op) are steroid responders, known glaucoma patients, axial myopes and type I diabetics. Where risks are known, follow-up at 2-3 weeks is advised. For steroid responders it is possible to stop steroids early and sharply, as the drops are prophylactic not treating uveitis.
Dr Gray advised that long-term, most patients will have lower IOP for a while, particularly those with closed-angle glaucoma. He advised considering early surgery, particularly if the IOP is progressively rising, and avoiding multifocal intraocular lenses (IOLs), as these patients are already compromised in their contrast-sensitivity function and possibly visual fields.
‘Getting the cat out of the bag’ was the enigmatic title for Dr Jo Sims’ presentation on the challenges of cataract surgery and uveitis, the first being to keep the uveitis quiet for a minimum of 3-6 weeks, but ideally at least three months prior to surgery, for better outcomes. The second is careful counselling of the patient to set realistic expectations and stress the need for full compliance with follow-up appointments. OCT of the macula is helpful and, once again, steer clear of multifocal IOLs. A team experienced with uveitis surgery and including anterior segment specialists, plus a good pre- and post-op medication and follow-up management plan is likely to produce the best outcome.
Dr Sims advised postoperative review at one week and monitor closely, particularly for cystoid macula oedema (CMO), which occurs in approximately 10% of patients, even with good management. Such cases should be followed up for longer, in case of rebound effect.
Posterior capsular opacities are very common, but clearing should be delayed until inflammation is under control, preferably for more than three months, and cover with topical steroid, she said. Despite the risks and complications, good outcomes are possible in most patients with uveitic cataract.
Dr Ziaei’s second presentation brought us back to New Zealand’s 30,000 annual cataract surgeries, with bilateral surgery becoming more common. Most surgeries are reviewed one day after surgery and it’s now apparent that a one-week follow-up offers no additional advantage. He shared a recent study showing 37.4% of patients without pre-existing dry eye disease developed this following cataract surgery, the peak severity being 1-4 weeks post-surgery. He stressed it’s vital to explain this likelihood to the patient.
Posterior capsular opacity (PCO) is the most common complication after cataract surgery, with a 50% rate of occurrence within five years, said Dr Ziaei. Risk factors include young age, posterior subcapsular cataract, previous vitrectomy and certain IOL types. He advised to wait at least four weeks before undertaking YAG capsulotomy and monitor for persistent inflammation or the emergence of lens fragments which may need to be removed. Symptoms indicating this include blurred vision, photophobia, tearing and redness, as well as persistent inflammation.
‘Raising the blind’
What a fabulous title for a presentation on blepharoplasty and ptosis surgery! Dr Paul Rosser entertained and informed us on his rationale for lid-raising surgery, based on functional loss such as superior visual field; patients’ subjective ‘bother’ index, such as heavy lids or trichiasis; and cosmetic appearance, otherwise known as ‘I’m starting to look like my mother’ syndrome. Surgery is mainly done under local anaesthetic and oral sedation. Patients can expect bruising and swelling for 4-6 weeks.
Dr Patel advised that gonioscopy is as important in open angles as it is in closed-angle glaucoma and needs to be included in any glaucoma workup. It can also help diagnose secondary glaucoma and sometimes even provides clues to other pathology, such as melanotic lesions. His tips for embracing gonioscopy included using a mini four-mirror gonio lens with a flange; practice, practice, practice on ‘normal’ eyes until you recognise abnormality; and following a systematic routine so you know where you are in the angle.
As an unusually subdued Dr Gray made his way gingerly to the podium for the final presentations, he headed off curious questions about his heavily strapped leg with a warning that holidays, however overdue, are detrimental to health and wellbeing. Stepping off a boat onto an exotic Fijian island can rupture the precious Achilles tendon!
His spirits lifted with his presentation on ‘Tinder-date drops’ (aka anti-presbyopia drops). The term refers to the length of time the drops will confer the youthful ability to read a menu without spectacles. The variety of miotic drops about to land on our shores was covered in NZ Optics December 2021, but the lens-softening drops are a new addition to watch for, though thus far, their results are not as good as the miotics’. The question is, if the drops increase lens elasticity, can they also slow cataract formation? Dr Gray’s message was to embrace the opportunity to start the conversation about eye health and alternative options for presbyopia.
A progress update on Aotearoa Charity Hospital (ARCH) provided an uplifting conclusion to the day. Since its inception ARCH has provided more than $1 million of pro bono surgery, mainly cataract but encompassing other procedures, for caregivers or to allow continuity of employment for those who do not meet public hospital criteria and cannot afford private fees. Surgeons add an extra surgery to their normal operating list, thereby using the same resources and donating their time and expertise. This year, in cooperation with the New Zealand Dental Association, 10 dental practices are also coming on board.
This was a great way to end a very interesting conference which packed in a full bag of pearls to take back to work on Monday.
Naomi Meltzer has worked in optometry for more than 30 years and runs an independent practice in Auckland specialising in low-vision consultancy. She is a regular contributor to NZ Optics.