It has been interesting to watch Thea Pharmaceuticals develop into a major player in eye care education over the last decade. If evidence for this were needed, it could be found in Manchester recently where Thea had organised a one-day Eye Health Conference.
Comprising a healthy mix of lectures, hands on workshops, discussion workshops and peer discussion session, run in two simultaneous tracks, one for anterior eye and the other posterior, the conference offered something to meet the demands of everyone in the packed audience.
Anterior eye
All delegates were invited to attend the keynote lecture of the anterior eye strand of education and were treated to a comprehensive review of red eye management delivered enthusiastically by Glasgow-based consultant ophthalmologist Sanjay Mantry. It is always refreshing to hear an ophthalmologist who is keen to utilise optometrist resource and Mantry certainly adopted this approach.
His discussion of infections and inflammatory diseases of the ocular surface and anterior chamber offered a useful revision of differential diagnosis and management of most of the red eye causes likely to appear in practice and, throughout, emphasised which conditions could be managed in practice, either by entry level or therapeutic optometrists, and those which benefited from referral to secondary care.
Professor Ed Mallen
Among the many clinical pearls offered was some useful advice on the management of the usually self-limiting viral conjunctivitis. The use of a preservative-free comfort drop was advised, though often acting simply as a placebo. Where symptoms are exaggerated, lid eversion may reveal a pseudomembrane.
Dr Scott Mackie about to take to the stage
Mantry suggested that removal of these is not always as easy as often thought and requires lubrication and anaesthetic before lifting with tweezers is attempted. In cases where there are no systemic (flu-like) symptoms, and when the red eye is unilateral, the much rarer condition of Thygeson’s keratitis might be considered.
Persistent epithelial defects are common and usually resolve but, when persistent, may require a bandage lens, or an amniotic membrane graft. Such persistent defects tend to occur in neurotrophic corneas, as might be found in diabetics.
Dr Peter Frampton offers guidance
Of the case studies discussed, most startling was a case of a man with Steven-Johnson syndrome which resulted from an allergy to ibuprofen and which eventually required 16 grafts before stabilising.
When discussing microbial keratitis, Mantry reminded the audience of the strong link with contact lens wear and its abuse. ‘Patients get too comfortable with their lenses and may ignore the initial symptoms of foreign body sensation before the keratitis becomes established.’ He also noted that there has been surges of acanthamoeba keratitis in recent times.
The lecture was well complemented by a peer discussion session led by Professor Christine Purslow and Dr Peter Frampton who presented a number of anterior eye disease cases which delegates had to diagnose and decide upon appropriate management. And for those wishing to develop their practical skills, there were opportunities to practice punctum plugging and blepharitis and dry eye disease assessment.
Practising ocular surface assessment techniques
These sessions were suitably followed by a review of the recently published Tear Film and Ocular Surface (TFOS) Society’s Dry Eye Workshop (DEWS II) given by TFOS member Dr Colin Parslow, a speciality ophthalmologist based in Hertfordshire. Much has already been published relating to DEWS II, not least of all in Optician, but it is always useful to hear another expert’s view.
Dry eye assessment
For example, Parslow emphasised how the three layer model of the tear film structure is now obsolete and we should instead consider the tear film as being two layers, one lipid and one muco-aqueous. He also stated somewhat soberly that, of the around 1,500 proteins to be found in the tears, very little is yet known about their function and this will be a key area of future understanding regarding dry eye disease; ‘the next breakthrough in dry eye management will be to do with tear proteins.’
Another important point raised was how pain is very much a subjective concern. ‘The brain upregulates, so even after treatment, symptoms may continue as if the condition were still untreated.’
Punctum plug fitting
The last lecture in the anterior eye strand was given by Scottish hospital optometrist Stanley Keys, who managed to take the ostensibly prosaic topic of adverse effects from glaucoma medications and, by encouraging audience participation, hold the attention of a post-prandial audience. Importantly, along with the more familiar BNF-listed adverse responses, Keys discussed other impacts such as patient compliance and lifestyle influences.
Posterior eye
In terms of media coverage, myopia progression therapy easily rivals the DEWS II report. Kicking off the posterior eye strand, Professor Ed Mallen (Bradford university) gave an excellent review of our current knowledge about myopia and attempts to treat it. Any thoughts that myopia is purely a refractive concern were quickly quashed by a reminder that myopes are 60 per cent more likely to develop primary open angle glaucoma and the prevalence of visual impairment in 85-year-olds was 9.5 per cent in emmetropes, but 33.7 per cent in myopes.
Topcon reveal its new pulsed light treatment for lid disease
Of the various interventions discussed, Mallen related that atropine had proved effective but, in standard dosing, suffered both from adverse side effects and also a significant rebound myopia upon cessation of use. The use of lower dose, 0.01% atropine, has proved to be effective but with a much-reduced rebound effect.
After a review of other interventions, such as orthokeratology and progressive power and peripheral focus spectacle and contact lenses, Mallen broached the important topic of how impact is measured and success defined. Refraction is too blunt a tool to measure progression limiting, he stated. Remembering that there is a 0.33mm axial length increase correlation with every 1.00D of myopia, Mallen suggested that biometry data as can be taken with instruments such as the IOL Master or the Lenstar biometers are more useful in myopia therapy monitoring.
Stanley Keys
This is worth practitioners considering as more become involved with this important new area of practice. Finally, the audience were warned of the dangers of the purely anecdotal. ‘Research evidence must underpin clinical interventions,’ Mallen reminded the audience and encouraged everyone to share useful data with the Myopia Consortium UK. Ending on a positive note, the speaker suggested that, regarding myopia therapy, ‘there are great times ahead.’
As expected, one of the more entertaining performances of the day came from Dr Scott Mackie, a practitioner with much experience in the use of nutritional supplements in managing eye disease. With a focus on macular degeneration, Mackie told how he ‘gave a supplement whenever a patient presents with two risk factors’ for AMD.
Citing NICE guidelines, he also mentioned how statins reduce while aspirin increases the risk of neovascular membrane formation. Another useful reminder was that ‘there is no need to inform a GP of any recommendation of supplements unless the patient is already on vitamin E supplementation.’
Mackie subsequently led a peer discussion session on retinal disease management, and there were also useful workshops on OCT technology and visual fields interpretation.
The final lecture, to which all delegates were invited, was focused upon papilloedema. Syrian émigré and Manchester-based ophthalmologist Ali Yagan began this fascinating talk with the stark fact that, since the Honey Rose case, his clinic had seen a ten-fold increase in referrals of suspect swollen discs. Many cases were never definitively diagnosed, but important in differential diagnosis were reduced acuity, colour vision desaturation, field defects and a relative afferent pupillary defect.
OCT had helped diagnosis greatly, though his clinic also used ultrasound and neuroimaging. Key to OCT assessment of elevated discs was to look for ‘all round’ elevation, rather than just localised as can happen with disc drusen or other congenital anomalies. He also explained that swollen discs can be usefully classified or graded from one to five by the Frisen classification. Grades four and five were ‘easy’ to diagnose, but grades one to three much less so. For this reason, any suspicion was worthy of consideration for referral to a specialist.
Variety
Covering both front and back of the eye with a diverse range of topics, Thea should be commended for an excellent day of education. Look out for future events as places are likely to be snapped up quickly.