New technologies and treatments in eye care

June 2018

Go deep, and wideNew tech takes you there

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SBM Sistemi I.C.P. OSA Ocular Surface Analyser•Multi-functional compact device for comprehensive evaluation of dry eye•Meibography – Evaluation of Lipid Layer- N.I.B.U.T.- Tear meniscus- Pupillometry ..and much more”

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June 2018

Published by Optometry Australia ABN 17 004 622 431 | Suite 101, 70 York Street South Melbourne VIC 3205 | Copyright © 2018 | Editor JEFF MEGAHAN | Publications Manager JESSICA doNAld | Phone 03 9668 8508 | E-mail j.megahan@optometry.org.au Cover ZEISS ClAruS 500 ultrA-wIdEFIEld FuNduS CAMErA

Comments in equipment are of a general nature and intended for guidance only. optometry Australia and the individual contributors expressly disclaim all liability and responsibility to any person in respect of, and for the consequences of, anything done or omitted to be done in reliance wholly or partly on anything in this publication. Acceptance of advertising does not necessarily include endorsement of advertised products.

www.optometry.org.au

FEATURES

Future-proof your practice dr Aaron lech 2

Seeing red? dr Karen tiuseco and Associate Professor Andrew white 3

OCTs in the modern practice dr Adrian S Bruce and roman Serebrianik 19

OCT buyer’s guide 20

In the news... 32 REVIEWS

Insights from a dry eye practice dr winter Chan and dr rebecca li 6

Enhanced pathology detection dr dirk den dulk 9

Glaucoma co-management dr Heathcote wright 12

Easy for patient and practitioner leesa Jager 14

Combined structure and function analysis aids detection of glaucoma dr George Kong 22

Diagnose and treat dry eye with ease dr Jennifer rayner 26

Truly flexible and upgradeable lachlan Scott Hoy 28

Wide scan protocol a clear step up Peter thompson 34

Investing in imaging Kirsty Banfield 36

OCT for our paediatric patient base Adrian Vecchio and Norm russo 37

Cutting edge portable perimetry dr George Kong 39

JUNE 2018 JUNE 2018 32

Let me start by assuring you that I do not consider myself a guru or a health care demographic soothe-sayer. I put my pants on one leg at a time. Like most everyone else in the eye care industry, my successes are the product of three things: a supporting team of work colleagues; a commitment to innovation; and vendor support for diagnostic solutions, data management and utilisation.

Still, as I look at the eye care market in the US and Australia, I can say with a certain level of guru-like confidence: I am compelled to believe that the future of optometry is quite bright.

As practitioners of optometry in Australia, you have been blessed

with two significant studies, which, when combined with current demographic changes, reveal the amazing opportunities for optometrists nationwide.

In 2005, The Eye Health in Australia study1 was published, setting out a background regarding the epidemiology of eye disease and injury in Australia. Based on data from the WHO (World Health Organization) and the IAPB (International Agency for the Prevention of Blindness), the study made clear that the optometric community needs to pay attention to the impact of population ageing.

The projected need for care

Analysis of the study data, including the number of patients that required active management of disease in 2002 and the projected need for care by 2032, indicates that over six million Australians will require medical eye care services. This doesn’t even include the surveillance of additional disease suspects and the treatment of uncorrected refractive error.

Further review of changing population demographics by 2032 reveal that

Australia will see a population shift among individuals over 55 years of age to the tune of 4.5 million people. This leaves a total of 8.9 million people requiring much closer surveillance. The shift represents a change in the ratio of patients likely to need eye care services from 1 in 5 to 1 in 3 (roughly 33 per cent of the population). When combined with the fact that an estimated 9.7 million Australians had at least one sight problem in 2002, greater than 50 per cent of the projected population will need some form of optometry service.

The second study, Optometric Supply and Demand in Australia: 2011–2036,2 published in Clinical and Experimental Optometry, set out to answer the question that troubles many optometrists: ‘are there too many of us?’ According to the conclusions of this study, there is a coming surplus of 1,200 optometrists given current demand for Medicare services (except in Queensland, Tasmania and the Northern Territory).

However, the study seemed to overlook a few key items. First, its assumptions were based on Medicare service demand only (which we all acknowledge is a moving target and is not the only reason patients seek our care). Second, ageing and disease demographic analysis was given minimal attention.

In fact, if you combine the findings of the optometric workforce supply study with the current trends in ophthalmology training programs and the projected epidemiology demands, a significant opportunity seems to be at the doorstep of Australian optometrists.

Future-proof your practice

Condition 2002 2032

AMD 640,000 1.29 million

Cataract 1.5 million 3 million

Glaucoma 110,000 222,500

Diabetes 609,000 1.2 million

Diabetic Retinopathy 134,000 271,000

Total ~ 3 million ~ 6 million

Table 1. Over six million Australians will require active management of eye conditions by 2032

Founder of ClearVue Eye Care in Roseville, California, Aaron Lech is a recognised innovator in the optometry field, and has pioneered diagnostic practice strategies over the past 15 years. In 2017, as a guest of ZEISS Australia, Dr Lech conducted a six-city tour of Australia and New Zealand to discuss how optometrists can improve efficiencies in a rapidly changing market.

Disease or not?

OCT has changed eye care and has become an integral part of the diagnosis of many ocular conditions. Thanks to this continually-evolving technology, timely diagnosis of some ocular diseases, early treatment and referrals to the appropriate specialists can be made with some degree of certainty.

However, the technology does come with a few drawbacks, most importantly when referrals are based on ‘red disease,’ where a non-existent disease is falsely interpreted from OCT readings riddled with errors. One study in the UK found that false positive readings of glaucoma referred to ophthalmologists by optometrists and general practitioners ranged between 29 per cent and 68 per cent on the basis of elevated intraocular pressures,

suspicious disc appearance or visual field results.1

Alternatively, seeing all green on the OCT does not necessarily ensure that everything is normal. ‘Green disease’ is when a patient with an actual disease is mislabelled as being normal because of a falsely negative green OCT, which may lead to missed diagnoses of glaucoma and/or progression and delayed treatment.2

Seeing red on an OCT often flags that something is abnormal, and consequently leads to a knee-jerk diagnosis and referral. OCT has a false positive rate of 15 per cent to 36 per cent.3 There are several reasons behind erroneous readings and it is important that these are taken into consideration before making any premature conclusions.

Errors on the OCT are commonly due to the imaging process or variations in the structure of the eye. The quality of the image is exhibited by the signal strength, which should ideally be greater than 6/10 with the Cirrus HD-OCT (ZEISS) or 50 with the Optovue (RTVue). Anything equal or lower than these values would be considered a poor signal strength and often results in artefacts and underestimation of

Misinterpretation of oCt scans and how to avoid false positives

1. Commonwealth of Australia. Eye Health in Australia; a background paper to the National Framework for Action to Promote Eye Health and Prevent Avoidable Blindness and Vision Loss [Internet]. Canberra: Department of Health; 2005 [cited 2018 Apr 17] Available from: http://www.health.gov.au / internet/main/publishing.nsf/content / 1A5409787D800F2CA257C73007F12F3 / $File / cov.pdf

2. Healy E, Kiely PM, Arunachalam D. Optometric supply and demand in Australia: 2011–2036 Clin Exp Optom 2015; 98: 273–82

When we note the ophthalmology workforce changes and projected graduation rates for the collective eye care profession, the ratios of providers-to-patients is quite favourable. In the ‘Workforce Study’ an assumed ratio of 18 optometrists to 100,000 members of the population was projected. Adjusting for static ophthalmology supply and increasing population growth, ratios could likely be closer to two ophthalmologists to 100,000 and 14 optometrists to 100,000. Essentially, we have a

Shifting demographics demand well-equipped professionals

tsunami of baby boomers affecting both patients and providers.

If these modest adjustments are accurate and the ageing population exerts the pressure on services similar to countries such as the US, the future is indeed bright. For optometry, these ratios indicate that an average of 3,500 patients will require care by each optometrist in Australia (7,100 x 50 per cent = approximately 3,500).

With this type of demand, optometrists must prepare by investing in the systems, equipment and education necessary to take our place in this new millennium of opportunity.

As I say, I am not a guru or a health care demographic soothe-sayer, but I am compelled to believe that the future of optometry is quite bright.

Future of optometryFrom page 2

the thickness of the retinal nerve fibre layer (RNFL).4-6 A study by Vizzeri et al. estimated the RNFL thickness to be falsely decreased by 2 µm for every unit of decrease in signal strength.6

Errors due to eye structure

Reductions in signal strength are commonly caused by media opacities such as corneal scars, dry eyes, cataracts, posterior vitreous detachments, and vitreous haemorrhage. Highly myopic eyes may also cause segmentation errors from increased axial lengths that induce ocular magnification resulting to a smaller measured optic disc size and a decrease in the apparent thickness of the RNFL.7-9 In contrast, hyperopia and shorter axial lengths may reflect an overestimation of the optic disc area and increase in the RNFL thickness on OCT.9

Errors due to imaging process

A poor image quality can likewise be produced by factors such as eye movement during the examination (blinking, microsaccades) and cyclotorsion (including head tilting),10 although newer OCT software has eye tracking capabilities and can often

Continued page 3

Continued page 4

Dr Aaron Lech od, FAAo

ClearVue Eye Careroseville CA uSA

Dr Karen TiusecoMd, dPBo (diplomate of the Philippine Board of ophthalmology) Glaucoma fellow, westmead Hospital

Clin A/Prof Andrew White  BMedSci(hons) MBBS Phd FrANZCoHead, department of ophthalmology, westmead Hospital and university of Sydney

JUNE 20184

adjust for minor movements.

OCTs are mainly operator-dependent and are therefore prone to errors related to image acquisition. Misalignment of the scan circle around the optic nerve head, for example, may significantly affect RNFL thickness measurements.11 Succeeding scans for each patient should be properly centred at each visit (and scanned with the same OCT machine) for consistency and better repeatability, which is particularly useful when assessing progression of glaucoma.

Other, simpler errors can lead to a red-disease diagnosis. The patient’s date of birth, if incorrectly entered, may lead to errors in data acquisition from erroneous comparisons to age-matched controls because of biological age-related decrease in RNFL thickness due to ageing.12

OCT has been one of the most important technological breakthroughs vital to the diagnosis of glaucoma. It is

imperative that errors in the OCT are identified and immediately addressed to prevent artefacts and data distortion. Optometrists and ophthalmologists alike should have a better understanding of the acquisition and interpretation of the data obtained from the OCT to avoid confusion, errors in clinical judgment, and inadvertently falling into the trap of the ‘red disease.’

1. Lockwood AJ, Kirwan JF, Ashleigh Z. Optometrists referrals for glaucoma assessment: a prospective survey of clinical data and outcomes. Eye 2010; 24: 1515–1519.

2. Sayad MS, Margolis M, Lee RK. Green disease in optical coherence tomography diagnosis of glaucoma. Curr Opin Ophthalmol 2017; 28:139–153.

3. Leal-Fonseca M, Rebolleda G, Oblanca N, et al. A comparison of false positives in retinal nerve fiber layer, optic nerve head and macular ganglion cell-inner plexiform layer from two spectral-domain optical coherence tomography devices. Invest Ophthalmol Vis Sci 2016; 57: 4194–4204.

4. Cheung CY, Leung CK, Lin D, et al. Relationship between retinal nerve fiber layer measurement and signal strength in optical coherence tomography. Ophthalmology 2008; 115: 1347–1351.

5. Wu Z, Huang J, Dustin L, et al. Signal strength is an important determinant of accuracy of nerve fiber layer thickness measurement by optical coherence tomography. J Glaucoma 2009; 18: 213–216.

6. Vizzeri G, Bowd C, Medeiros FA, et al. Effect of signal strength and improper alignment on the variability of stratus optical coherence tomography retinal nerve fiber layer thickness measurements. Am J Ophthalmol 2009; 148: 249–255.

7. Kang SH, Hong SW, Im SK, et al. Effect of myopia on the thickness of the retinal nerve fiber layer measured by Cirrus HD optical coherence tomography. Invest Ophthalmol Vis Sci 2010; 51: 4075–4083.

8. Shoji T, Nagaoka Y, Sato H, et al. Impact of high myopia on the performance of SD-OCT parameters to detect glaucoma. Graefes Arch Clin Exp Ophthalmol 2012; 136: 1843-1849

9. Savini G, Barboni P, Parisi V, et al. The influence of axial length on retinal nerve fibre layer thickness and optic-disc size measurements by spectral-domain OCT. Br J Ophthalmol 2012; 96: 657–661.

10. Hwang YH, Lee JY, Kim YY. The effect of head tilt on the measurements of retinal nerve fibre layer and macular thickness by spectral-domain optical coherence tomography. Br J Ophthalmol 2011; 95: 1547–1551.

11. Vizzeri G, Bowd C, Medeiros FA, et al. Effect of improper scan alignment on retinal nerve fiber layer thickness measurements using Stratus optical coherence tomograph. J Glaucoma 2008; 17: 341–349.

12. Parikh RS, Parikh SR, Sekhar GC, et al. Normal age-related decay of retinal nerve fiber layer thickness. Ophthalmology 2007; 114: 921–926.

Figures 1 and 2. OCT scans taken from the same patient. She is a glaucoma suspect based on suspicious optic discs. The first scan was taken through a small, undilated pupil which created multiple artefacts and decreased signal strengths. A second scan was taken after pupillary dilation with better signal strengths (but could no longer be improved from cataracts). Nevertheless, it shows how much improvement was achieved with better scan acquisition and quality.

Introducing the NEWHuvitz OCT HOCT1- (OCT) &

HOCT-1F (OCT + Fundus)

CombiningEverything

you needinto One!

Seeing redFrom page 3

JUNE 2018 JUNE 2018 76

Dry eye is defined by the Dry Eye WorkShop II (DEWS II) as ‘a multifactorial disease of the ocular surface characterised by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and

neurosensory abnormalities play etiological roles.’1

As the definition suggests, dry eye is an extremely complex disease. Yet, it is often underdiagnosed.2 There are millions of dry eye sufferers worldwide. The disease has no cure and it is one of the most common reasons for patient visits to their eye care practitioner. Symptoms include ocular redness, grittiness, foreign body sensation, watering, stinging and burning. The condition can lead to reduced quality of life, limited ability to socialise, and even depression. Dry eye can further degrade quality of life through its ability to reduce quality and stability of vision.1,3 Therefore, it is important that eye care practitioners view dry eye disease as a serious eye condition.

Often dry eye patients are not given the time and care that they require. They often present at our Dry Eye Group practices, reporting they have seen a string of optometrists or ophthalmologists yet were only

given numerous eye drops that did not work. They also often report ceasing warm compresses after a week since there was no improvement in their symptoms. These frustrations experienced by dry eye sufferers can be mitigated with a thorough assessment, treatment plan and comprehensive patient education. Optometrists also need to give their patients realistic expectations regarding the speed that symptomatic improvement will occur considering dry eye is a chronic disease.

Assessing the signs and symptoms

According to DEWS II,1 before a diagnosis of dry eye is given, a positive score on one of two symptom questionnaires should be obtained. This should be obtained via the Ocular Surface Disease Index (OSDI) or The Dry Eye Questionnaire 5 (DEQ-5).4 These symptom surveys are also helpful in providing a benchmark for comparison in disease progression or improvement in symptoms after treatment.

In addition to a positive symptom questionnaire score, DEWS II states that at least one positive clinical sign suggesting reduced non-invasive tear break up time, abnormal tear osmolarity or ocular surface staining is necessary for a diagnosis of dry eye disease.1,4 As a result, it is important to ensure that all these tests are covered in a dry eye workup.

Even if access to advanced imaging techniques is limited, at a minimum, a comprehensive slitlamp assessment — looking for signs of anterior blepharitis, meibomian gland dysfunction (MGD), corneal and conjunctival staining and a rapid tear break up time — should be executed. The presence of partial blinking should also be noted. Evaluation of the patient’s systemic health can be carried out in conjunction with their general physician.

Devices that can aid the practitioner in diagnosing dry eye and assessing severity are increasing in number. One such device is the OCULUS Keratograph 5M. This device quickly and easily measures the tear meniscus height, non-invasive keratograph break-up time, meibography and fluorescein imaging. The resulting images are useful not only for diagnosis but excellent for patient education.

In addition to meibography, expression of the meibomian glands can play a valuable role in assessing the severity of MGD. Gland expression

can be conducted with a variety of tools including the Mastrota paddle, expressor forceps and gland evaluators such as the Korb Meibomian Gland Evaluator. The secretions are graded from ‘no secretion,’ ‘inspissated secretions,’ ‘cloudy secretions’ or ‘normal secretions.’5 Images of the secreted meibum are then shown to the patient. This can often be a powerful tool to enhance patient motivation and compliance with their treatment.

Overall, a comprehensive workup allows optometrists to evaluate the presence of the subtypes of aqueous deficiency and evaporative dry eye. It is important to understand that the two subtypes of dry eye are not mutually exclusive and patients will usually exhibit traits of both.1,4

Diagnosis and Treatment

Grading the severity of the subtypes of dry eye is often an important guide for determining the level of treatment required. At the Dry Eye Group, treatment plans are guided by the DEWS II recommendations.

In milder cases of dry eye, treatment usually involves non-preserved ocular lubricants. These can be either aqueous or lipid-based, depending on the dry eye subtype present. Lid hygiene, warm compresses and essential fatty acid supplementation are also recommended. Environmental modifications such as reducing exposure to artificial heating and air conditioning is encouraged.

Communication with the patient’s general physician regarding potential modification of offending systemic and topical medications should also be considered. Patient education regarding the chronic nature of dry eye is also essential.

In moderate cases of dry eye, a short course of topical corticosteroids may be added to therapy, as well as in-office physical heating and expression of the meibomian glands with devices such as Blephasteam, Intense pulsed light (IPL) or LipiFlow. Oral tetracyclines, punctal occlusion and moisture chamber spectacles, such as 7eye glasses, may also be appropriate depending on the dry eye subtype.

In more severe cases, autologous serum eye drops, soft bandage lenses or rigid scleral contact lenses and surgical interventions may be necessary.

Managing MGD

In moderate-to-severe cases of evaporative dry eye associated with MGD, in-office meibomian gland therapy may be necessary on top of the traditional therapies of Omega 3 supplementation and warm compresses.

Many patients will seek out clinics locally, or even interstate, for advanced MGD treatments such as IPL and LipiFlow. These treatments can be helpful in improving both the signs and symptoms of dry eye.10,11 They can significantly improve a patient’s quality of life, as well as being rewarding for the practitioner.

There are currently a number of IPL devices available. Each proposes slightly different mechanisms of action for improving MGD. IPL treatments can be useful in targeting heat to the periocular area to melt thickened meibum in MGD. Depending on the device utilised, IPL can also be useful in reducing the bacterial burden at the eyelid margin, in reducing eyelid inflammation through photocoagulation of intravascular red blood cells10 and stimulating parasympathetic nerves to stimulate the secretion of meibum.12

LipiFlow utilises heat and Vectored Thermal Pulsation technology to

Insights from a dry eye practice

Figure 1. OCULUS Keratograph 5M

Figure 2. Jenvis dry eye report (OCULUS Keratograph 5M)

Evaluating symptoms and offering treatment options

Dr Winter Chan BSc od

Dr Rebecca Li Boptom BSc (Hons)

the dry Eye Group, Melbourne

ProductsoCuluS Keratograph 5MBlephasteam by theaMastrota paddleoptimel Manuka + dry Eye drops optimel Antibacterial Manuka + Eye Gel

Supplierdesigns For Vision

Continued page 8

JUNE 2018 JUNE 2018 98

gently massage the eyelids, removing obstructions from the meibomian glands. LipiFlow applies direct heat towards the meibomian glands from underneath the eyelid, rather than from the dermal side as with IPL and Blephasteam. Patients often find LipiFlow comfortable and easy to tolerate. Up to 79 per cent of patients may experience improved dry eye symptoms and comfort after treatment.13,14

Understandably, IPL and LipiFlow technologies may be costly for both the patient and practitioner to access (although IPL and OPE systems with lower ongoing costs are now available). Blephasteam and gland expression is a potential alternative. Blephasteam is an eyelid warming device which provides moisture and heat therapy to help relieve dry eye symptoms. The warm moisture chamber helps melt thick, stagnant meibum within the glands. Each Blephasteam treatment session takes approximately 10 minutes and manual expression should be performed after each session to improve meibum flow.15

Conclusion

Overall, dry eye is a multifaceted condition that is often time-consuming for both the patient and the practitioner to treat. However, it can also prove to be rewarding to the motivated optometrist and can also be a great practice builder. As the clinical scope of optometry continues to broaden and our understanding of dry eye continues to improve, optometrists are well placed to provide more advanced levels of care to our dry eye patients. Regardless of the treatments provided, patient education is paramount to optimise both patient compliance and satisfaction.

The eye drops for the patients who ‘have tried everything’

These days, optometrists have access to a range of non-prescription eye drops which can provide a more targeted approach to dry eye. A few drops that optometrists can add to their armamentarium include:

HYLO-FORTE A preservative-free drop which contains 0.2% sodium hyaluronate. Sodium hyaluronate provides increased ocular surface wettability and can also have mild anti-inflammatory properties.6

NovaTears A unique preservative-free and water-free lubricating lipid layer stabiliser. It provides an evaporative barrier to improve tear film stability and quality.7 Patients with mild to moderate evaporative dry eye and MGD may benefit from using NovaTears four times a day. Improvement in symptom questionnaire scores, tear film break up time and corneal staining can occur after six to twelve weeks of use.8

Optimel Manuka+ Honey Dry Eye Drops and Antibacterial Manuka+ Eye Gel May help to reduce Staphylococcus epidermidis counts along the eyelid margin, reduce the need for ocular lubricants and also improve meibomian gland expressibility. The gel may provide the additional benefit of improving meibum quality. Optimel Drops are indicated for mild to moderate dry eye, with the gel effective for more severe cases. Temporary redness and stinging are usually the only reported adverse side effects.9 Ensure your patient is not allergic to honey before recommending this drop.

Dry eye practiceFrom page 7

In June 2016 our Wollongong group practices purchased one of the first Eidon Confocal Digital Laser Scanners in Australia. This had a huge positive effect on our diagnostic capability.

Eidon combines scanning laser ophthalmoscopy (SLO) with true-colour imaging. Although the image quality of SLO systems is considered superior to conventional fundus cameras in many ways, SLO systems typically do not provide colour images and they usually use multiple, monochromatic laser sources which result in black and white or pseudo-colour images. By incorporating true-colour imaging, Eidon provides a high-quality image, 60-degree field in a single exposure, a confocal view of the retina, three different imaging modalities* and dilation-free operation.

Before each patient enters the consulting room, a true-colour, mosaic, digital image is taken. Then, the images are transported via blue tooth to every computer monitor in the practice. The Eidon scanner is operated via a tablet with a multi-touch, high-resolution, colour display. It works with a dedicated software application and operates as a stand-alone unit. It can be operated in modes that go from fully automated to fully manual.

A non-mydriatic, high resolution, wide-view image (up to 110 degrees horizontal, 95 degrees vertical, with multiple exposures) is a permanent, evidential record. The beauty of this process is the automatic function, and unlike its competitors, it’s easier on the patient, taking only minutes to achieve and deliver a quality series of scans. The fundus records I have acquired for patients from age five and above give indisputable testament to clinical findings.

The unfortunate truth about the introduction of Eidon is that we learned that were not doing our job (diagnostically) as effectively prior to its introduction. The case study I would like to present to support this statement is on a patient who

Enhanced pathology detection

presented with a left eye temporal visual disturbance six weeks after I had seen him last.

Corrected visual acuity was RE 6/6 LE 6/9. Fundus dilation revealed a posterior vitreous detachment with no obvious retinal involvement. However, with the help of the Eidon, we found a very shallow retinal detachment, barely perceptible. Subsequent to this finding, BIO with indentation, visual fields test and ocular coherence tomography further uncovered the reality of the pathology.

I have shown one of many examples of Eidon magic. Because of findings like this example, our practice group of three has recently purchased the second Eidon and we will be equipping our third practice with another in the new financial year.

I could go on and on with my praise of this new technology, instead, I’ve included a few images (above). As they say, a picture is worth a thousand words.

*true-colour, red-free and infrared.

Dr Dirk den DulkBoptom GradCertocther (uNSw)woonona Eye care

ProductEidon true-Colour Confocal Scanner

SupplieroptiMed

Figures 1 – 3. Gallery of images taken with our first Eidon confocal scanner

CASE REPORT1. Craig JP, Nichols KK, Akpek EK et

al. TFOS DEWS II Definition and Classification Report. Ocul Surf 2017; 15: 276–283.

2. Shah S, Jani H. Prevalence and associated factors of dry eye: Our experience in patients above 40 years of age at a Tertiary Care Center. Oman J Ophthalmol 2015; 8: 151–156.

3. Moss SE, Klein R, Klein BE. Prevalence of and risk factors for dry eye syndrome. Arch Ophthalmol 2000; 118: 1264–1268.

4. Bron AJ, de Paiva CS, Chauhan SK, et al. TFOS DEWS II Pathophysiology Report. Ocul Surf 2017; 15,: 438–510.

5. Bron AJ, Benjamin L, Snibson GR. Meibomian gland disease: classification and grading of lid changes. Eye 1991; 5: 395–411.

6. Aragona P, Papa V, Micali A, et al. Long term treatment with sodium hyaluronate-containing artificial tears reduces ocular surface damage in patients with dry eye. Br J Ophthalmol 2002; 86: 181–184.

7. NovaLiq, NovaTears, http://www.novaliq.com/products/novatears/

8. Kaercher T, Steven P, Messmer E, Beckert M et al. 2016. NovaTears as new Therapy in Dry Eye Results from three prospective, multicenter, non-interventional studies in different patient populations. TFOS 2016

9. Albietz JM, Schmid KL. Randomised controlled trial of topical antibacterial Manuka (Leptospermum species) honey for evaporative dry eye due to meibomian gland dysfunction. Clin Exp

Optom 2017; 100: 603–615 10. Toyos R, McGill W, Briscoe D. Intense

Pulsed Light Treatment for Dry Eye Disease Due to Meibomian Gland Dysfunction; A 3-Year Retrospective Study. Photomed Laser Surg 2015; 33:, 41–46.

11. Lane SS, DuBiner HB, Epstein RJ, et al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea 2012; 31: 396–404.

12. E-Eye. 2013. France Medical Pty Ltd, http://www.dry-eyes.com.au/mgd/how_does_it_work/

13. Greiner JV. A Single LipiFlow Thermal Pulsation System Treatment Improves Meibomian Gland Function and Reduces Dry Eye Symptoms for 9 Months. Curr eye res 2012: 37; 272–278. 10.3109/02713683.2011.631721.

14. Lane S, DuBiner H, Epstein R, et al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea 2012: 31; 396–404.

15. Villani E, Garoli E, Canton V, et al. Evaluation of a novel eyelid-warming device in meibomian gland dysfunction unresponsive to traditional warm compress treatment: an in vivo confocal study. Int Ophthalmol 2015: 35; 319–323.

JUNE 2018 11

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JUNE 2018 JUNE 2018 1312

I am a cataract and glaucoma surgeon working out of private clinics in Bellfield, near Ivanhoe (Melbourne Comprehensive Eye Surgeons) and Sunbury (Sunbury Eye Surgeons). I undertook my surgical training at the Royal Victorian Eye and Ear Hospital before travelling to the UK to undertake a surgical fellowship at Bristol Eye Hospital. I have a research interest in health economics and service delivery.

The case for co-management

Glaucoma is the perfect condition for co-management. It is a slow insidious disease that causes problems in only a minority of patients and it can be safely monitored using images that can be remotely viewed and assessed.

Co-management is straight-forward when the optometrist and ophthalmologist have complementary equipment and a shared Electronic Medical Record. The imaging software ZEISS Forum and Glaucoma Workplace collate data from CIRRUS OCT scans, Visucam digital photographs and Humphrey Field Analyzer visual field results from within a practice to produce accurate assessments and to monitor progression.

Understandably, the sharing of these data outside the practice is made more seamless when the co-managing partner is similarly equipped.

Glaucoma is a progressive optic neuropathy characterised by typical optic nerve head changes and characteristic visual field defects for which elevated intraocular pressure is the only known modifiable risk factor. There are many forms of glaucoma but the most important, from a public health point of view, is primary open angle glaucoma (POAG), which

accounts for about 85 per cent of glaucoma.

The price of glaucoma

POAG is a disease that becomes more prevalent from the age of 50. It is a chronic disease that many patients will live with for several decades. During this time, patients will need to be reviewed at least every 6–12 months and may expect to have 50 or more eye care consultations over their lifetime.

When you multiply this number by the expected 410,000 people who will have POAG or ocular hypertension by 2025 and the estimated cost of over $150,000 per disability-adjusted life year (DALY) avoided you can see that there is an enormous burden on the health care system. Glaucoma is estimated to cost Australia $4.3 billion annually by 2025.

The imminent storm

The Australian health care system is totally unprepared to deal with this impending tsunami of glaucoma patients. As with other chronic diseases, many patients can expect to remain stable for long periods of time, often decades without requiring significant change to their management plan. Yet despite the stable nature of many patients, a large majority are managed by highly-trained ophthalmologists or in overburdened public hospital outpatient clinics.

Optometrists have the ability to adequately manage stable patients under appropriate conditions. Due to their greater numbers and broader distribution, access to optometrists will be easier for many patients, particularly those in regional and remote areas. A visit to an optometrist

would generally represent a significant cost saving to the patient compared to an ophthalmologist.

Models of glaucoma shared-care have been successfully used in the UK for over 20 years and have more recently been effectively established throughout parts of Europe. However, despite the existence of a funding model for shared-care within the Medicare framework, shared-care in Australia has not taken off. The reasons for this are not clear but may relate to issues of inter-profession trust between ophthalmologists and optometrists.

Glauconet

I have developed a web-based Electronic Medical Record (EMR) called Glauconet that allows ophthalmologists to share a single electronic patient record. I record all my clinical information on Glauconet including high resolution disc photographs, OCT of the RNFL and GCC as well as visual field test results. A clinical decision is made about the patient who essentially is classified into three categories:

• High risk or complex patients, including those likely to need surgery within the next 12 months, are not suitable for shared care and are monitored by myself in the rooms. This is approximately 10 per cent of patients.

• Low-to-medium risk patients without complicating factors and unlikely to need surgery within the next 12 months are suitable for shared-care and are assigned to an optometrist.

• Patients without glaucoma or who a negligible risk of vision problems from glaucoma can be discharged to routine optometric care without the need for establishing a shared care arrangement.

Glaucoma co-managementthe time has come to get virtual

Dr Heathcote Wright BSci (hons) MBBS PG dip ophthalmic Sci Phd FrANZCoSunbury Eye Surgeons

ProductHumphrey Field Analyzer 3Visucam 524 Fundus ImagingCirrus Hd-oCt 5000

SupplierZEISS

Glauconet is completely customisable and can facilitate any combination or permeation of co-management visits.

After each optometrist reviews the record including fields, disc images and OCT, IOP and clinical history can be reviewed by the treating ophthalmologist to ensure that there is agreement with the optometrist’s interim decision.

That decision can be confirmed or altered with instantaneous feedback to the treating optometrist.

Co-management utilising complementary equipment and a shared EMR represents a triple win. It is more convenient and cheaper for patients. It is better for glaucoma specialists as it concentrates those patients most likely to need their specific skills in the ophthalmologist’s clinic. It also allows optometrists to maintain an extra stream of clinical work and maintain an interest in a complex disease with the close support of a glaucoma specialist.

JUNE 2018 JUNE 2018 1514

Leesa JagerBoptom(Hons)Graduate Certificate of ocular therapeuticsEye see eyes optometrist

Productoptovue iScan oCt

SupplierBoC instruments

Figure 3. iVue OCT retinal scan of both eyes

Figure 4. iVue OCT retinal scan of the left eye

CASE REPORT

Figures 1 and 2. Dilated retinal examination revealed a macular hole in the right eye, left eye appeared normal but OCT scan indicated otherwise.

Easy for patient and practitionerState-of-the-art technology assists early diagnosis

I am a solo practitioner with an independent optometry practice in Orange NSW. I completed my therapeutics course in mid-2017 and felt that an OCT was a necessary addition to my practice. After researching the many options, I decided to purchase the Optovue iScan for a number of reasons.

The iScan is compact and easy to use for both the patient and the optometrist. The unit has a space-saving design that takes up as much space as a slitlamp. Because of the software system program, the patient simply places their head in the mask, the optometrist selects which scan is required and the patient is vocally guided through the scanning process. Focusing and centring of the scan is all automatic. I can select a ganglion cell complex (GCC), retina or anterior eye scan—or all three.

With the purchase of the Optovue i-Scan, operators are given access to the Optovue Academy, an online course presented by Larry Alexander (OD, FAAO). I found the program

was helpful in developing my understanding of the anatomy of the retina and it improved my ability to interpret OCT scans. That course, in addition to the purchase of two OCT textbooks and my therapeutics training quickly gave me confidence to use the OCT effectively and most beneficially for my patients.

A 68-year-old female presented for her first eye examination in over 20 years. She had distance spectacles, but noticed that her vision was blurry for the last year or so, even with spectacles.

Her unaided visual acuity was R: 6/30- L: 6/30-. Refraction: R: 0.00/-0.50x40 6/30- Pinhole 6/30- Add +2.50. L: +1.00/-2.50x160 6/9.6-.

A dilated retinal examination revealed a macular hole in the right eye, left eye appeared normal but OCT scan indicated otherwise.

The OCT retinal scans show a full thickness macular hole with detached vitreous interface and operculum above the fovea in the right eye. In the left eye, there is significant vitreomacular traction with intraretinal cysts and disruption to the macular contour. This may progress to a lamellar or full-thickness macular hole. Since the OCT scan clearly shows what is happening at the macula, the patient could easily see and understand the cause of her blurred vision.

In this case, the macular hole was visible with indirect ophthalmoscopy and retinal photo but the vitreomacular traction at the left macula was not. The OCT scan was instrumental in the detection of the pathology, and a prompt referral to a retinal specialist for possible treatment was organised.

The majority of OCT scans done in my practice are for suspected glaucoma and macula issues. It is satisfying to be able to offer my patients this state-of-the art technology to assist in early diagnosis of ocular pathology.

JUNE 2018 JUNE 2018 1716

Auto-Refraction

Non-contact Tonometry Auto-Keratometry

Non-contact Pachymetry

Corneal Analyser with Infra-Red Placido disk topography.

Automated alignment, focus and capture – controlled by colour touchscreen or digital control stick

Includes Meibomian Gland imaging, tear film breakup time, and Zernike Analysis reports

Topcon TRK-2P

Topcon CA-800

Completely automated alignment, focus and measurement acquisition.Flexible colour touch-screen for versatile positioning. Integration with Practice Management Software.

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Computerised Vision Tester - optional integration with PC-50s LCD Visual Acuity Chart.

Automated Refractor Head controlled by KB-50 colour touch screen & dial controller

Advanced integration – pull through previous script and/or auto-refraction. Export final subjective data to practice management software

Topcon CV-5000

Y O U R V I S I O N . O U R F O C U S .

Homogeneous LED illumination

5-step magnification up to 40x 14mm Slit illumination

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Topcon SL-D701Topcon’s premium digital ready Slit Lamp with tower style illumination column.

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Swept Source OCT – 1 micron Light source Multi-Modal Imaging Swept Source OCT Angiography

Topcon Triton Swept-Source OCT

1300 DEVICE (338 423) customers@device.com.au device.com.au

JUNE 2018 JUNE 2018 1918

At OptiMed our focus is always on helping you make your practice perfect with the latest diagnostic instruments, consultation room furniture and laboratory equipment.

Call 1300 657 720 or visit www.optimed.com.au for more information.

S Y D N E Y • M E L B O U R N E • B R I S B A N E • P E R T H • A D E L A I D E • A U C K L A N D

Phone 1300 657 720 Email sales@optimed.com.au Web www.optimed.com.au

At OptiMed our focus is on making your practice perfect.

This new LED slit lamp from Takagi will open your eyes to a new

standard of clinical observation. Easy to upgrade to digital option.

TAKAGI 700 GL

Large range of consulting room furniture options including our best selling DUO wheelchair

accessible stand. Customise with your own colour combination.

DUOAutomated auto ref/keratometer with

Corneal Topography. Extensive topography analysis tools and reporting.

Additional dry eye analysis software available.

REXXAM RET-700OCT just became more versatile by the introduction of biometry. World’s

fastest scanning OCT @ 110,000 scans per sec. Ideal for OCT

Angiography. Fully Automatic with voice control Wide angle scanning.

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Optical Coherence Tomography (OCT) is a breakthrough technology in eye care. It’s non-invasive, quick and safe to use. When first introduced into Australia over 10 years ago, the instruments were expensive and their role was specialised.

However, in the past five years the OCT revolution in clinical eye care has massively expanded, and in 2018 the OCT role is now on the verge of becoming a standard of care. How does any clinical technique, including OCT, become a standard of care? If a vision-threatening or even life-threatening condition can be detected with a technique, and not in other ways, then that technique often becomes a standard of practice. An example would be a mydriatic fundus examination when a patient has symptoms of retinal detachment. Intraocular pressure measurement can be a standard of care in many patient groups even in the absence of symptoms, since glaucoma is often asymptomatic. At the Australian College of Optometry (ACO), we use a range of OCTs from a range of manufacturers.

OCTs in the modern practicethe new standard of care in optometry

OCT bUyERS GUIDE PAGES 20-21

OCT scans on some patients in the last 12 months have shown changes to the back of the eyes characteristic of brain tumour, stroke and other lesions. Typically bilateral, the OCT macula maps can show homonymous or binasal thinning. Since only the transparent retina is affected, these signs are essentially invisible with normal clinical examination.

In addition to areas of macula thinning in pituitary adenoma, OCT can also quantify swelling of the optic nerve (papilloedema) due to meningioma, or photoreceptor loss in cancer associated retinopathy (CAR). The trend toward OCT as a standard of care for cranial lesions is supported by increasing evidence. Professor Michael Kalloniatis’s group has published an extended case series on retrograde conditions,1 and Vien et al2 showed head trauma causing a quadrantic homonymous OCT defect.2 In this way, OCT eye scans may be sight or life-saving, particularly with brain tumours that may be asymptomatic in the early stages. A medico-legal precedent may also help establish a standard of care.

Certainly the ‘Honey Rose case’ in 2017 in the UK focused the attention of the eye care profession onto the importance of detecting papilloedema. Since an RNFL scan that shows ‘white’ on the normative data scale is often indicative of optic nerve swelling, the OCT can form a key element of clinical risk management for patients of all ages. For more information on the use of OCT with either the ‘routine’ or the ‘same day referral’ conditions, the ACO have introduced a new online resource: ‘OCT Interpretation - By the Colours’. Written by clinicians for clinicians, this introductory lecture covers the common conditions through to the rare but serious.

www.aco.org.au

1. Zangerl B, Whatham A, Kim J, et al. Reconciling visual field defects and retinal nerve fibre layer asymmetric patterns in retrograde degeneration: an extended case series. Clin Exp Optom 2017; 100: 214–226.

2. Vien L, DalPorto C, Yang D. Retrograde degeneration of retinal ganglion cells secondary to head trauma. Optom Vis Sci 2017; 94: 125–134.

Dr Adrian S bruce BScoptom Phd FAAo Roman Serebrianik Boptom PGraddipAdvClinoptom PGradCertocther FACo Australian College of optometry

OCT BUYER’S GUIDE

Presented by

Model Combined OCT & retinal camera Normative database

OCT-A A-scans/sec Glaucoma progression analysis software

Anterior segment

Weight (kg)

Dimensions (mm)

What the catalogue says... Contact

Optovue Avanti XR3 No – 3D Retinal Reconstruction Yes

Optional - OCTA Essential

or OCTA Comprehensive

package

70,000 Yes Yes 65W: 950 D: 600 H: 690-995

State-of-the-art imaging from the cornea to the choroid with exclusive technology that will change your approach to disease diagnosis and management.

BOC Instruments (bocinstruments.com.au)Optovue i-Scan No Yes No 26,000 Yes Yes 19.5

W: 508 D: 406 H: 457

The fully-integrated OCT that practically runs itself, setting the standard for simplicity in OCT.

Optovue i-Vue Optional with iCam Yes No 26,000 Yes Yes 36W: 486 D: 874 H: 669-870

The benchmark for eye care practitioners seeking unmatched OCT performance and value, with capabilities you would expect to cost far more.

Nidek RetinaScan RS-3000 Advance No Yes Optional 53,000 Yes Optional 34W: 380 D: 524 H: 515

A combination of high-speed spectral domain OCT with Scanning Laser Ophthalmoscope (SLO) and advanced auto-focus/auto Z alignment technology offers outstanding precision and ease-of-use. Includes auto-tracking function, which tracks eye movement and guides to the OCT scanning position of previous examination (Baseline).

Designs for Vision

(dfv.com.au)Nidek RetinaScan RS-3000 Advance2 No Yes Optional 85,000 Yes Optional 34

W: 380 D: 524 H: 515

Extends Nidek’s OCT capabilities while retaining the advantages of SLO and autofocus/alignment technology. Includes auto-tracking function, which tracks eye movement and guides to the OCT scanning position of previous examination (Baseline).

Nidek RetinaScan RS-330 DUO12MP non-mydriatic fundus camera

Angle of view: 45° Optional Fundus Autofluorescence (FAF)

Yes No 53,000 Yes Optional 38W: 370 D: 536 H: 602

Combined OCT and fundus camera system that is a user friendly and versatile unit providing high definition images and value added features.

Topcon 3D OCT-1 MaestroNon-mydriatic ‘true-colour’

fundus camera Angle of view: 45°

Yes No 50,000 Yes Optional 21W: 307-442 D: 472-668 H: 518-722

Topcon has set the bar for providing a patient friendly, easy-to-use and completely automated comprehensive OCT for today’s eye care needs.

Device Technologies (device.com.au)

Topcon DRI Triton Non-mydriatic fundus camera.

Angle of view: 45° Colour and red-free

Yes Optional 100,000 Yes Optional 21.8W: 320-359 D: 523-554 H: 560-590

Using the latest swept source scanning technology and 100,000 A-scans/s speed, the longer swept source wavelength of 1,050nm provides DRI Triton with deeper penetration through to the choroid and better penetration through opacities, resulting in stunning clear and detailed images.

Topcon DRI Triton PLUS

Non-mydriatic fundus camera Angle of view: 45°

Colour and red-free. Fundus Angiography (FA)

Fundus Autofluorescence (FAF)

Yes Optional 100,000 Yes Optional 23.8W: 320-359 D: 523-554H: 560-590

With the same functionality as the DRI Triton - which includes swept-source OCT with combined colour fundus imaging - the Triton PLUS version also adds Fluorescein and Auto fluorescence imaging modalities.

MS-39 AS-OCT No Yes Yes 90,000 Yes Yes 10.4W: 505 D: 315 H: 251

The MS-39 AS-OCT is the most advanced device for the analysis of the anterior segment of the eye. France Medical (francemedical.com.au)

Spectralis OCT Advanced

Optional cSLO ModulesMulticolor Module

Blue Peak AutofluorescenceWidefield 55° Fundus and OCT

Panning Camera Mount

YesOptional (85kHz

OCT2 & OCT-A modules)

40,000 standard. 85,000 with 85kHz OCT2 module

Yes

Optional (Anterior Segment module)

13W: 330 D: 450 H: 600

Combines scanning laser fundus imaging with simultaneously acquired high resolution OCT, including Heidelberg’s TruTrack Active Eye Tracking, a patented technology that uses a second laser beam to actively track the eye during OCT scanning to avoid motion artefact and ensure accuracy in follow-up scans. As an expandable platform, it can be upgraded with additional scanning laser fundus imaging modalities, such as BluePeak autofluorescence and MultiColor, as well as advanced modules such as OCT2, the Glaucoma Module Premium Edition, OCT-Angiography, and the N-Site Neurological Module.

Heidelberg (HeidelbergEngineering.com)

Huvitz HOCT-1 NoJune 2018,

pending TGA approval

No 68,000 Yes Yes 30W: 330 D: 542 H: 521

Provides high-speed scan & high-quality images by using Huvitz’s outstanding optical technology and innovative image software.

Opticare (opticare.com.au)

Huvitz HOCT-1F 12MP non-mydriatic fundus camera Angle of view: 45°

June 2018, pending TGA

approvalNo 68,000 Yes Yes 30

W: 330 D: 542 H: 521

By combining OCT, Full Colour Fundus Camera, and PC, the Huvitz 1F can generate high resolution images providing multi-purpose functions for diagnosis.

Canon HS-100 No Pending release No 70,000 Yes Yes 29

W: 387 D: 499 H: 474

Operating an OCT has never been easier. The OCT HS-100’s extensive automatic functions simplify and optimise examinations.

Optimed (optimed.com.au)

Optopol SOCT Copernicus REVO OCT No - live fundus reconstruction No Optional 80,000 Yes Yes 23W: 382 D: 549 H: 462

Position the patient and press the START button to acquire examinations of both eyes. The SOCT Copernicus REVO , using vocal messages, guides the patient through the process, increasing comfort and reducing patient chair time. The SOCT Copernicus REVO is OCT-A, OCT Biometry and OCT Topography capable.

Optopol SD OCT Revo NX No - live fundus reconstruction No Optional 110,000 Yes Yes 23W: 382 D: 549 H: 462

The world’s fastest scanning speed allows for more achievable and more detailed exams while reducing scanning time. The SD OCT Revo NX is OCT-A, OCT Biometry and OCT Topography capable.

CIRRUS HD-OCT 5000 No Yes Optional 27,000-68,000 Yes Yes 36W: 460 D: 650 H: 530

The CIRRUS HD-OCT 5000 allows you to discover, track and analyse single pathological events from structural and vascular perspectives.

ZEISS (www.zeiss.com.au/meditec/

products.html)

CIRRUS HD-OCT 500 No Yes No 27,000 Yes Yes 34W: 460 D: 650 H: 530

Essential OCT capabilities with a broad range of clinical applications in an easy-to-learn, easy-to-use instrument.

CIRRUS photo 6005MP full-mydriatic & non-mydriatic fundus camera; angle of view: 45° Colour, red-free, blue, red and FAF

Yes No 27,000 YesYes (optional

ASPM for further functionality)

33W: 410 D: 480 H: 680

Broader clinical insights, greater diagnostic certainty and added practice value – the new CIRRUS photo from ZEISS delivers all that in a single, integrated system for both fundus imaging and OCT.

CIRRUS photo 800

5MP full-mydriatic & non-mydriatic fundus camera; angle of view: 45°

Colour, red-free, blue, red & FAF Fluorescein angiography & ICG angiography

Yes No 27,000 YesYes (optional

ASPM for further functionality)

33W: 410 D: 480 H: 680

Correlate data from high-density OCT cubes, thickness and layer maps with results from superb colour fundus images as well as fundus autofluorescence and fluorescein angiography images, all in one convenient sitting.

PRIMUS 200 No Yes No 12,000 No Yes 40W: 800 D: 1200 H: 1500

Utilises a simple 3-step process for capturing all anterior and posterior segment scans. This optimised workflow helps to increase operator efficiency while minimising patient chair time.

PLEX Elite 9000 swept-source OCT No No Yes 100,000 No No 45W: 660 D: 1040 H: 710

Swept-source OCT allows clinical researchers the potential to see deeper, wider, and in more detail from the vitreous to the sclera in the posterior segment.

JUNE 2018 JUNE 2018 2322

Glaucoma is a chronic condition that causes progressive neuronal loss and functional impairment if inadequately treated. Therefore early detection of the disease is the key to allow patients to preserve best vision possible and to maintain good quality of life.

Unfortunately, in clinical practice we are often faced with situations where detection of glaucoma is difficult due to structural characteristics of the optic nerve. From the Glaucoma Optic

Neuropathy Evaluation (GONE) project, we know that certain characteristics of optic nerves such as tilt and size makes assessment of the nerve more difficult to interpret.1,2 Fortunately, the development of sophisticated guided progression analysis (GPA) that combines both structural and functional information can often provide greater confidence to the clinician in the detection of disease. Furthermore, the addition of ganglion cell complex (GCC) analysis gives greater information than

retinal nerve fibre layer (RNFL) alone in identifying pathology.

The case below illustrates how structure-function analysis assists in my clinical practice.

GPA reports

The ZEISS Glaucoma Workplace allows the annotation of commencement of ocular anti-hypertensive medication on the visual field timeline, facilitating

Combined structure and function analysis aids detection of glaucomainterpretation of future results.

This case report is one of many cases were the GPA has improved detection of disease progression in my patients.

Importantly, the GPA reports were particularly useful in this case in demonstrating the structure-functional changes to the patient clearly on the screen, increasing the patient’s understanding of his condition and ensuring future treatment adherence.

A 72-year-old patient had been monitored for suspicious left optic disc since 2013 on a background of having mild myopia. He does not have family history of glaucoma. He has stable epiretinal membrane on his right eye and no other ocular history. His intraocular pressure in both eyes varies between 14 to 21 mmHg, with central corneal thickness (CCt) of 516 µm right eye and 510 µm left eye. His refraction is -3.50 / -1.00 x 75 degrees on the right and -3.25 / -0.50 x 50 degrees on the left and has mild nuclear sclerosis cataracts in both eyes.

Gonioscopy finding showed open angles. Since 2013 he has been monitored by my general ophthalmologist

Figure 3. A comparison of ganglion cell complex (GCC) analysis between 2016 and 2018

Figure 2. Guided progression analysis

Figure 1. The structure-function report

Dr George Kong MBBS BMedSci Phd FrANZCo ophthalmologist and glaucoma subspecialistMount waverley Eye Surgeons

ProductsZEISS Cirrus Hd-oCt 5000ZEISS Humphrey Field AnalyzerZEISS ForuM Glaucoma workspace

SupplierZEISS

characterisation of this patient’s condition, I used combined structural-functional analysis with ZEISS Glaucoma work-place on ZEISS Forum. the ZEISS Glaucoma workplace is unique in that it collates the data from all available visual field analyses and optical coherence tomography (oCt) scans to create highly-sophisticated progression analysis. the reports are colour-coded to aid the clinician in identify-ing pathology quickly.

the structure-function report provides important diagnostic information (Figure 1). Focusing on the left eye, the presence of rNFl and GCC deviation defects are shown on the devia-tion maps, particularly evident is the superior rNFl thinning.

Some might dismiss the paracentral loss in visual field sensitivity shown in total deviation and Pattern deviation as trivial because it is not reflected in the Graytone map, however, careful examination shows that the superior rNFl

thinning correlated closely to the inferior paracentral defect on visual field. this combined structure-func-tion abnormality gives confidence to a finding of pathology in the left eye. of note: abnormality in patient’s right eye GCC analysis is the result of ErM affecting the accuracy of retinal segmentation.

the presence of left eye structure-function defects is not a confirmation of glaucoma because such defects can sometimes be found in myopic patients. In this instance, the structure-function GPA provided an important clue that this is indeed a progressive process and is likely caused by glaucoma (Figure 2). on the structural aspect, the Progression Map of rNFl for this patient highlighted areas where the rate of thinning occurred greater than that expected of normal ageing as Possible loss (orange) and like-

CASE REPORT ly loss (dark red). on the functional aspect, Event analysis highlighted points in the paracentral region as possible progression, again correlating with areas of structural change. A comparison of GCC analysis between 2016 and 2018 showed progressive thinning of GCC over this period (Figure 3), confirming a progressive glaucoma-tous process.

the combination of these analyses provided me with the confidence to make the diagnosis of normal tension glaucoma in the left eye of this patient. Given his thin CCt, we aimed for a target pressure of ≤ 13 mmHg and he was commenced on brimonidine topical eye drop to his left eye.

1. Kong YX, Coote MA, O’Neill EC, et al. Glaucomatous optic neuropathy evaluation project: a standardized internet system for assessing skills in optic disc examination. Clin Experiment Ophthalmol 2011 39: 308–317.

2. O’Neill EC, Gurria LU, Pandav SS, et al. Glaucomatous optic neuropathy evaluation project: factors associated with underestimation of glaucoma likelihood. JAMA Ophthalmol 2014 132:, 560-566.

colleague for optic disc asym-metry with greater cup-to-disc ratio in his left eye, however due to slight disc tilt, diagnosis was not certain. He was given a treatment of latanoprost previously for possible normal tension glaucoma for sever-al months in 2014, however due to the patient developing side-effects to latanoprost and lack of concrete evidence of progression, the decision was made by my colleague to moni-tor without treatment.when the patient was referred to me for opinion, I noted the patient had optic nerve asym-metry with particular thinning of neuro-retinal rim superi-orly in the left eye. For better

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JUNE 2018 JUNE 2018 2726

Alleve Eye Clinic is Adelaide’s first dedicated dry-eye-only clinic. It’s a non-dispensing practice that returns all patients back to their referring optometrist for continued care. Over the last several years, co-owner Rene Malingre and I realised that treatment of dry eye in a clinical practice depends on the ability to provide the appropriate amount of time, dedication and equipment needed to manage it successfully.

Recent research and technological advances have transformed our understanding of the aetiology and pathological pathways of dry eye. Today, optometrists can offer patients effective, sustainable and often life-changing management solutions.

Designs For Vision are our go-to suppliers for most of our dry eye equipment. They have always gone out of their way (even when I was running a general optometry practice) to keep me updated on dry eye advances and new products and technology available. As a dedicated dry eye practice now, I value the time and consideration they have provided to help us grow our business and treat patients.

Mr X, a 65 year-old gentleman presented with irritable, stinging eyes. On initial examination, his tear break-up time with fluorescein staining appeared reasonable at six

Dr Jennifer RaynerBAppSc(optom) GradCtocther(uNSw)Alleve Eye Clinic

ProductoCuluS Keratograph 5M Blephasteam By theaEye Eco dry Eye relief Mask, d.E.r.M.

Supplierdesigns For Vision

Diagnose and treat dry eye with ease

to seven seconds and some meibum was expressed from a few glands superiorly and inferiorly. As part of any dry eye workup – full or partial – we rely on the OCULUS Keratograph 5M to assist with our diagnosis, prognosis and management options. In this case, I suspected there was incomplete meibomian gland function contributing to an unstable tear film and we proceeded with imaging. While the lipid layer function does not give data, it provides an invaluable objective visual recording of the interference pattern of any oil present (Figure 1).

There was a clear band of coloured inference centrally, while both the superior and inferior portions of the cornea were noticeably absent of this phenomenon.

Looking for confirmation, I proceeded to record his tear break up time using instilled topical fluorescein.

Figure 2 illustrates the corresponding central tear film stability with impaired superior and inferior break-up time that I expected to see after the lipid layer imaging. This made sense of his presenting symptoms and I proceeded with an in-rooms Blephasteam session and meibomian gland expression.

The Blephasteam has the advantage of pre-heating the system to the ideal 42 degrees Celsius, then constantly maintains the heat source for the desired duration of 10 minutes. The disposable moisture rings provide the humidity also required for optimum meibum melting. I personally find

CASE REPORT

that this heat source usually offers a significant improvement of the meibum consistency and most patients comment on the improved comfort they feel after the session.

After treatment

Figure 3 shows a more consistent lipid layer spread across the cornea. We keep Blephasteam goggles in stock, and sell them, with a complementary box of replacement rings. Patients, particularly those with chronic and advanced dry eye, appreciate the superior treatment the Blephasteam goggles offer them.

I always follow a Blephasteam session with lid expression using my favourite Mastrota paddle. I also have the Gulden paddle which is particularly good for upper lid expression, but I prefer the smaller footprint of the Mastrota paddle for varying pressure that can be applied to individual glands. In Mr X’s case, heat and expression yielded significantly greater meibum than with a ‘cold’ expression and, as I expected, he reported a significant decrease in his symptoms. As part of our ongoing initial protocol until a plateau of symptoms has been achieved, I ask the patient to continue at least once-daily warm lid compresses using the Eye Eco Dry Eye Relief Mask (D.E.R.M.) mask and manual lid massage.

The D.E.R.M offers both warm and

Figure 1. Assessment of the interference colours of the lipid layer (right eye)

Figure 2. Central tear film stability with impaired superior and inferior break-up time

Figure 3. A more consistent lipid layer spread across the cornea

cool compress options (the latter is particularly useful in hay fever season—especially here in South Australia; it can be a lifesaver for patients. It’s also good for reducing lid puffiness. (I have one mid-20’s patient who is a model; he uses the heat for his dry eye treatment at night, cools it down, then pops it in the freezer to use first thing in the morning to reduce lid puffiness). While the mask itself is not washable, it comes with disposable liners which both extend the heat treatment and protect the mask from collecting dirt and make-up—washable covers are now available to protect it even further.

We’d certainly be lost without the OCULUS Keratograph 5M as a diagnostic tool for dry eye. Meibo-Scan, using infra-red imaging shows any potential limitation of treatment success from meibomian gland dysfunction or loss, a JENVIS report provides a succinct baseline and printed take-home report with data analysis of non-invasive tear break-up time, conjunctival redness, LIPCOF function, OSID questionnaire and tear meniscus height. All you need to see and understand dry eye much more clearly.

Lastly, the topography functions are excellent for contact lens fitting and management. As contact lenses and dry eye go hand-in-hand, your patients love the fact that you can go the extra mile and give them relief from what can often be a debilitating

disease process.

Designs For Vision offer excellent after-sales service and have always been happy to follow up any questions that they have not had an answer for. I know they have their finger on the pulse when it comes to dry eye equipment and our next view is to trial the new Eye-Light OPE/IPL system.

Traditionally, treating dry eye may have been seen as time consuming, unrewarding and confusing. However, with the tools and research now available, diagnosing and treating even moderately irritating and early dry eye can be as simple as assessing meibum function at the slitlamp using the Mastrota paddle, prescribing the D.E.R.M. mask for at-home treatment and relief or taking it a step further and assessing the tear film and glandular function with the Keratograph 5M to take it to the next level.

As we often say: ‘never underestimate the power of treating early dry eye and the loyalty that patients will offer in return when you do.’

Dr Jennifer Rayner is the principle consulting optometrist, and co-owner with Rene Malingre of Alleve Eye Clinic.

JUNE 2018 JUNE 2018 2928

As OCT in an optometric practice becomes more common, practice owners are faced with what can be a very daunting decision. The purchase of an OCT is likely the most expensive piece of equipment to be purchased for a practice, and the decision is now made more complicated by the amount of choice on the market.

A little over seven years ago, I purchased my first OCT, the NIDEK RS-3000, leaving me with little change out of $100K. At the time – and still today – it provides quick, non-invasive observation and measurement of the anterior and posterior structures of the eye through undilated pupils (> 3mm) with confocal scanning laser ophthalmoscopy and A scan OCT. The NIDEK system delivers a resolution of 4 microns, capable of 53,000 A-scans a second, with up to 9 mm line, box grid, and radial configurations.

As I wrote for this same publication five years ago, the imaging is mind blowing, and the normative population data for macula, retinal nerve fibre layer, and ganglion cell layer thickness has enabled me to diagnose, monitor and manage glaucoma, and retinal pathology with confidence. One of the reasons I chose the NIDEK at the time was the width and quality of the anterior OCT imaging. In a busy contact lens practice the anterior OCT has become an integral part in the

management of keratoconus, corneal pathology, angle imaging and scleral contact lenses.

After seven years of having an OCT at my city practice in Adelaide, but not at my suburban practice in Woodville, it was time to invest and utilise OCT diagnostic imaging technology at both locations. This time the choice was 10-fold greater than it was seven years ago and the technology has evolved immensely.

Op gear

Over two years, I did a significant amount of research, and most of the equipment suppliers were good enough to let me test-drive their OCTs in practice. Compared to my first machine, current OCT technology includes – but is not limited to – faster scanning rate; advanced eye tracking; increased image sampling and averaging; noise reduction; automatic

rescan; wider and deeper A scans; and much more.

Like the car industry, the OCT industry has machines at widely-differing price points. They also have manual, automatic, and driverless options and upgrades, hybrids (OCT and fundus camera), optional extras, software upgrades, and a full complement of warranty and servicing packages. Like watching an episode of Top Gear, over the few years I have opened this publication and seen new models hit the market that go faster, smarter and have drool-worthy features—only to find that my machine can’t do everything, and I would need to trade-in to upgrade.

Literally, out of this world technology

Anyone who has a smart phone, purchased an Apple product, or followed Elon Musk and his companies

Space X and Tesla would be familiar with the ‘software-powered hardware’ renaissance. Heidelberg Engineering and their OCT platform, the Spectralis, is an example in the ophthalmic imaging industry of this design model, where the high-quality engine is powered by ever-evolving upgradeable software.

Heidelberg’s German-made hardware is industry-leading, meticulously manufactured and has even passed a rigorous evaluation by NASA prior to its rocket launch to the international space station, where a commercially-made Spectralis resides, monitoring the long-term effects of microgravity on the eyes of astronauts.

The Spectralis is a truly flexible and upgradeable platform that can be customised to fit the needs of each individual practice. Defying the similarities of the ophthalmic imaging and car industry’s impetus to trade in your outdated machine and sell you the latest model, over the last decade Heidelberg has enabled eye care practitioners to utilise the same engine and hardware and upgrade the platform through software. Practitioners can be confident in the knowledge that a Heidelberg OCT platform will grow with you and your clinic. As new technology becomes available, you can simply add new imaging modalities, providing you with additional information to enhance clinical decision-making and preserving patient data for precise follow-up.

After seeing the Spectralis in action at the 2017 ODMA conference I knew I was getting a faster machine, higher resolution imaging, better eye tracking, wider anterior segment imaging, and I liked Heidelberg’s business model. Six months after taking delivery of my Spectralis, and putting over 1,000 patients on my HEYEX database, I can say I am a better clinician, my clinic runs faster and I have a better understanding of retinal and optic nerve pathology. In my opinion, the two best upgrades to the base model are the ‘Glaucoma Module Premium Edition’ and the ‘Multicolour Scanning Laser Imaging’.

Multicolour scanning laser imaging is a pseudocolour composite using green (518 nm), blue (486 nm), and infrared (815 nm) laser wavelengths

simultaneously to provide diagnostic images that show distinct structures at different depths within the retina. The high-resolution, detailed multicolour images can highlight structure and pathologies not visible on ophthalmoscopy and fundus photography. Recent studies comparing multicolour and traditional colour fundus photography concluded that multicolour imaging allowed for improved detection, definition and evaluation of early and late-stage ARMD,1 geographic atrophy due to ARMD,2 and papilloedema phenotypes.3

In practice, compared with traditional fundus photography, multicolour is fast; convenient when coupled with OCT on the same instrument; achieves excellent images through an undilated pupil, in patients with cataracts, astigmatism, higher order aberration, and nystagmus; and it has a greater sensitivity and specificity in the detection and definition of retinal pathology.

One of my greatest frustrations with my first OCT was its inability to image and evaluate the optic nerve heads of patients with high myopia and tilted optic nerve heads (ONH). Retinal nerve fibre layer (RNFL) and ganglion cell layer (GCL) imaging in OCT is known to have a high specificity for identifying healthy eyes and the detection of early glaucoma damage.4 However, cases of high myopia with large axial length, peripapillary atrophy and tilted disc often results in poor capture and a high false positive occurrence.5

bruch’s membrane opening

The Spectralis OCT Glaucoma Module Premium Edition provides a new, objective method of ONH analysis using Bruch’ membrane opening (BMO). The neuroretinal rim assessment is performed from the BMO to the nearest point on the internal limiting membrane (ILM), and this shortest distance measurement is referred to as BMO – minimum rim width (BMO-MRW). This parameter considers the orientation of the rim tissue relative to the point of measurement, and the highly variable anatomy of the ONH both within and between individuals, and quantifies the rim width perpendicular to the trajectory of axons. Moreover, the new software provides an anatomic positioning system (APS) where acquisition of data is based on fovea-to-BMO-centre axis, reducing the inter-individual variation.6

The result of this technology is the highest sensitivity at 95 per cent specificity in early glaucoma of any optic nerve head marker.7 In regards to myopic tilted discs the BMO-MRW false positive rate of eight per cent is significantly lower compared with RNFL (62 per cent) and GCL (50 per cent).8 The specificity of the BMO-MRW is also significantly higher compared to using RNFL in low myopia (89.7 per cent vs 41.4 per cent) and moderate myopia (95.2 per cent vs 33.3 per cent). In a clinic that manages a lot of high myopia as a consequence

Lachlan Scott HoyBAppSc(optom)Hons FIAo FCClSA optometrist and director Innovative Eye Care, Adelaide Australia. director, Innovative Contacts, Adelaide Australia director, Clinical research and lens design. Innovatus technology, Adelaide Australia

ProductHeidelberg Spectralis

SupplierHeidelberg Engineering

Truly flexible and upgradeable

Figure 1. OCT A scan of an EyeSpace scleral contact lens

Figure 2. OCT of an eye with adult-onset vitelliform macular dystrophy and an epiretinal membrane

Continued page 30

JUNE 2018 JUNE 2018 3130

Figure 3. Multicolour Fundus image of an eye with adult-onset vitelliform macular dystrophy and an epiretinal membrane

Figure 4. A tilted ONH in a patient with moderate myopia. MRW, RNFL, and retinal thickness all display a thinning inferior temporally in a patient with ocular hypertension and pigment dispersion syndrome

of a large RGP contact lens practice, the Glaucoma Module Premium Edition has given me greater diagnostic power and confidence when managing what are often very complicated eyes.

The Heidelberg Engineering Spectralis OCT comes packed with German-made hardware, providing the engine for those who want a driverless vehicle that takes them to their destination with minimal effort, or top-of-the-range performance, power, control, precision and accuracy of a ‘silver arrow.’

1. Graham KW, Chakravarthy U, Hogg RM et al Identifying features of early and late age-related macular degeneration: A Comparison of Multicolor Versus Traditional Color Fundus Photography. Retina 2017 Aug 22. doi: 10.1097/IAE.0000000000001777. [Epub ahead of print]

2. Ben Moussa N, Georges A, Capuano, V, et al. MultiColor imaging in the evaluation of geographic atrophy due to age-related macular degeneration. Br J Ophthalmol 2015; 99: 842–847.

3. Malem A, De Salvo G, West S. Use of MultiColor imaging in the assessment of suspected papilledema in 20 consecutive children. J Aapos 2016; 20: 532–536.

4. Silverman AL, Hammel N, Khachatryan N, et al. Diagnostic Accuracy of the Spectralis and Cirrus Reference Databases in Differentiating between Healthy and Early Glaucoma Eyes. Ophthalmology 2016; 123: 408–414.

5. Hwang YH, Yoo C, Kim YY. Myopic optic disc tilt and the characteristics of peripapillary retinal nerve fiber layer thickness measured by spectral-domain optical coherence tomography. J Glaucoma 2012; 21: 260–265.

6. Bin Ismail MA, Hui Li Lillian K, Yap SC, et al. Effect of Head Tilt and Ocular Compensatory Mechanisms on Retinal Nerve Fiber Layer Measurements by Cirrus Spectral Domain and Spectralis Optical Coherence Tomography in Normal Subjects. J Glaucoma 2016; 25: 579–583.

7. Chauhan BC, O’Leary N, Almobarak FA, et al. Enhanced detection of open-angle glaucoma with an anatomically accurate optical coherence tomography-derived neuroretinal rim parameter. Ophthalmology 2013; 120: 535–543.

8. Rebolleda G, Casado A, Olanca N, et al. The new Bruch’s membrane opening - minimum rim width classification improves optical coherence tomography specificity in tilted discs. Clin Ophthalmol 2016; 10: 2417–2425.

SpectralisFrom page 29

JUNE 2018 JUNE 2018 3332

A new device used at home by AMD patients detects progression earlier, enabling timely treatment.

Recently cleared by the US Food and Drug Administration (FDA), but unavailable in Australia, ForeseeHome AMD Monitoring Program from Notal Vision enables optometrists and ophthalmologists to detect wet AMD earlier and preserve functional vision in at risk patients by starting treatment sooner.

This is done through detection and characterisation of central and paracentral metamorphopsia including, but not limited to, choroidal neovascularisation.

Patients with stable fixation do a daily three-minute test per eye and results automatically go to a monitoring centre which alerts practitioners if there is a significant change

from baseline that may indicate progression.

Home monitoring may also contribute to better management of glaucoma patients and suspects, according to a new study.

Researchers trained 40 patients with the Icare HOME Tonometer (available in Australia) and found self-

tonometry enabled robust measures of diurnal IOP and detected changes to IOP in response to treatment. Four measurements daily over seven days provided robust estimation of IOP patterns that would otherwise require weeks of monitoring.

They found two dominant fluctuations – peak IOP on awakening and at midday. Diurnal IOP in the first week also correlated to diurnal IOP across the study period.

Patients said the device was easy to use although there were some difficulties with correct alignment.

www.notalvision.com

Optom Vis Sci. March 2018 doi:10.1097/OPX.0000000000001172

In the news ... Industry innovations and announcements

902 - MM - E300 Banner AD - Opt Mag Australia-2.indd 1 2017-04-10 4:17 PM

Optical coherence tomography (OCT) and OCT angiography may help identify pre-clinical Alzheimer’s disease, according to a small study presented at the American Academy of Neurology’s annual meeting in Los Angeles, California in April.

Researchers from the Washington University Alzheimer’s Disease Research Center said the future aim would be to identify patients in the pre-clinical stage before there was too much neuronal loss, and potentially intervene.

Research previously provided evidence of retinal changes in Alzheimer’s; OCT metrics in Alzheimer’s patients with cognitive dysfunction showed some evidence of vascular and microvascular dysfunction in the retina. But it was unknown if similar retinal changes occurred in pre-clinical Alzheimer’s.

Their study, supported by Optovue, developers of OCT angiography, found that 16 of 30 patients were biomarker-negative for Alzheimer’s.

The 14 who were biomarker-positive and classified as

OCT might show pre-clinical Alzheimer’s

Home monitoring beneficial in AMD and glaucoma

Optomed Oy (Ltd.) Finland, a market leader in hand-held fundus imaging, has recently launched their innovative, non-mydriatic retinal camera, the Aurora. Billed as ‘the next generation hand-held fundus camera,’ the Aurora introduces a totally new concept in fundus imaging and design where high quality imaging and sleek Finnish design meets ease of use.

The Aurora is the only hand-held fundus camera in the market with a 50-degree field of view, featuring a clear 4-inch high quality screen display, new state-of-the art modern design, dual charger, eye surface imaging module and an intuitive interface with simple icons.

Its portable compact size with WLAN or USB connectivity makes the Aurora ideal for hand-held or slitlamp mounted use for fundus and anterior eye imaging.

BOC Instruments is the Australian distributor for Optomed. For further information please contact: BOC Instruments Ph: 1800-804-331 email: sales@bocinstruments.com.au

Aurora hand-held fundus camera

having pre-clinical Alzheimer’s had inner foveal thinning (75.4 versus 66 µm) which was ‘congruent with the body of literature looking at OCT in established Alzheimer’s disease.’ They also had an enlarged foveal avascular zone (0.30 mm2

versus 0.40 mm2).

Researchers said the mechanism was not entirely clear but it could be due to capillary deposition of collagen and amyloid, resulting in cellular apoptosis and vessel drop-out.

BOC Instruments has announced its newest range of chair and stands, the Baha series, which offer a practical sleek modern versatile clinical design.

Standard features include a magnetic lock mechanism to lock the table in any position, dimmable LED reading and head lamp, easily accessible multi-functional control panel, phoropter arm, rotating chair with foldable footrest and foldable armrests.

They can be installed as either right or left sided table to best suit consulting room layout. The Baha II design has a dual instrument sliding table and the Baha III incorporates a rotating table to accommodate three instruments. Both

these versions are also available with optional motorised table top elevation and reclining chair, and also as wheel chair versions which provide compatibility for full wheel chair access.

The standard configurations include a drawer suitable to accommodate a trial lens set, or can be supplied with space saving short length configuration without drawer.

For further information please contact: BOC Instruments Ph: 1800-804-331 email: sales@bocinstruments.com.au

New baha series of chairs and instrument stands

ZEISS Australia has announced the release of the CLARUS 500, the next generation, ultra widefield fundus imaging system.

The CLARUS 500 creates true-colour, high-resolution, 200-degree ultra-widefield images that closely resemble the colouration of the fundus as seen during clinical examination, which is critical for differential diagnosis and when evaluating such anatomical features as the optic disk and nevi.

By utilising precision ZEISS optics, the CLARUS technology allows for high-resolution, 7 micron images from the macula to the far periphery. This allows the clinician to zoom in and resolve fine details on structures such as the optic nerve head and macula, eliminating the need for a separate traditional fundus camera.

Each colour image can also be split into red, green and blue channels. Furthermore, the CLARUS 500 is the only device of any category that features both blue and green fundus autofluorescence, allowing clinicians to visualise lipofuscin fluorescence in the retinal pigment epithelium (RPE), an indicator of RPE health.

The device features a stable patient chin-rest while the operator brings the optics head to the patient with a joystick controller. To further simplify the process, the operator is assisted with an infrared preview image and alignment tools to give them the best opportunity to capture a high-quality image the first time.

www.zeiss.com.au

CLARUS 500 fundus camera

Continued page 34

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Figure 1. 3D wide Hood report with visual field testing point.

Wide scan protocol a clear step up

Peter ThompsonBoptom Postgrad ocular therapeutics deniliquin Eyecare, NSw

Producttopcon triton Swept Source oCt Supplierdevice technologies

I have had the benefit of using a Topcon Spectral Domain OCT in my practice for the last seven years. The multi-modality of the instrument, combining retinal photos and OCT scans in one acquisition (and the benefit of pinpoint registration between the two) has provided a massive boost to my diagnostic capabilities and, therefore, to my patients’ care.

About 18 months ago I was made aware of the new Topcon Triton Swept Source OCT and I started to consider its benefits over my existing system. Upon investigating further, I soon realised that there were many reasons to consider an upgrade.

First of all, my OCT-2000, while still operating well, was getting old. (OCT technology moves fast). Secondly, with the Triton, I could get the benefits of

Figure 2. 3D wide glaucoma report, left and right eyes.

Swept source tech combined with a 3d-wide glaucoma report with visual field test points offers greater clinical insights

Swept Source OCT into my practice. These benefits really excited me on a number of levels.

While my Spectral Domain OCT was a clear step up from a Time Domain OCT, I felt it still had a number of limitations:

• I was struggling to get a decent scan through moderate cataracts

• I could visualise haemorrhages on my retinal photos, but could not see beneath them

• The depth of images was quite restricted, especially on higher myopes

• I couldn’t penetrate the sclera to visualise the outer retina

• It was difficult to visualise both the choroid and the vitreous in one scan

Swept Source OCT has taken all of the above issues away. The capability of the Triton to see through cataracts, through bleeds and through the sclera to get full data sets on high myopes and to get the depth to enable us to visualise what is happening in both the vitreous and the choroid is quite

extraordinary.

The Hood Glaucoma Report

We now have the added feature of the ‘Hood Report.’ Topcon’s exclusive OCT report developed in collaboration with Dr Donald C Hood, Professor of Visual Science at the Department of Ophthalmology at Columbia University.

The Hood Report utilises the Topcon 3D Wide 12mm x 9mm scan protocol to assess glaucomatous damage through analysis of the ganglion cell and nerve fibre layers.

The damage to these layers is transposed into a predictor of field loss within the report. Taken as a whole, the reports have, in our practice, highlighted the importance of a denser array of visual field plots within our field testing strategies.

This enhances our understanding of the early detection and progression of glaucoma and is a wonderful tool that has been added to our armoury.

Anterior imaging

The Topcon Triton also offers an anterior imaging platform that allows

me to take a 16 mm radial anterior scan. This allows me to very quickly see angles at 24 different points in one acquisition.

It also allows me to see how my RGPs are sitting on the cornea, once again saving time and giving me confidence in the lens fit I am providing.

We are now utilising the 12mm x 9mm widescan protocol as our primary scan. This scan protocol provides data against normative for the following:

• Retinal thickness around the macula

• Retinal Nerve Fibre Layer (RNFL) around the disc and the macula

• Ganglion cell layer (GCC)

• Ganglion cell complex (both GCC and RNFL around the macula)

This wider scan has given me greater clinical insights. In the examples shown, the wide scan protocol highlighted the disease to a degree that it was unmissable.

NEWSFrom page 33

A recent five-centre study offers independent confirmation of the performance improvement of SITA-Faster compared to SITA-Standard and SITA-Fast.

An international group of researchers established a study to test the new algorithm which was recently developed for the Humphrey perimeter called SITA Faster (SFR). SFR is a modification of SITA Fast (SF) and was designed to further reduce test time.

126 eyes with manifest or suspect glaucoma of 126 patients underwent 24-2 threshold perimetry with SFR, SF and SS in randomised order, with tests repeated in reversed order at a second visit. Five centres, Berkeley CA USA, Hong Kong China, Malmö Sweden, Tajimi Japan, and Tampere Finland participated. Results were pooled and analysed in terms of test time, VFI, MD, and number of significantly depressed test points in total (TD) and pattern deviation (PD) probability maps. Test-retest variability was also studied.

The researchers found that SITA Faster reduced test times by 30 per cent (compared with SITA Fast) and 53.5 per cent (compared with SITA Standard). Other findings include: SITA Faster is clinically equivalent to SITA Fast; and SITA Faster’s small differences compared to SITA Standard were similar to those seen between existing SITA Fast and SITA Standard.

The study authors concluded that SITA Faster saved considerable test time as compared to SF and SS and endorsed SITA Faster as a new time-saving alternative for SAP threshold testing.

www.zeiss.com.au

SITA Faster proven faster

JUNE 2018 JUNE 2018 3736

In my over 30 years in optometry, it has been wonderful to see our practice, and the profession, grow and expand over the years. Today, Mount Martha Optical is the primary eye care providers to our community. We have seen our relationships with our patients, local GPs and ophthalmologists strengthen, and the expectation for us to provide quality care has never been higher.

Undoubtedly, one of the biggest changes in my practice has been in investing in imaging equipment. Designs For Vision has helped me every step of the way, starting with the purchase of the Kowa

Kirsty banfieldBoptomoptometrist and owner, Mount Martha optical

ProductKowa nonmyd 7 retinal cameraKowa nonmyd 8 retinal cameraNidek rS 3000 Advance retinaScan oCt/Slo System

Supplierdesigns For Vision

Investing in imaging

nonmyd 7 (non-mydriatic) camera over 12 years ago. Over this time the camera has provided excellent, quality photos of the central retina with the option of both a 20 and 45 degree field.

The small pupil setting allows photos through a 3.7 mm pupil. The red-free filter helps further assess the retinal nerve fibre layer, and the stereo assessment of the optic disc function allows for even better glaucoma evaluation. Retinal photography with the Kowa nonmyd 7 has been a wonderful way to accurately record patient retinal health and to monitor any changes. It has also been a great tool in educating patients in their eye health, particularly for my diabetic patients who are reassured when they see their own healthy retina when compared to a photo of an eye with diabetic retinopathy changes. Based upon this experience, I have recently purchased a newer version of the Kowa retinal camera, the nonmyd 8 which now has a fundus autofluorescence (FAF) setting, allowing even better assessment of geographic atrophy in patients with dry AMD.

I purchased the Nidek RS-3000 Advance RetinaScan OCT over four

years ago and have found it invaluable to further investigate retinal changes, particularly in the macula region, and to better assess the optic nerve for glaucoma. The ability to take baseline images and use the progression analysis tool has improved my ability to diagnose those patients with glaucoma more accurately and I also feel more comfortable knowing which patients I can watch and review.

The interesting outcome of using OCT technology is that I probably refer fewer patients compared to when I just relied on retinal photography and traditional means of viewing the retina. As with the now-current RS-3000 Advance model, it also has an anterior segment module which allows assessment of the cornea, anterior segment and anterior chamber angle. A further attractive option with the Advance is OCT-Angiography imaging.

Designs For Vision has worked closely with me over the years to provide the best equipment to fit in with my practice. The staff are well informed about their products and the after sales and technical support is second to none.

Adrian Vecchio BSc Boptom

Norm Russo BScBoptom FACo FACBo

russo + Associates optometry

ProductSoCt Copernicus rEVo

SupplieroptiMed

Do you need an OCT when you have a large paediatric patient base? This is the question that has been on our minds for some time, and when we heard whispers of an OCT that had a biometry function, our interest was piqued. We have a large paediatric client base, and a strong history of myopia control management. The prospect of an OCT that could be used to benefit both adults and children was very enticing.

We trialled the SOCT Copernicus REVO, which has a scanning speed of 27,000 scans per second and biometry function, and we found it surprisingly easy to use. It is a fully-automated device. All that is required of the operator is to position the patient and hit the ‘START’ button, and the machine does the rest.

The standard retinal OCT functions were easy to use, and gave nice repeatable data, as per other brands of OCT.

The biometry function was also simple to use, the REVO takes an anterior segment scan followed by a retinal

OCT for our paediatric patient baseA powerful tool in myopia management

scan. The scan took about six seconds, however it should be three times faster on the 80,000 scan/sec model which is now available. Even with the six-second scan time, we were able to capture very accurate and, more importantly, repeatable data on a wide range of patients. The data is expressed in a table showing corneal thickness, anterior chamber depth, intraocular lens thickness and axial length.

A notable example of the ease-of-use of the REVO was a recent, wriggly five year-old patient with ADHD and reduced vision. He had a very dull retinoscopy reflex, and we were worried about high myopia. We were able to capture a scan quite easily on him, and he was found to have average 23 mm eyes. This prompted a difficult but ultimately satisfactory slitlamp examination that revealed subtle posterior sub-capsular cataracts.

CASE REPORT

Continued page 38

JUNE 2018 JUNE 2018 3938

Figure 3. Screen display of biometry measurements showing axial length, anterior chamber depth, lens thickness, and central corneal thickness

I am a practicing glaucoma specialist and IT expert. In 2016, along with Professor Algis Vingrys, an optometrist and vision scientist with a long track record in visual field developments, I founded GLANCE Optical. Our goal is to develop portable vision tests that can be used by practitioners and patients alike.

cystoid macular oedema unresponsive to anti-VEGF agents or intravitreal triamcinolone.

Her latest visual acuity measurements were 6/36 in her right eye and 6/9 in her left eye. Intraocular pressures were right 14 mmHg and left 12 mmHg on iCare rebound tonometry. Her mobility is severely limited by her rheumatoid arthritis and peripheral neuropathy from diabetes. She also requires wheelchair assistance.

For the past three years, Ms LW has not been able to perform a reliable visual field test or structural imaging due to her inability to reach chin-rests of testing machines. She also takes Plaquenil (hydroxychloroquine) 400 mg BD long term. The inability for the clinic to perform regular visual field assessment is of particular concern.

To address this, we performed visual field testing for her using the Melbourne Rapid Fields perimetry software. A 12.9-inch Apple iPad Pro, running version 2 of MRF Glaucoma software was used. Ms LW remained in her wheelchair while performing the test. While wearing her reading glasses, each eye was tested separately by covering the fellow eye. The tablet was positioned 33 cm from her face with a

Dr George Kong MBBS BMedSci Phd FrANZCo ophthalmologist and Glaucoma subspecialist Mount waverley Eye Surgeons

ProductMelbourne rapid Fields

SupplierGlANCE optical

Cutting edge portable perimetryThe REVO was invaluable in helping to establish the correct cause of his decreased vision, and appropriate referral.

During our trial period with the REVO, we saw patients with high myopia and 27 mm eyes, a patient with a monocular script change, which was able to be confirmed as they also showed asymmetric axial lengths. We were also able to get axial lengths on several children who fall into the ‘at risk’ category for myopia progression. We see the device as being a powerful tool in myopia management. It will allow us to establish baselines and monitor progression of myopia with an extreme level of accuracy and ease.

On the whole, we have been very impressed with the REVO OCT and the additional biometry function. We recently ordered the 80,000 scan per second model, and we are looking forward to seeing it in action. This should help make the capture and scan time even more patient-friendly. REVO’s idea to incorporate a biometry function appears to have tapped into an area which will become even more useful as time goes on. We think it will quickly become another tool in optometry’s armoury in the fight against myopia.

The REVO OCT is available with a full complement of posterior and anterior tools as standard with biometry, OCT-A and the soon-to-be-released Corneal Topography modules available as optional extras.

Figure 1. Axial length table of 13yo congenital myope

Figure 2. Screen capture showing biometry measurements

CASE REPORT

Paediatric patientsFrom page 37

Melbourne Rapid Fields (MRF) is the first product for our group. MRF is a portable perimetry tool that performs to industry standards for visual field thresholding. The name reflects the adoption of contemporary cutting-edge logic to yield fast and accurate vision testing.

In our clinics, we often face the challenge of looking after patients who are affected by various factors that makes performing standard automated perimetry difficult. One such factor is the issue of positioning, alignment and mobility demanded by conventional perimeters.

I have been looking after a 69-year-old lady ‘Ms LW’ who was on insulin for type 2 diabetes mellitus; she also suffered from rheumatoid arthritis and lupus. Ms LW has had past ocular history of proliferative diabetic retinopathy with bilateral panretinal photocoagulation in both eyes. She takes topical medication (alphagan and brinzolamide) for primary open angle glaucoma. Her right eye underwent a vitrectomy for vitreous haemorrhage in 2011 and following this, she had cataract surgery in 2012, which was complicated by chronic Continued page 40

Melbourne rapid Fields

JUNE 201840

specially-designed viewing box. She responded to the stimuli by pressing the spacebar button on an attached keyboard.

Speed

Visual field thresholding requires fixational eye movements to test the entire 24-2 grid and takes approximately 3.5 minutes per eye on the standard size 9.7 inch iPad. Test time reduces to two minutes on the larger 12.9 inch iPad Pro, due to the fewer fixational movements.

Figure 1 shows the patient’s MRF test output and her previous 2015 visual field test in Figure 2. As shown, she had good fixation (0 per cent fixation loss), low false positive and negative rates. Her threshold map showed that she has not had significant progression of her peripheral visual condition compared to 2015.

Her reported Mean Deviation of -4.79 dB has been adjusted to match that of the Humphrey Field Analyzer and again showed no deterioration. Of concern however, were several points in the foveal and inferior parafoveal regions, where a reduction in threshold to 12 and 22 dB was observed. This may have been due to her moderate

Figure 1. The patient’s Melbourne Rapid Fields (MRF) test output from 2017

Figure 2. The Patient’s visual field test from 2015

cataract and/or mild diabetic macular change. However, it could also have been related to very early maculopathy from Plaquenil.

The MRF allowed us to document Ms LW’s current peripheral and paracentral retinal thresholds accurately, despite the fact that she was wheelchair bound. This gave us greater confidence in helping her to maintain the best vision possible in her only good eye.

Discussion

MRF is the world’s first perimeter with the flexibility of performing threshold testing in the office or at home. As a stand-alone perimeter, clinical trials have shown that it can produce reliable thresholds across the visual field with results comparable to current industry standards (SITA-standard and SITA-fast).

The small footprint of the iPad tablet means vision testing can be conducted anywhere, including rural and remote areas, on outreach programs, at the bedside in geriatric or hospital clinics and for domiciliary visits.

MRF software comes fully equipped with everything required to get started with vision testing. In-built voice

commands, configurable in one of twelve languages, act as a ‘robotic clinical assistant’ to guide patients through the test. Visual acuity testing is also available in high contrast (as in your practice), low luminance, low contrast (eye disease), or immersed in luminance noise (brain disorder [amblyopia]) for a full assessment of visual capacity.

Software packages need to be tailored for the patient’s underlying chronic eye condition and are available on the Apple App Store to target: glaucoma, age-related macular degeneration, diabetes and neurological disorders.

Flexibility

Patients can self-monitor their vision from home with their own tablet devices. Weekly self-monitoring has been shown to detect vision change in one third of the time required for standard, six-monthly in-clinic visits. MRF vision test results are saved to a cloud server where artificial intelligence detects early vision change and notifies the patient’s doctor immediately leading to targeted medical intervention for those who need it.

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MRFFrom page 39

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