14-16 December 2018, Seoul Korea

I’m writing this on the plane back coming back from the Asia Pacific Vitreoretinal Society Congress in Seoul, Korea. Although it may have been cold outside, there were a lot of warm hearts and minds inside!

One of the sessions I chaired was the APVRS “Young Ophthalmologists” Symposium. We were unprepared for the level of interest and it was “standing room only”! My talk highlighted the following 15 points:

1.      Every step counts

2.      Have a Plan A (and B and C)

3.      You are only as good as your team

4.      Know your equipment

5.      Visualisation is everything

6.      Tips on doing a systematic vitrectomy (keep the magnification low to improve your depth of field)

7.      Tips on inducing a posterior vitreous detachment (use a soft-tipped extrusion cannula)

8.      Tips on repairing retinal detachment (avoid excessive laser retinopexy which can lead to retinal necrosis)

9.      Dealing with a poor view from endophthalmitis or a dense vitreous haemorrhage (use an AC infusion if a pars plana infusion is not visible, look for retinal blood vessels)

10.  Dealing with proliferative vitreoretinopathy (place the cutter on top of membranes facing away and allow the membrane to curl back up into it)

11.  When removing silicone oil, “skim” off the surface of the fluid-air interface to remove residual oil

12.  Remember that there’s a patient attached to the eye (and that they can hear everything since most surgery is performed under local anaesthesia)

13.  At times of stress- stop, reassess and don’t rush which often makes the situation worse

14.  Document all surgery with a good pre- and post-operative diagram

15.  Learn from your experiences and those of others

I also had an opportunity to be part of the Leadership Development Program (LDP), mentoring an ophthalmologist in the Philippines and even won a prize for a poster on Klebisiella enodphthalmitis!

Posted: 17/12/18

Tuberculosis is becoming an increasingly common cause of uveitis in Australia. Most cases aren’t from ”active” TB, where the patient has symptoms such as cough, haemoptysis and fever. Instead, these patients have “latent” TB, where the infection has been contained. This paper describes the benefits of giving anti-TB treatment to patients with “latent” TB uveitis.

Read more here…

Posted: 08/12/2018

1/12/18, Sydney

Another year has flown by and last night we had our annual Retina & Macula Specialists Christmas Dinner. It has become a bit of a tradition now to have a game show format. This year it was “Wheel of Fortune!”. I certainly had a lot of fun and want to thank all our staff and referring optometrists for their work and support over the last 5 years making our clinic one of the best in Sydney. I’m truly proud to be part of such a wonderful team of people!

Posted: 5/12/18

17-21/11/18, Adelaide

November is RANZCO season and this year it was in Adelaide. After so many conferences I was only able to manage a short visit. I had the opportunity at the ANZSRS meeting to present an interesting case of bilateral peripheral exudative vasculopathy in a young female patient. Usually with peripheral exudative vasculopathies we consider Coats disease, but this is said to be males 80% of the time, and unilateral 90% of the time. In addition, its sporadic, whilst examination of the patient’s mother found her to be affected too (wide-field fluorescein angiography is useful in detecting subtle disease). It just goes to highlight the importance of taking a detailed family history and examining relatives when given the opportunity. After over 1 year’s wait, the genetics have come back and the patient has a rare condition called “fascioscapularhumeral dystrophy”. Normally these patients get muscle disease of their face, shoulders and arms, but retinal disease in the absence of systemic disease has been described.

Posted: 25/11/18

9-12/11/18, Zhanjiang, China

Zhanjiang is a small Chinese city located at the Southwestern end of Guangong Province, bordering the South China Sea. “Small” is a relative word here- it still has a population of 7 million inhabitants (as per a 2010 census). I’ve been invited here by Lifeline Express, a charitable organisation established in 1997 to reduce blindness in China, particularly in rural areas. Over my three-day visit I had the opportunity to consult on some challenging patients and deliver lectures to the local hospital faculty. Actually I was pleasantly surprised by the high level of ophthalmology here, particularly the surgical skills which are excellent given the limited resources. Some of the most challenging cases were patients with neuro-ophthalmic pathology- a good neuro-ophthalmologist would have a lot to offer.

Posted: 13/11/18

7-8/11/18, Guangzhou, China

Zhongshan Ophthalmic Centre (ZOC) is one of China’s largest ophthalmology hospitals. I’ve been invited to its new facility as an international guest of the Lifeline Express/ZOC International Retinal Conference, 2018. The last few days have been a wonderful experience, sharing our thoughts on retinal topics with specialists from the USA, UK (Moorfields Eye Hospital) and China. There has been thought provoking discussion on the differential phenotype of “dry” AMD in China and Asian countries, a lecture I gave on the management of subretinal haemorrhage and lots of good food! I’d like to take this opportunity to thank the organisors for their kind hospitality.

Posted: 13/11/18

30-31/10/18, Irvine, California

I’ve spent the last few days reconnecting with my colleagues of the “International Retinal Panel” a group of young researchers from all around the world (UK, Australia, Argentina, Israel, Italy, Thailand and Turkey). Over the last three years we’ve met twice a year and this time it was in Irvine, one hour south of Los Angeles, California. The opportunity was to visit the UCI Health Gavin Herbert Eye Institute and the headquarters of Allergan Inc., the American global pharmaceutical company that manufactures dexamethasone intravitreal implant (Ozurdex). Particularly interesting was the tour of the Allergan facility which included viewing of their animal laboratory and where Ozurdex is manufactured. As a clinician and researcher I’m aware of the phases of studies required to get a product from benchtop to commercial release. What I wasn’t aware of was all the other steps required: studies on pharmacokinetics (some which are computer simulated), device ergonomics, and market research to name a few. We also had an inspiring talk by Mark Humayan, recipient of the National Medal of Technology and Innovation for his work on the Argus retinal prosthesis, or “bionic eye”.

Posted 3/11/18

14/10/18, Canberra

Today I went back to my home town- Canberra! Its been years since I’ve been back and it was refreshing not to have to deal with the traffic we have in Sydney. The theme for this year’s conference was Myopia, and I of course focussed on the retinal aspects. Currently the world is facing a myopia epidemic, with more than half the global population expected to be myopic by 2050, and 10% being high myopes. Nowhere is this problem more prevalent than in South East Asia. Some tips:

• To look for dome-shaped maculopathy, do a vertical OCT raster, not just a horizontal one, otherwise you might miss the “dome”
• Myopic chorioretinal atrophy is now classified into:

o   1. Tesselated fundus

o   2. Diffuse chorioretinal atrophy

o   3. Patchy chorioretinal atrophy

o   4. Macular atrophy.

o   A “higher” classification is associated with a greater chance of myopic choroidal neovascularisation (CNV).

• Myopic macular haemorrhages can occur in the absence of CNV. In these cases, fluorescein angiography is important to make the distinction. Myopic CNV is highly responsive to intravitreal anti-VEGF therapy.
• Most (85% of) Myopic Traction Maculopathy (MTM) will remain stable. Vitrectomy surgery is usually required if there is a full-thickness macular hole or a macular detachment.
• Asymptomatic atrophic retinal holes do not usually require treatment
• The risk of retinal detachment after cataract surgery in very high myopes (-15D or more) is 8% at 3 years.
• Surgical correction of myopic refraction can be achieved by:

o   1. Laser corneal refractive surgery

o   2. Phakic intraocular lenses

o   3. Refractive lens exchange.

o   Some studies have shown that in high myopes (more than -8D), phakic IOLs may have better vision than laser and less complications than refractive lens exchange.

Posted: 16/10/18

9/9/18, Melbourne

It isn’t very often that I have the opportunity to speak to an audience of more than 800 participants, but this was exactly what happened today when I flew to Melbourne for the 8^th Specsavers Clinical Conference (SCC). Invited to talk on ocular oncology, it was a privilege to share my knowledge with optometrists from around Australia. I covered three groups of tumours: pigmented tumours such as ocular melanoma, vascular lesions like choroidal haemangioma and retinal capillary haemangioblastoma and what I call “white” lesions- entities such as choroidal metastases and vitreoretinal lymphoma. I truly believe this is some of the most important work that I do, since correct diagnosis of an intraocular tumour can save a life. My “Top 10” tips for optometrists were:

1. Know the mnemonic “To Find Small Ocular Melanoma” (Thickness, Fluid, Symptoms, Orange pigment, Margin near the optic nerve) to help differentiate choroidal naevi and melanoma.
2. Always send digital photos with your referral to the ophthalmologist
3. Not all choroidal naevi/melanomas are pigmented (they can be amelanotic)
4. Beware of pseudo-colour on photographs (especially those taken on confocal systems such as the Optos ultrawide-field imaging system)
5. Haemorrhage is rare for melanoma
6. CHRPE lesions are flat, show thinning of the retina on OCT and have jet-black autofluorescence
7. In young males with unilateral hard exudate, consider Coat’s disease
8. Always ask about a history of cancer (choroidal metastasis is the most common intraocular malignancy)
9. In an elderly patient with unexplained vitritis without CMO, consider vitreoretinal lymphoma
10. Take a step back and check the whole patient (anterior segment, face, skin etc. for syndromes)

Posted: 14/9/18

9/9/18, Sydney

Intravitreal dexamethasone implant (Ozurdex) was PBS listed for the treatment of macular oedema secondary to retinal vein occlusion on 1 November 2018. This supplements its prior indications for diabetic macular oedema and posterior, non-infectious uveitis. I had the opportunity to chair the educational launch night, where we heard insights from Professor Paul Mitchell and Dr Stephanie Young. Although intravitreal anti-VEGF therapy remains first-line treatment for most cases of macular oedema secondary to retinal vein occlusion, there is an unmet need in that some patients do not respond well to anti-VEGF and some require frequent injections to maintain a “dry retina”. Ozurdex may have advantages in targeting alternative inflammatory pathways and having a longer duration of 3-4 months. Disadvantages are its two main side effects: cataract and intraocular pressure rise.

Posted: 11/9/18

25-26/8/18, Sydney

I’ve been convening the annual conference “Ophthalmology Updates!” for 3 years now, and am truly grateful for all the support I have received from speakers, sponsors and of course delegates. This year’s meeting was the largest to date, with 200 ophthalmologists around Australia attending. A highlight for me was listening to Emeritus Professor Ron McCallum, who was Dean of Law at the University of Sydney. I intentionally invited him because he is blind (from Retinopathy of Prematurity). I wanted to hear the perspective of a blind person outside of my clinic environment. Ron was able to explain the challenges of the visually impaired, and how recent technology and attitudes continue to improve their quality of life. He commanded the stage like a true professional, and had one of the best receptions of the weekend. www.ophthalmologyupdates.com.au

Posted 7/9/18

Coats disease is characterised by a sporadic, unilateral, telangiectatic exudative vasculopathy in male patients. This paper describes a case where I injected intravitreal bevacizumab (Avastin) resulting in an unexpected detrimental effect.

Read more here…

Posted: 03/09/2018

7/8/18, Sydney

I always enjoy presenting to the local optometrists near my practices at Miranda and Hurstville. Tonight was a chance to present some interesting cases for discussion, and probe the doctors brains! One of the cases presented was of hydroxychloroquine toxicity:

·         Toxicity is rare before 5 years of hydroxychloroquine usage (the risk before 5 years is less than 1%, but this rises to 20% by 20 years)

·         Higher risk of toxicity occurs at over 5mg/kg of real weight/day.

·         Concomitant use of tamoxifen and renal disease increases the risk.

·         Screening is recommended with SD-OCT and automated visual fields. Supplementary tests may include fundus autofluorescence and multifocal ERG.

·         Asian patients have paracentral disease, so a 24-2 or 30-2 Humphrey visual field (instead of the standard 10-2 in Caucasians) is recommended.

·         Maculopathy is irreversible, and there is no cure.

www.maculaspecialists.com.au

Posted: 12/8/18

28/7/18, Sydney

Chairing the retinal panel, I was able to pick some of the best minds in retina on controversial and unresolved questions. Here was an opportunity to go “back to basics”, but in a nuanced way:

1. A) Choroidal neovascularisation

• What is today’s the role for fluorescein angiogram in the routine management of neovascular AMD? (apparently less and less!)
• What is your treatment regimen (we now have evidence for treat and extend with the TREX-AMD and ATLAS studies)
• What is your maximum treatment interval? (around 3-4 months)
• What do you do with non-responders? (options: shorten interval, switch, intravitreal steroids, PDT, argon laser)
• What is the role of OCT-angiography in diagnosing CNV? (good for neovascularisation secondary to central serous chorioretinopathy)

1. B) Diabetic Macular Oedema

• What is the role of focal laser in the management of diabetic macular oedema? (extrafoveal oedema)
• Is there a difference between drugs? (Protocol T showed a benefit of aflibercept at 1 but not 2 years)
• What is the role of intravitreal dexamethasone implant (Oxurdex) (good for refractory patients, contraindications to anti-VEGF: pregnancy, recent stroke, vitrectomised eye)
• What is role of anti-VEGF for proliferative diabetic retinopathy (still a preference for PRP, given the lack of long-term data for anti-VEGF and the need for strict patient compliance in follow-up)

Posted: 3/8/18

21-22/7/18, Sydney

The Retina Beyond meeting had two streams: a retinal stream and a glaucoma stream. The retinal stream focussed on diabetic macular oedema. To start the meeting, an interesting keynote lecture was given by Kirk Vallis from Google, who talked about disruptive innovation, a concept that advances in industries occurs stepwise in major shifts, rather than a linear path. One thought provoking message was that “your expertise limits your ability to think differently”. Its important to challenge conventional thought by collaborating with experts in fields outside of your own. Two key principles of innovation were:

1. Understand that you don’t have to be serious to solve serious problems and

2. A good idea is one in which you feel uncomfortably excited.

Posted: 22/7/18

Optic disc pit maculopathy is a condition where there is sub-retinal fluid emanating from the optic disc. The key is to look for dimple in the optic nerve- usually at the temporal margin. It can often be mistaken for central serous chorioretinopathy. In this paper, we describe features to look for to make the correct diagnosis.

Read more here…

Posted: 15/07/2018

27-30/6/18, Chiang Mai, Thailand

MOAC, the “Midwest Ocular Angiography” is one of my favourite meetings of the year. It’s a small gathering of around 40 retinal specialists who each present interesting cases as diagnostic dilemmas. Although it originally started in the Midwest of the USA, these days the meeting locations are much more exotic! (it moves around the globe every year). At this year’s meeting I presented an interesting case of a raised white choroidal lesion that proved to be tuberculosis, a case of rapidly developing epiretinal membrane following intravitreal Avastin for Coats disease and a case of Combined Hamartoma of the Retina and Retinal Pigment Epithelium (CHRRPE). I even had time to visit the elephants and tigers!

Posted: 4/7/18

Optic disc pit maculopathy is a condition where there is sub-retinal fluid emanating from the optic disc. The key is to look for dimple in the optic nerve- usually at the temporal margin. It can often be mistaken for central serous chorioretinopathy. In this paper, we describe features to look for to make the correct diagnosis.

Read more here…

Posted: 01/07/2018

23-24 June 2018

What is the best way to treat polypoidal choroidal vasculopathy (PCV)? This was the question I posed as the Chair of the first session of the Global Retinal Network Program held in Hyatt Regency Hotel in Sydney last weekend. The two esteemed speakers were Professor Paul Mitchell from Westmead, Sydney and Professor Gemmy Cheung from the Singapore National Eye Centre.

There have been two major studies assessing the role of intravitreal anti-VEGF for PCV. Everest-II compared intravitreal ranibizumab (Lucentis) monotherapy versus ranibizumab plus photodynamic therapy (PDT) at baseline. The combination arm did better than the monotherapy arm in terms of vision at 1 year. In the PLANET study, intravitreal aflibercept (Eylea) monotherapy was compared with Eylea followed by PDT only if it was thought this was required (“rescue” treatment”). Both arms benefitted, but there was no significant difference between them.

When comparing the monotherapy arms across the studies, aflibercept (10.7 letter gain) did better than ranibizumab (5.1 letter gain), but comparing studies like this has to be done very cautiously as there are too many differences in the baseline characteristics (for instance the baseline visual acuity in the Everest-II study was better so there may have been a ceiling effect).

Several questions remain:

·         Does PCV have a different phenotype in Caucasian and Asian populations?

·         Polyp closure was higher in the Everest-II arm that contained PDT at baseline, but is this important?

·         If we use aflibercept, are we missing out on visual gains if we don’t use PDT at baseline?

·         Can PDT reduce injection frequency? (PLANET didn’t show a reduction in injection frequency with rescue PDT).

·         PLANET used fixed dosing in the first year. How appropriate is a treat and extend regimen?

Posted 26/6/18

Capsular bag distension syndrome is a condition where turbid material builds up between the intraocular lens and the posterior capsule. In this paper we describe a couple of cases treated with vitrectomy surgery.

Read more here…

Posted: 08/05/2018

April 29 – May 3 April 2018, Honolulu, Hawaii

The Association for Research in Vision and Ophthalmology meeting is the largest basic science gathering for vision researchers in the world. This year it was held in Honolulu, Hawaii! For me, the absolute standout keynote lecture was given by Jennifer Doudna, from the University of California – Berkeley. She is the pioneer of CRISPR-Cas9 gene editing, a new technique that utilises the immune system of bacteria to act as “scissors” that can accurately cut genomes when a where a scientist wants. This method is much faster, cheaper and more precise than older techniques, and has wide-ranging applications in the treatment of all genetic diseases such as cancer and inherited conditions. At the end of her talk, Professor Doudna sounded out a warning on the ethical implications of germline (reproductive cell) gene editing and the need for international collaborative regulation.

Posted: 6/5/18

17 March 2018, Hunter Valley

“Floaters- Life and Death” was the topic of my talk at the NSW RANZCO Conference. Did you know that so called “physiological” floaters are associated with higher rates of depression, perceived stress and anxiety? In fact, when surveyed, patients with severe symptomatic floaters have been reported to gamble a 11% risk of death! Of course, not all floaters are benign, and may signal a retinal tear or detachment, vitreous haemorrhage or uveitis (inflammation). Red flags include:

• Acute, unilateral floaters with photopsiae
• High myopes
• Trauma
• History of uveitis or surgery
• Cells in the vitreous
• Presence of a PVD (best seen by looking at the OCT)
• Other signs of uveitis (chorioretinitis, snowbanks, retinal vasculitis, optic neuritis)

Posted: 18/3/18

20-21 February 2018, Los Angeles

The International Retinal Symposium (IntRIS) is a relatively new meeting organised by some of my friends: Bailey Freund, David Sarraf and Srnivas Sadda at the UCLA Stein Eye Institute and Doheny Eye Institute. In only its 4^th year, it’s one of the premier events worldwide to learn what’s cutting-edge in retinal imaging. Some pearls I learnt included:

• The outer nuclear layer is a useful biomarker for geographic atrophy, but can only be accurately imaged with directional OCT
• OCT angiography (OCT-A) now allows us to identify a new entity known as “vascularised drusen”
• The severity of diabetic macular oedema appears unrelated to retinal ischaemia
• A new entity called “Suspended Scattering Particles in Motion” (SSPiM) can be seen by OCT-A in some exudative diseases like diabetic macular oedema, vascular occlusions and neovascular AMD.

Best of all, I had the opportunity to catch up with my close friend and mentor, Professor Lawrence Yanuzzi. I even had time to visit the Griffith Observatory, where the planetarium scene from the movie “La La Land” was filmed!

Posted: 23/2/18

8-11 February, 2018 Hong Kong

This year’s APAO was held in Hong Kong. I was fortunate to be invited to speak at a symposium on “New Retinal Surgical Techniques”.

Conventionally, following cataract extraction the intraocular lens (IOL) is placed in the lens capsule, or “bag”. In cases where the posterior capsule is torn however, this is not possible and attempts will be made to place a 3-piece IOL in the “sulcus”, or the space between the anterior capsule and the iris. Sometimes, the capsule is completely absent. In these cases there are 4 options:

1. Anterior chamber IOL (AC-IOL)
2. Iris clip IOL
3. Scleral sutured IOL or
4. Sutureless scleral tunnelled IOL.

Each of these have pros and cons. AC-IOLs are best avoided when there is corneal pathology, such as Fuch’s endothelial dystrophy. Iris clip IOL’s should be avoided when there is anterior uveitis or iris trauma. Scleral sutured and sutureless scleral tunnelled IOLs are possible if the patient is aniridic. In these cases, sometimes an iris prosthesis can be implanted with the IOL.

Posted 15/2/18

Endogenous endophthalmitis (endophthalmitis that arises from a systemic infection, rather than a localised procedure such as cataract surgery or intravitreal injection) is rare. Even rarer is when it caused by an infection called Klebsiella pneumoniae. The incidence is however increasing, especially in Asian patients with liver abscesses.

Read more here…

Posted: 05/02/18