Common Causes of Chronic Vision Loss
Jessica
Good evening everyone. My name is Jess and I will be hosting tonight's webinar. In tonight's session of the Rural Health Webinar Series, we will explore current practice and techniques in the diagnosis and management of common causes of chronic vision loss. Collaborative care, telehealth and new developing treatments and pathways will be addressed to assist rural GPs with their patient management. Our presenters for this evening are Michael Yapp and Alex Craig. Michael is the head of clinical operations at the Centre for Eye Health, where he has worked since 2009.
He also advocates for the optometry profession through his role at Optometry Australia. Michael has diverse clinical experience including private practice locum work in Australia and the UK, running an optical charity and working in ophthalmology practices. He has been involved in optometric education since his time as a staff optometrist at the University of New South Wales, and continues to speak at conferences globally. Alex is originally from Zambia and completed his education in Northern Ireland and the USA before moving to Melbourne for his optometry doctorate. He has been practising in Karratha in Western Australia for 10 years where he opened Karratha Eye Care in 2019. Alex has developed a strong interest in community education and referral pathways in optometry.
We would like to begin tonight's webinar by acknowledging the traditional owners of all the lands that we are coming together from and the lands on which this event is being broadcast. I would like to pay my respects to their elders past, present and emerging and would also like to acknowledge any Aboriginal or Torres Strait Islander people who have joined us this evening.
Just before we begin, a couple of housekeeping tips to cover. You are all set to mute as a participant to ensure that the webinar is not disrupted by background noise, but we encourage you to use the Q&A panel and box to ask questions. The webinar has been accredited for one hour educational activities through CPD. To be eligible, you must present for the duration of the webinar. We also kindly ask that you complete the short evaluation at the end of the webinar. This should only take a few minutes to complete and will help us improve the format and content of future webinars.
Finally, by the end of this webinar, you will be able to outline the current diagnosis and differential diagnosis of chronic vision loss describe the GP role in chronic eye disease management in rural Australia and briefly discuss available referral pathways, but for now, I will hand it over to our presenters for this evening Michael and Alex. Thank you.
Michael Yapp
Fantastic. Thanks, Jessica and thanks for joining us all tonight. What we are talking about tonight is chronic causes of vision loss in Australia. We have been previously through a lecture. Alex myself a couple of weeks ago on acute disease, but the major causes of vision loss are actually chronic. Some of the data I am going to be throwing at you comes from this2017/2018 National Eye Health survey, but there is actually a new version of this just underway as we speak, which is an eye and ear health survey. It is due out with results towards the end of this year where they are looking at the same cohort they looked back in 2017/2018. We will give you a couple of quick stats on those as preliminary numbers coming out of that particular study. The crux of the story is across the world, the major cause of vision loss is actually not having a pair of glasses, and that includes not being able to read courtesy of all of us getting over 50 in our arms getting too short.
When you look at these percentages here, these numbers are looking at the percentage of vision loss caused by that particular condition, not the percentage of people that have vision loss across the population. Up to 64% of vision loss based on these surveys in Australia is based on not having a pair of glasses. The good news is the preliminary data from the latest Eye and Ear survey underway at the moment shows that up to 94% of the population that needs glasses actually has them, so that nber should come down significantly in the latest survey because Australians are generally fairly well off in terms of being able to access glasses if they need them. The main reason they may not have a pair of glasses is social inequity, and that in places like nursing homes in particular. As an aside, the latest report in Lancet just came out that showed that actually not having a pair of glasses and/or vision impairment increases the risk of dementia.
One of my first takeaways for tonight's lecture straight off the bat is that if you are working in aged care facilities, vision checks really should be a key part of the routine cycle of care because it makes a huge difference to many, many aspects of their lives not only currently but also in future deterioration. take home message, aged care facilities, watch out for vision checks. It may decrease their risk of dementia if they can have the appropriate care. In terms of getting access to glasses, every state has their own subsidised spectacle scheme. They are all means tested, but there is marked variability as to what each state has. Some will subsidise complete pairs of glasses, some will give a dollar value towards glasses and there are some separate First Nations programs. There is a website listed there that will give you access to what each of the schemes are in your areas.
If you are interested in knowing what those spectacle schemes are. Importantly, once again out of the latest eye and ear survey, the data showing that in particular in First Nations and indigenous populations, they rely much more heavily on the spectacle spectacles subsidy schemes to access glasses when they need them. Ultimately, not being able to wear a pair of glasses is a reason for having poor vision, but in Australia, thankfully that is less of a problem and becoming less of a problem through distribution.
Then we come to the big four. What we are looking at now is cataracts, AMD diabetic retinopathy and glaucoma, and once again, those statistics are based on the percentage of vision loss caused by those particular conditions, and you can see there is some significant differences between First Nations and non-Indigenous Australians which we will touch on as we go through the talk in more detail. When it comes to the differences between metropolitan, remote, regional and rural, there was this great document that was brought out recently by the NHRA, collaborated with by both RANZCO and Optometry Australia, which looked at the differences in eye and vision health across rural Australia. The crux of the story is nothing new to those of you listening to this talk. In that country, areas tend to have socioeconomic deprivation at higher levels than metropolitan. Similar story there is lower levels of education and education attainment and lifestyle factors play a role. The two main ocular diseases that showed much higher incidences in remote and regional areas were pterygia and ocular trauma, not unsurprising given the lifestyle of the people we are talking about. The other major standout was diabetic retinopathy in indigenous and particularly remote Indigenous Australian communities, which once again is not a surprise I am sure to most of you on this talk.
In terms of the major cause, cataract is probably the main cause of correctable vision loss in terms of pathology. When we talk about cataracts, we think about a few different things taxes, death, tariffs if you are Donald Trump and cataracts are inevitable parts of life. If you live old enough, it will happen to you at some point, but there are lots of different types of cataracts and they occur for many, many different reasons. When we are talking about grading cataracts, we tend to grade it on where the cataract is in terms of the lens, as well as how dense that cataract is. In particular, in research studies, this this scale is used quite often, which is the LOCS III scale, not used all that much in private practice, but ultimately it gives us a scale that says how bad that cataract is. Age obviously is the most common cause, but trauma is also a big one, as is medications and some nutrition.
Diseases can play a big part, so people with diabetes and myopia tend to get cataracts much younger. Congenital cataracts also exist, as do radiation. One of my favourite ways of describing cataracts was explaining how the soft tops on cars go from that clear window to that sort of brownish yellow hazy colour. Unfortunately, you do not get many soft top cars anymore, so I am having to change my explanation, but for people that understand that concept, it is a really good example of how age basically turns something that is clear into something you cannot see out of anymore. One of the big steps then, with cataracts, knowing that they are eminently treatable is when to remove them, but ultimately, the first step of the process is to confirm that the cataract is actually the cause of the reduced VA, and that throws me into a little bit of a detour in terms of talking about some of my toys, otherwise known as fancy imaging devices are available in ophthalmic practices. Ultimately what we need to do is we need to prove that the cataract is the reason why that person is not seeing clearly, and that comes in a whole bunch of range of devices. We can look at the shape of the cornea through topography. Dry eye plays a role. We have got videos and cameras connected up to our slit lamps. We have got cross-sectional scans very much like a CT device that looks at the front of the eye. We have got retinal photographs, bear in mind you are all very familiar with these, but the retina goes out to 240 degrees. It is curved, but this photograph only gives us 45 degrees.
We have got some fancier toys that allows us to get much further out into the periphery with some trade offs, but the major tool that is really revolutionised disease diagnosis and treatment is the OCT. So an OCT basically is the same concept as a CT scan, or another way of looking at is it is an optical ultrasound. It is a single point source of light moving at high speed backwards and forwards, creates a line scan, builds that into a volume scan, and we end up with three dimensional renderings of the retina. It is accurate down to about 3 or 4 microns. We can get great pictures of the macular architecture. We can look at the optic nerve and with angiography we can now look at the blood flow within the retina in a completely non-contact method. Most importantly it is highly repeatable. We can do the same scan in the same location and get the same results down to within 3 or 4 microns each time. What that means is that these tests are highly amenable to telehealth. I can take a scan and I can have someone else look at that scan, and the vast majority of diseases now are diagnosable and discussable through telehealth courtesy of things like OCT. Even more to the point, the vast majority, if not every now regional and rural optometric practice will have an OCT, which Alex will talk about a little bit later when we talk about methods of diagnosis and management. Ultimately, this is what it looks like. We take a standard 45-degree photograph in this case my left eye, and we then take a cross-sectional slice using a wide variety of different toys, and this is the picture we get.
This is 0.2 of a millimetre through the centre of the fovea, but each of these different shades breaks down different anatomical structures. We can now break it down almost on a cellular basis where we can say that exact layer of the retina is what is defective, therefore it is likely to be these particular diseases then come up with a diagnosis and management plan as a result. As I mentioned with angiography, what we are looking at is vascular flow within the retina itself. We can see areas of dropout where there is no flow in ischaemia, or we can see areas where there is new blood vessels growing, such as in diabetic retinopathy. Previously, this was done with a fluorescein angiogram where we injected fluorescein intravitrously and we looked at the flow through the retina as it passed into the eye and through the vascular beds, and that still has some significant advantages in some circumstances, but it is a lot more invasive, whereas the OCT angiography scans if we get good scans can be done in seconds. Ultimately, the first concept is the cataract the cause of the VA. Now it may be the cause of the VA, but the cataract also causes a change in the refraction. It may be that the cataract is the problem, but it may also be that that can be fixed by an update in their glasses, either through a myopic shift or through astigmatism. When it comes to when to remove the cataract, a big part of it is it affecting their daily life, and that can be variable between individuals. Some people obviously have much higher visual needs.
Some people, as our Type-A personalities, are much more particular about changes in their vision. There are questionnaires that are available that are generally used for pre and post op surgery outcome measurements, but some of the hospitals are actually asking for these as part of the referral to prove that this person actually is at the point where they need cataract surgery. Another big part of when to remove cataracts obviously is the driving standard and a commercial versus a recreational car license. There are other pathologies why we sometimes need to take the cataracts out. If we cannot see the fundus properly to prove they do not have another disease, then sometimes the cataract has to come first. There are some other complications which increase the risk of surgical complications which may accelerate the need to remove a cataract. Things like Pseudoexfoliation syndrome, which we will touch later on in glaucoma and medications like Flomax, which can affect the floppy nature of the iris, complicating surgery may decide to bring the surgery to different times and ultimately sometimes whether one eye or both eyes need to be done, obviously, if they have got a strong prescription for their glasses and you only do one eye, that can create problems as well. In terms of going public, as I am sure you know, the metropolitan areas have large hospitals that have outpatient departments, but they have variable wait times depending on where you are lucky enough to live.
Some of the hospitals actually promote those waiting periods, and what you are seeing in that table is the metropolitan Adelaide, waiting times for patients who have been referred that do not have an appointment yet. These are category two, category three referrals as of September 2024. If you are lucky enough to live in the north of Adelaide, Modbury Hospital has a five and a half year wait before you get an appointment to have your cataract looked at through the public system. Now obviously that will vary enormously depending on where you are, and it also depends on whether we are talking about a category 1, 2 or 3 triage and whether it is your first or second eye. In terms of the public system, there is also limited choices in what type of implants are available, but one of the good things that is happened recently is that there has been statewide referral criterion developed for the vast majority of ophthalmic conditions at different stages in different states.
What we now have is fairly clear guidelines in what the public hospitals want in terms of both information and criterion as to when to refer these particular patients. It does vary. A lot of it is based around 6/12 and not because 6/12 is the right answer, but because that is the driving criterion. All of them now are asking for what are their effects on their day to day life, and most are also asking for an optometrist or ophthalmologist report to prove that the cataract is the main reason by doing scans such as OCT scans to make sure that that retina in behind the cataract is healthy and there is not something else that needs to be treated. That is the story in terms of metropolitan areas. What I will do is I will pass over to Alex to talk about the regional version of that.
Alex Craig
Thanks, Mike. In regional Australia obviously this this varies by region to region, however the premise of referral pathways are still very much the same. We believe and especially what we have been able to see works really well in regional Australia is that these cataract referrals or query cataract referrals, truly do belong in optometry to triage and not necessarily in outpatient departments or on visiting ophthalmology lists. Especially in regional Australia where we end up with reduced days and reduced accessibility to tertiary care or tertiary eye care in our regional sub centres. Referrals for intervention can best probably be served liaising with primary eye care and direct referrals obviously from GPs to optometry to figure out where the patient fits best or how quickly the patient needs to be referred, we find to be probably most appropriate. If the initial referral is to private ophthalmology, the adjudication levels that we typically do find for the level of cataract and the appropriateness of surgery is very typically completed in-house, and often these surgeries are typically done bilaterally. In WA, when we are sending patients for private surgery, they have to leave the region, so that is another thing to consider as well because we do not have any ability to do private eye surgery in regional WA.
Those patients that are then referred obviously into the public system, and Mike touched on this needed to be added to a public list, and this has different definitions then for private surgery, typically the bigger problem is the wait for the waitlist, so this is undirected referring to the public health systems ultimately increases the burden, and this is what we are seeing is that patients are sitting in a bottleneck waiting to actually be triaged into specific clinics cataract surgery, etc. Obviously going via optometry is often recommended, as we are more aware maybe of the gate kept metrics for successful referrals. These often as Mike has talked about are best corrected visual acuity and activities of daily living, whereas in private surgeries, contrast, colour and other aspects of visual function might play a role in successful surgery outcomes. There are marked variations in initial visit costs and wait times. Obviously, in the public system, wait times are longer, and this is only because of the bottleneck of triage. In regional practices, we have come up with some novel ways to fast track this and bypass the wait list with the wait list, which we will come to and talk about one of those being telehealth.
In Karratha, we have one of the locations that has the least amount of ophthalmology days per year, but we have one of the lowest waitlist times as well, and a lot of that is because all of the consenting and all of the other pre and post op is done via optometry, and typically via VC or via telehealth, and then obviously there are other ways to fast track patients through ACCHS or through Aboriginal Medical Services as well. Working better together, so this is Optometry Australia's call to action. This is a brilliant docent that outlines all of the collaborative care that Optometry Australia is currently working on. This document is available on their website. If you have not had a chance to read it, I would implore you to have a chance to just flick through it. Ultimately, GP is or you guys are the most trusted practitioners, and as a result, we want to try to avoid duplication of referrals from multiple locations from both parts.
What we have seen works and what helps avoid this is that we can adopt a plan or a co-management plan to allow for all the adjudication for query cataracts to go through optometry again because we have the ability to ensure that the reason for vision reduction is going to be from a cataract and not necessarily from like something else on the retina. What we are finding is that we do not want to be burdening your rooms with patients that we could see, maybe quicker and have them moved on and moved into ophthalmology if they require at a much faster rate, obviously, unless it is urgent. Patient communication and awareness in the referral process is paramount to ensuring follow ups, and attendance and again, having an awareness of First Nations or CALD pathways and options as they are likely beneficial for patients who have late stage cataracts and need quick intervention, and then just a word on combine referrals, so this is really just about us all being on the same page.
For example, opinions on referrals. There are situations where we have run into where GPs are referring for cataract and the optometrist then does not necessarily think that that is necessary or they do not meet the standard, and so the patients are bounced around in the public healthcare system and then ejected back out again without an outcome, and ultimately then we have more than one opinion and patients that are relatively confused, and so trying to sort of streamline patients through optometry, especially for eye related conditions like cataract, we find to be best practice and also health summary. Sending health summaries with your referrals to optometrists is really helpful for us. This ultimately gives us an opportunity when we are making decisions to triage whether the patient needs a more acute referral or not. This is really just a call to communicate better on primary care referrals.
This is an infographic here on the right of what we typically the way that we would define our workflow or our workforce coordination in Western Australia or in regional Western Australia, and obviously, GPs and general health services being a large part of seeing patients or primarily being the forefront of where patients mostly would present alongside then being optometry and then ultimately linking in ophthalmology, which we do a lot of through telehealth. The telehealth models that we run obviously the benefit is it is a three-way live discussion, very typically of the referral or the reason for referral, potential outcomes and obviously consenting for surgery. This service that we run is run by Lions Outback Vision out of Broome, and is actually really accessible and has changed the way that we are able to manage so much chronic diseases as a result of image sharing as well. Mike touched on things like OCTs.
We actually have a platform above that called Harney which allows for us then to take all that OCT data, visual fields, wide field photography and within 30 seconds that is sitting on a computer in Broome, and a minute after that we are able to live VC in ophthalmology. We are able to keep a lot of patients locally as well, which again reduces burden of travel, and streamlines patients into to the appropriate service as required. They are not sitting on wait lists in the public healthcare system. Vision vans are common. I think there is two in Australia or two big ones in Australia. Again, one of them run by Lions Outback Vision, limited stuff that we can do on the van, but very similar outcomes to telehealth and good for chronic disease management, especially for stable disease, and then obviously we have the visiting services and most of these are going to be surgical in Karratha. We now have a visiting service that comes every month. In some places it is not even as much as a every quarter. These services are very typically exclusively for surgical services and not necessarily for consulting or opinions or triaging, things like cataract. Thanks Mike, you can switch.
What does surgery look like? So this is microsurgery, and very typically with excellent outcomes. When we are consenting, we are consenting that 1 in 1000 second surgery, and 1 in 100 will heal a little bit slowly, and so if you are calculating those odds, it is it is absolutely fantastic, and very typically we are ending up with brilliant outcomes, obviously as a result. The majority of patients that we see will end up with monofocal options, so obviously there is three main types of lenses that we can be putting in. Monofocal is by far the most common and typically the best in terms of prognostic ability. We are looking at distance vision correction in both eyes. This is calculated very typically using a specific type of formula, and the data comes off of a biometer. These are often available obviously as a sphere, so just a sphere power or with astigmatic treatment as well. The other one would be Monovision so distance in one eye and then a reading power in the other eye, and this we find works really, really well, especially with patients who are used to taking their glasses off to read, patients who are myopic, and then there is the multifocal implants.
In regional areas, we find that there is not as much ambient light. We find that the pupil does some funny things. It typically sits a little bit larger, a little bit more mid dilated, and we have found that patients have relatively poor outcomes with these multifocal implants as a result of being in parts where there is far less light and so they end up in the wrong section of the lens, or they get a lot of really, really, really bad haloing. Obviously there has been significant improvement in these areas, and then there is obviously the choice of a lens really depends on the suitability, especially if there is coexisting ocular disease. Typically, I will just avoid on post op care. Most post op care is day one, and we actually do that through a phone call, and then there is week one and then typically a 4 to 6 week review with optometry. Most patients are going to be on a steroid eye drop up to four times a day and typically still not all, but most ophthalmologists are giving a topical antibiotic as well.
Just a point obviously on the second eye, so obviously when patients who have high refractive error having cataract surgery done in one eye can cause quite a bit of binocular discomfort, and so depending on that power in the other patients who are highly myopic for instance, or even highly hyperopic, for instance, can get quite a bit of binocular discomfort so that sometimes changes their triage category than for the second eye, and the last thing then being that that around 25% of surgeries that we are finding end up with a little bit of a film growing over or a little bit of scar tissue growing over the posterior capsule that requires a YAG laser capsulotomy to clear up. If patients have had cataract surgery and they are at the six month, 12 month mark complaining obviously of reduced vision, this could potentially be the cause referrals of optometry. This is very easy to see on a slit lamp. It is certainly warranted in this stage.
Thanks, Mike. Key messages or take home messages, so obviously number one, super vital ensuring that cataract is a cause of reduced visual acuity. We are your best mates in this. We have all of the tools and the majority of regional practices in Australia have an ability to see the retina and have an ability to image on a 3D level. Number two, coordinating referral processes with local optometrists. Again, this is really what we are here to discuss or here to try to really promote is that optometry as primary eye care service is positioned really, really well to understand the standards and to really take care of your patients. Good for you guys to all understand how waitlists work and what the difference is between public and private and how that operates in your local areas and obviously local optometry like we have, may have equipment like biometry that speeds up the process. In regional Australia and especially in regional in regional WA in Karratha where patients are referred, they come in, they get a biometry done, they get a comprehensive eye check done at the same time, and basically they are waitlisted on the day of their referral, which is fantastic. They are not sitting waiting on a waitlist like you would in parts of Adelaide. Brilliant. Thanks, Mike.
Michael Yapp
Fantastic. Thanks, Alex. So that brings us into AMD. You will notice a big difference in percentages here between non-Indigenous and indigenous and quite a number of reasons for that. Ultimately, the hallmark of AMD is this lovely thing called Drusen, which a hyaline or basically deposits in underneath the retina itself. The major trick to this, though, is that there are lots of different types of Drusen and Drusen are not unique to macular degeneration. They can occur in a wide range of conditions, but are still the hallmark of AMD itself. There is a specific AMD classification system that starts when you have very small Drusen that are just basically a normal part of getting older. Once they get a little bit larger to medium sized Drusen, then it is early AMD once they get larger again, then they become intermediate AMD. The big difference here though is you can have one large Drusen where you can have multiple confluent areas of Drusen and that is still all intermediate AMD and all of these are associated with these pigmentary changes that go alongside these Drusen, which add an extra risk to these progressing faster.
Ultimately that leads us into late AMD, which unfortunately for some reason involves two main very distinctly different conditions. One is neovascular where you have new vessels growing and bleeding and fluid leaking in the back of the eye as opposed to geographic atrophy where it wastes away with time, and ultimately this is where the confusion of dry and wet kicks in. It is a very common situation to call macular degeneration either dry or wet, but the problem is when you are talking about dry, it is early, intermediate and geographic AMD, all fall into that concept of dry macula, and so it is not the greatest of terms because ultimately it can be a little bit confusing as to whether you have something that is atrophic and wasting away, or you have something that is a potential to go on and cause problems as opposed to wet, which is in itself pretty much a unique or definition as itself. In terms of progression, what we are looking at here is these yellowish lumps, which are the large Drusen which on an OCT shows up as these bumps underneath the retina. With time, that can progress and it becomes an area of atrophy.
This is intermediate AMD progressing into geographic or late or dry AMD which looks in my opinion a little bit like ET. For those of you that are old enough to remember what ET looked like. The difference between atrophic and neovascular is instead of wasting away, the body tries to solve the problem. It grows new blood vessels, but those blood vessels leak, so we end up with fluid fibrovascular deposits, oedema and a whole bunch of other problems going in, but it can spread a whole lot faster. Atrophic is relatively slow in most cases, but neovascular can be very fast, and the treatment we want to have within one week of diagnosis ideally. In terms of the cause, there is a whole range of underlying reasons for macular degeneration. Inflammatory is a big part of it, and that underpins a lot of eye disease is the inflammatory cascade is becoming more and more inherently known to be a big part of all of our eye diseases.
Vascular obviously is a part of it, and genetics play a big role. One of the big areas that GPs play a massive role in intermediate AMD is the risk factors for progression, and the risk factors progression are things like diet, antioxidants, smoking and obesity, and these are areas where your optometrist should be working with you regularly to help our patients minimise the risk of their AMD getting worse and progressing to something that causes significant vision loss. In terms of patients monitoring themselves, that good old Amsler grid is a nice concept. It is basically a piece of graph paper. There are newer versions using apps and all sorts of things coming out so patients can self-monitor themselves. Ultimately, what it is trying to do is to try to find conversion from intermediate to neovascular, where they notice a change in between when they get their eyes tested, but ultimately it is OCT where the answers really come in.
The Macular Disease Foundation is fantastic. They have all sorts of brilliant information for patients, including counselling and different ways of helping them if they do have macular disease. Ultimately then when we talk about treatment of neovascular AMD it comes down to bleeds. What we are talking about now is new vessels leaking, but we now have good treatments that allow us to control that, and I will pass over to Alex to talk you through those.
Alex Craig
Thanks, Mike. 10% of macular degeneration is going to be neovascular macular degeneration or wet AMD. This picture on the right here just gives you an indication of what your patients might be seeing, so it obviously ends up with a burnout or a geographic atrophy of the central photoreceptors, which is that central sort of 10 or 15 degrees. These patients never truly go black blind. So I think that is something that to remember, teaching them how to utilise eccentric fixation and utilise a little bit of their mid peripheral retina in some cases, especially in low vision, once we do a lot of management of low vision, which we will talk talk about in a minute, is really beneficial. Anti-VEGF is the gold standard. This is intravitreal injections into the eye. This is the gold standard for treatment, and once it started, it typically is run every month on a treat and extend protocol. Initially, there is typically a series of six injections, which we then try to extend out a little bit longer, and if it is going really, really well then we typically are maybe injecting every 2 to 3 months depending on the patients depending on the disease.
Macular degeneration though something for you to remember is inexorable. It is moving forward, regardless of what we are trying to do obviously is to slow it down. This idea of using anti-VEGF is to create a rapid suppression of the abnormal blood vessel growth and leakage at the macula, which essentially over time is waterlogging the macula or creating damage to the photoreceptors and their ability to process light as it comes to the front of their eye. These time frame to get intervention is essentially as soon as possible. If patients are reporting acute vision loss or acute changes to their vision or encouraging these patients, especially patients with typical comorbidities around either other family members having macular degeneration or cholesterol associated or hyperlipidaemia. These are patients that typically should be screened for macular degeneration as well, and intervention as soon as possible or as soon as fluid is noted at the macula is what we would recommend.
And again like I said, the number of injections and ongoing care is case by case, but very typically there is a series of injections every month, obviously in patients up here for ten years and seeing them every month for an injection for ten years, and we just cannot get them off of that monthly injection. Access to pathways in regional areas, really requires practices that have an OCT. So I think checking with your local optometrist and figuring out which ones have the ability to image the retina, especially on a 3D level for patients that have macular degeneration is paramount to ensuring that the referrals are appropriate or that treatment is done appropriately. Patient costs, so this is obviously subsidised heavily. In the public healthcare system, you would have seen that there was a little bit of discussion around whether private health insurances should still subsidise this, and at the moment ruling of that adjudication has been kept.
Typically these injections, if they were not subsidised would be costing between $800 and $1300 per injection, which if we then consider the demographic that typically is suffering from macular degeneration, it can be quite obviously quite cost prohibitive or it can be a significant financial burden for them, primarily because the full name is age related macular degeneration and very typically happens to people in their sixth, seventh, eighth generation, eighth decades of life. The role of lasers and fluorescein angiography in treatment of neovascular AMD is I think it is important for you guys to be able to discuss or be able to understand what does fluorescein angiography show us.
Mike showed a picture of the OCT, so it is really giving us an indication of where these leakage or where these abnormal vessels are in and around the central pole. What is the GP's role? Obviously, we are really hoping that we can develop or encourage you guys to develop really good relationships with your local optometrists, so liaising with optometrists to assist your patients, especially patients that are not presenting for ongoing care. This type of treatment can often be daunting, just as an aside, getting a needle or getting an injection stuck into your eyeball is not something that I have ever seen any patient super keen to do, and so I think this is something that that needs to be probably handled a little bit delicately or at least referred on to optometry to allow for really good general discussion around why this is necessary and why this is the best way forward, essentially because when we lose compliance in these patients because they get a needle injury or they get a really bad subconjunctival haemorrhage, as a result, we typically see their compliance drop off.
This is on the horizon, so everybody is in a race at the moment to try to figure out how to actually target the majority of cases of macular degeneration that obviously would be geographic or dry macular degeneration, Syfovre is a current IVI or an intravitreal injection that is just waiting obviously on PBS approval at the moment, so watch this space for this one, and ultimately these patients will become low vision, so these patients will slowly start to lose their ability to be independent. Their activities of daily living is something that obviously becomes something that we need to discuss, obviously with loss of independence, mental health is something that often needs to be watched quite closely.
The three main aspects here or the four main aspects is adaptation to loss, counselling early, going through mental health plans, what is going to happen if you do lose your vision, how are we going to ensure that their quality of life is maintained, understanding that these patients then also will start to fail driving standards because it does affect central vision however, sometimes hard to pick up, especially if you are especially if you are just doing visual acuity. These patients sometimes require visual field testing, primarily because we rove we are binocular and we move our heads, and so noticing small changes or scotomas can be quite, quite hard for patients and often quite dangerous.
Obviously, looking after their activities of daily living, so, we just talked about how that ties into their independence, and then really our whole point here is really trying to encourage GPS and optometrists to work together to really ensure early detection. Low vision service providers, especially in regional Australia number one is going to be your optometrist. I have a suitcase from invisibility WA that sits in my consulting room that is full of handheld magnifiers and different, different things that patients can use to really improve their overall quality of life as they start to lose their central vision, like Mike touched on the MD Foundation offers telehealth provision and online support visibility WA if you are in WA, does remote visits, so coming out and going through people's houses and working on increasing contrast and giving big remote controls and big phones and things like that that allow for them to remain independent for as long as they possibly can. Vision Australia and as well as Guide Dogs Australia also do regional outreach programs and provide telehealth and phone services as well.
AMD key take home messages are: Number 1 is regular examination is the key to early detection. Even in very early AMD, counselling we find to be really-really important especially around things like modifiable risk factors like smoking as well as dietary choices, etc. Even though the research would suggest that there is maybe a 20-25% chance of slowing disease progression by having foods that are high in antioxidants in kales and things like that, even just utilising these as touch points, we find to be really beneficial in patients understanding what tends to happen in late stage disease. Number 2 is access to regular injections is critical for saving vision. I would probably add to that not just regular injections but early regular injections is critical to saving vision, maintaining the macular structure and the foveal pit and where the photoreceptors sit, remembering that 50% of all of the photoreceptors are sitting at the macula.
Losing central vision is and can be quite harrowing for patients. Number three coordination of health and diet recommendations. We talked about this. The two papers or the AREDS studies, they both give dietary information on certain food choices that that do make a small difference to the overall progression of disease. Then ongoing co-management of quality of life by optometrists and GPs links all those three take-home messages together. Thanks, Mike.
Michael Yapp
What we are talking about there is age-related macular degeneration, which when we are looking at the numbers is about 9% in non-indigenous Australians. The one to watch for though in the future is myopic macular degeneration. By the year 2050, half of Australians will be short-sighted based on current projections. What we are looking at in this graph is the growth of vision loss from myopia. The numbers suggest that up to 43% of visual impairment in the US will be directly due to myopia. We are talking at the moment 9% from AMD. In the future, that might be up to 43% of macular degeneration caused by myopia. Basically, what it comes down to with myopia is if you stretch it far enough, eventually it is going to break.
That is what is happening with myopia. We are looking at excessive elongation. The eyeball is stretched lengthwise which is called a as posterior staphyloma, so we end up with this outpouching of the back of the eyeball, which then starts to stretch and cause mechanical damage to the nerve and to the retina itself. We can see it funduscopically through areas of pigmentary change and changes to the optic nerve. We can see it through curvature on OCT scans. We can see it on B-scans where you can see this outpouching of the retina through an ultrasound. You can even see it on a CT scan, which I think is kind of cool when you see the cross-sectional slice showing this elongation or staphyloma of the retina itself. These are all the different things that can go wrong as a result of pathological myopia. There is a long list there which we have not got time to go into, but ultimately the big ones are increased cataracts, retinal detachments up to 21 times more likely if you start getting up to about a -5 myopia and a 40 times increase in myopic macular degeneration, but there is still a significantly higher risk even at low levels of myopia.
This is something that is going to be an epidemic in Australia and around the world. There is an awareness campaign coming very soon from Optometry Australia in the next few weeks to try and minimise the incidence of progression of myopia through three main things off-screen, outside, optometrist to get it tested because there are methods to try and slow progression of myopia that are a key part of our strategy going forward.
That leads us into diabetic retinopathy. As you can see, this time the percentages have completely switched between indigenous and non-indigenous Australians in terms of the incidence of vision loss from these particular conditions. When we talk about diabetes, everyone jumps straight to diabetic retinopathy, but ultimately there is a whole bunch of other ocular complications of diabetes that are important from prescription changes, dry eyes, cataracts, neurotrophic keratitis, swollen optic nerves, anterior ischaemic optic neuropathy and cranial nerve palsies, in particular cranial nerve IV. Glaucoma is a debatable one, but in some studies, there is an increased risk of glaucoma in patients with diabetes as well. Ultimately, diabetic retinopathy is where it all lands, but there is a whole bunch of other stuff that people with diabetes should also be checked regularly for. In terms of the risk of developing diabetic retinopathy, the key one is the HbA1c. Once that goes above 7, the risk of developing diabetic eye disease increases significantly and quite dramatically once you get into the poorer controlled levels.
Kidney disease, pregnancy and hypertension are also key factors in developing diabetic nephropathy as is ethnicity. In terms of once you have got diabetic retinopathy, it is a different set of risk factors. Whether it was present at the time you were diagnosed, rapid changes in glycemic control, whether you have got retinopathic changes outside of the central 45 degrees. Diabetic retinopathy out here in the periphery is a key part of an increased risk of progression. If the retina is not breathing well from ischaemia, it is obviously going to progress faster. There are specific things for type 2 and type 1, including triglycerides in type 1 being a key factor to look out for. The one that goes the other way around though if diabetic retinopathy is present, they have a higher risk of developing both peripheral neuropathy and nephropathy. It goes the other way around in some ways, if the reports are coming back to you that they have got diabetic retinopathy, from our perspective, it is a twig to say, let me double check both peripheral neuropathy and nephropathy because they are more likely to have that as well, if it is affecting the eyes.
Be careful. There is a lot of other causes of vascular changes that are not diabetic retinopathy, including hypertensive retinopathy. There are all sorts of cool stuff that goes on with vascular changes that can be indicative of different systemic diseases, which is another whole talk in itself, which we will have to skip over for the sake of getting to the other good stuff.
In terms of the reason for vision loss, the major reason for vision loss in diabetes is actually coming from macular oedema. There are all sorts of grading scales, but this is the one most commonly used for grading diabetic retinopathy and macular oedema. I am sure you are well and truly across this in terms of how to grade diabetic retinopathy itself. Ultimately, what it comes down to from a GP perspective, though, is the concept of whether fenofibrate is worth an additional prescription, I suppose, in trying to manage these patients.
There were two big studies that looked at fenofibrate in diabetes, but they were actually looking at hypertension. What they basically showed is that there is no significant impact of taking fenofibrate on the incidence of diabetic retinopathy or diabetic macular disease, but if used, it can reduce the need for interceptive therapy. It may stop it from progressing into further areas. There is some suggestion that fenofibrate may introduce how much exudate is happening in macular oedema, but those studies were published before a whole bunch of things like anti-VEGF. There is newer drugs for treating diabetes and there are a lot of them are done before OCT was widely used.
There is a new study underway which will look at this in more detail to look at fenofibrate, but it is not due for a couple of years yet. Ultimately, the clinical tip as far as fenofibrate is concerned, if there is moderate NPDR that is progressing towards severe or they have got macular oedema heading towards needing injections and they are already on treatment for hyperlipidemia, it may be that you will get a letter back from your optometrist asking you to consider whether or not fenofibrate is appropriate for that particular patient in amongst the rest of their systemic disease profile. I will pass over to Alex in terms of treating diabetic neuropathy with a caveat. Alex, we are almost out of time already, so we need to keep ourselves moving.
Alex Craig
Okay. I will move quite through this. Ultimately, when to refer to Ophthalmology. What we would use is we use changing visual acuity, but also because we can see the macula, we can image the macula with an OCT anytime there is fluid in the macula or bleeding at the macula that that is centre involving. This is typically when the patients are going to require some form of intervention that is outside of our scope of practice. Ultimately, also just a point on diabetes as well is that if we are picking up diabetes or we are picking up microaneurysms or changes in the retina, we just had a conference on the weekend that suggested that the patient then has already probably had diabetic or poor glycemic control for for up to 8 to 10 years prior to us finding those retinal haemorrhages. Ophthalmology, like I said, is involved when there is proliferative disease.
When there is centre or fovea involving diabetic oedema, there are various studies that suggest different jumping off points, but most utilised will be the protocols from the Diabetic Retinopathy Clinical Research Network. These are really easy to read and really easy to access. These usually balance starting vision and the presence of pathology as dual factors for initiating treatment. Some ophthalmologists hold off depending on what the total vision is like despite the fact that there is oedema at the macula. These are also treatment extended protocols.
We are very clear with our patients that this is not fixing their diabetes, but this is purely saving their eye or buying them time while they get their diabetes under control. Patient's access to treatment in rural and remote needs organisation much-much earlier, so we do really implore GPs in the regional areas, especially in regional areas like regional WA to refer patients that do have diabetes and even early diagnosis of diabetes so that if they do need treatment intervention, we can organise getting the medication up to the Pilbara or up to areas that are outside the urban and built up areas much earlier on. Again, early intervention in these cases makes a significant difference in how well patient fares over the long term.
Cost to the patients. Public, again, typically is under the PBS as well as there is options to get it done under private health insurance. For concession, it typically costs $7.70 and for non-concession, it is about $31.60. Again, that is based on the fact that it is heavily subsidised, and these injections are costing somewhere between $800 and $1,300, if they were not on the PBS. Utilising telehealth, we use telehealth a lot as an alternative pathway for monitoring with access to OCT and access to our images, ophthalmology does not have to see the patient in person. For treatment of these patients, especially in regional Australia, there is a lot of talk at the moment around things like non-medical injectors. Hospitals like Moorfields in London use non-medical injectors as a way to ensure that patients are getting seen in a timely fashion because there purely is not enough Ophthalmology to deliver the service.
I am not going to go through this, but this is just for you guys to see a bit of a breakdown of the different types of approach to treatment of diabetic retinopathy or proliferative retinopathy. What are we using laser for? Very typically this is PRP. It is panretinal photocoagulation of the peripheral retina. Essentially it is killing off tissue, so it is to reduce the oxygen demand to the eye, and as a result then allows for vascular permeability to be turned down.
Next is anti-VEGF. We talked about this. This is the the gold standard of intervention especially for macular disease or for macular oedema. Sometimes steroid is used but steroid typically only used in those that are pseudophakic. Otherwise, it can cause cataract and combinations of the above. Combinations of anti-VEGF, laser and steroids. It gives you a bit of a pro and con table there to to have a look at if you are thinking about referring.
Michael Yapp
I am going to skip that poll sorry because we have run out of time for a poll.
Alex Craig
That is all right. We will kick on to the diabetic retinopathy. Key messages. Regular examination is the key to early detection, the eye being the only place in the body without cutting them open or getting an expensive fMRI or a CTV gives us access to the blood vessels, so we can look at the arteries and the veins, we can grade pathology. We can look to see whether that is getting worse or whether management plans are appropriate. Regular examinations is a key to early detection and maintenance of management plans.
Glycemic control is critical to minimising the risk of vision loss. In general, fenofibrate is a possible option for progressing DR and a good jumping off point of talking with your local optometrist. Multiple possible ocular complications of diabetes as well, so it is not just vision loss. The eye, you get the same effect around peripheral neuropathy in the cornea. Contact lens wearers and diabetics are a really big hot-button topic as well. Then diabetic retinopathy related to increased risk of neuropathy and nephropathy as well.
Michael Yapp
Fantastic. We are pretty much out of time already. I am going to maybe just do a highlighted package on glaucoma. The crux of the story is it is a very difficult condition to diagnose. If you ask 10 different ophthalmologists, is it glaucoma, you are probably going to get 10 different answers. There is a whole bunch of pathology as to why we get it, but the crux of the story is, it is not necessarily about IOP. It is ultimately how we treat it. If you look in countries like Japan, up to 92% of people do not have elevated IP in their glaucoma, and that can be termed normal tension glaucoma, but there are lots of different discussions around where we go with that. Lots of different types of glaucoma, not just primary open angle, lots of different causes with obviously primary open angle the most common. Lots of different historical risk profile as to why people are more likely to get glaucoma as part of the management profile.
Lots of different tests that are required to come up with a diagnosis, and adding all of those together to come up with the package that says this is something that needs to be treated and lots of different treatment methods from four different classes of drops through to microscopic implants through to laser treatments, major surgical intervention, a whole bunch of different ways of treating it. The vast majority of those are done in collaborative care these days with Optometry. There is a rule in current that optometrists will refer within four months to Ophthalmology for a confirmation of the diagnosis, but then that is often done through telehealth and monitored through Optometry going forward.
The big tips in glaucoma, open angle is asymptomatic. Ensure patients who are getting repeat scripts are regularly assessed, so they are not just getting their scripts and not getting checked. Check their compliance with eyedrops because that is one of the main reasons glaucoma gets worse is that people are not using their treatment. There are lots of optometrists that work in co-management and telehealth, both with GPS and ophthalmologists.
Last detour is into dry eye. Dry eye is incredibly common. You are all very aware of it. One in five Australians experience it frequently. Lots of different causes that are modifiable and non-modifiable. Ultimately, though, there is a staged management process for dry eye. There is much more to it than just eye drops. One of the main ones that is in there is oral macrolide or tetracycline antibiotics as a major treatment protocol for dry eyes. Dry eye can be incredibly debilitating. It has a very standard diagnostic and management protocol which involves a lot more than just tears. Optometrists will be regularly referring for treatment for meibomian gland disease because at the moment we are not allowed to prescribe orals in particular, tetracycline and azithromycin are a big stay in dry eye disease, which is a massive problem in most parts of Australia.
As per usual, we have talked way too much. Some things to consider about tomorrow. Ensure vision/eye health is included in your history and your care plans as part of your at-risk communities in particular. Collaborative relationships with Optum is going to work best for everybody in terms of helping your patients. Make sure you are aware of what services are available in your region, what pathways and how you can best help your patients through helping them with their eye diseases and management going forward. Hopefully that still leaves us time for a few questions.
Jessica
Thank you so much, Michael and Alex. That was a fantastic presentation, so much information to digest and really valuable. We have had quite a few questions come through the Q&A panel, so let us start going through them. Hopefully, you will be able to get through at least some of them in the next few minutes, if that is okay. The first question that is come through, is macular degeneration treatable with eye specialist access being difficult and expensive, how can patients obtain treatment for their macular degeneration?
Michael Yapp
Yeah, it is a very good question. It often depends on where you are. The answer to that question will vary dramatically between metropolitan and rural and also dramatically in rural situations depending on the access to ophthalmology. At this stage, it is very much a developing area in terms of how the management is performed in terms of how do they access the injections. One of the problems we have is these patients need to keep having them. So once they start having them, the problem is Ophthalmology time can be very regularly chewed up by just doing that and not doing other things.
Unfortunately, the answer is not an easy one because it is going to vary dramatically between locations. I would suggest the easiest answer is to speak to your local optometrist and ophthalmologists about the care pathways in your region because there will be different ways to help patients who cannot afford access to private care through different mechanisms and using the safety net and other options. I do not know if I answered that particularly well. Sorry.
Jessica
That is all good. Thank you, Michael. Next one is what about patients going overseas to have their cataracts because it is cheaper. Would you be against this approach? What are the risks?
Michael Yapp
From my perspective, I think it would be no different to what you would say to your patients for every other condition that they are suggesting going overseas for. Cataract surgery is one of the major, if not the main, outpatient surgery that is done. It is routine, but at the end of the day, 1 in 1000 in Australia goes horribly wrong, but can be recovered. Ultimately, a lot of people will have a very, very good outcome. If it was me, I would prefer to have it done in Australia, but that is not saying they would not necessarily get a very good result overseas. I do not know if you have come across this much, Alex. I know when I worked in the UK, it was more common with people going over to France and so on, but I have not come across it much personally.
Alex Craig
I have a little bit. People tend to go on medical holidays to Indonesia quite a bit from WA. It is a two-hour flight to Bali. I do have quite a bit of patients coming through and I do counsel against it primarily because even though the risk is very-very low, if there is an infection after surgery, it typically ends up in endophthalmitis and the loss of the eye, so managing that can be quite challenging, especially across different countries. I counsel against it.
Jessica
Absolutely. Okay. The next one when do you stop anticoagulation for cataract surgery or any other eye surgery?
Michael Yapp
Alex, you want to take that one?
Alex Craig
Typically, eye surgery is relatively bloodless, and so really the only medications that we are asking for patients to stop taking is things like Flomax that can cause floppy iris or changes to the actual internal structures of the eye that would be relatively dangerous for the surgeon. We keep most patients on most of their medications as they go through surgery because it is a relatively bloodless surgery. I had an ophthalmologist have to do an evisceration the other day, and he was horrified at the amount of blood because he is not used to seeing that amount of blood in his surgery, so typically anticoagulation is fine.
Michael Yapp
I think the risk of complications in eye surgery compared to the risk of complications from stopping their systemic treatment is very much outweighed and so most surgeons are quite happy to say, look, I can deal with complications and there is less likely to be them, so stick with it.
Jessica
Great. Thank you for that. What about glaucoma drops? When should those be stopped? Is it safe to continue until a patient is in a nursing home?
Michael Yapp
Ultimately, the problem with most of these diseases that we have talked, all of these diseases, once they start, they do not stop. Unfortunately, once the treatment stops, the condition starts to deteriorate again quite rapidly. Nursing homes are a major concern and unfortunately something that is not handled particularly well from an eyeball perspective because of the complicated nature of responses and not being able to test all of our fancy toys as easily, but yes, if they are on glaucoma drops and they are in nursing homes, they still should ideally have regular checks in the nursing home. Ultimately, they need to be on those drops if they have been prescribed and keep them coming. Otherwise, the risk of vision loss is significantly higher.
Alex Craig
Just a point on that, especially those in nursing homes is dexterity. we do find that these patients are not putting their drops in well or they are missing their eye completely. Ensuring that they are getting seen quite often is really good or if they are coming to you for scripts more often than they should be, then typically probably compliance is going to be a problem.
Jessica
Thank you both. Romani is stating that referral pathways in Queensland are very complex. Is there any easy guide or pathway we can refer if a patient wants to go public or is it always private first?
Michael Yapp
Your local optometrist will have a very good handle on that. Generally speaking, in the regional areas, it is private first who then will list them publicly onto their list that they do through the different hospitals that they have surgical rights with. There are obviously a lot of surgeons that are very happy to discuss options for patients that cannot afford that, but ultimately what I would suggest is talking to your local ophthalmologist and/or optometrist and finding out what they have and what they offer, so you know what the story is, but generally speaking, it is private. first for the initial consultation and then listed after that through the public systems. Alex, anything you wanted to disagree or change?
Alex Craig
No, that is fine.
Jessica
Excellent. Another one. I think this is referring to macular degeneration. Can you please elaborate on dietary factors that we could advise patients on?
Michael Yapp
Absolutely. From a concept of dietary changes, there is a lot of material out there, I suppose. Ultimately, it is not going to stop someone from getting macular degeneration who is going to get it, but there is a lot of evidence that it can slow it down. There is not a lot of evidence that it stops it from occurring, but once they have it, the evidence is that it will decrease the risk of progression. That said, diet, lifestyle and general health is good for everything at the end of the day. One of the things that we are discovering with eyeballs is everything that we are trying to tell patients about their diabetes, about their macula, about their glaucoma is absolutely the same stuff that you will say to patients about their hypertension, about their cholesterol and everything else.
We are talking good healthy diets, green leafy vegetables, all the same stuff on top of things like exercise. There is lots of evidence that it makes a difference in terms of decreasing the rate of change. What I would suggest if you want more information, jump onto the MD Foundation website. They have got whole cookbooks. They have got whole sections on the best things you can do in terms of diet and lifestyle to assist with that side of things. I saw a question on there about Macu-Vision, Macu-Tech and the supplements that falls into the AREDS supplementation that has had wide ranges of study, and absolutely, there is evidence that taking those does decrease the risk of progression in combination with diet and lifestyle as well. Certainly, it is on high on our list of recommendations.
There are potential complications, albeit small with those. Often optometrists may refer back to their GP's to say I want the patient to start on this. They are also taking all these other things. Can I check with you to make sure that you are comfortable with the patient being on this as well? But the risk is very low, and yes, there is evidence that it does slow the risk of progression.
Jessica
Fantastic. Thank you. We have still got a few more. Are you happy to stay on for a little bit longer?
Michael Yapp
Works with us. Obviously if people disappear, that is more than fine. I am not counting the numbers.
Jessica
That is okay, we are recording this as well, so people can catch up later if needed. Steven is asking would it be helpful if GPs were trained to manage eye conditions to the same level as an optometrist? Would that improve eye care for patients, especially diabetics? I find patients usually come for their scripts, and if we can catch them during these visits to have their eyes checked instead of making them take more time off to see an optometrist.
Michael Yapp
It is a brilliant and incredibly controversial question. The concept of diabetic vision screening is one that has debates going on left, right and centre all around Australia, all around the world as to the best way of screening for diabetic retinopathy. There is talks about doing it in pharmacies. There is talks about doing it through cameras in GPs. As I am sure you know, there is an item number for a GP to take a retinal photograph and interpret the photograph. Ultimately, yes, I think if a GP is highly trained and can assist with diabetic retinopathy screening, fantastic. A couple of caveats. What happens in the central 45 degrees of the retina is not necessarily telling you what is happening in the rest of the retina.
There is a whole bunch of other things that diabetes can cause, and a whole bunch of other conditions associated with diabetes that should also be tested for. Testing through a small sized pupil without dilation with a cataract that inevitably is there with diabetes as well decreases the ability to screen through photography alone. Ultimately, absolutely, the more GPs know about diabetic retinopathy, the better they are at screening and the more options and the more occasions of service we can hit these patients with when they come in to get other things done to make sure they do not have diabetic retinopathy. Absolutely fantastic.
I do not think necessarily a GP needs to go out there and buy an OCT, which is where the big stuff comes in, in terms of making sure macular oedema is detected as soon as possible because that is when people start vision loss. Ultimately, the concept of detecting there is a problem and knowing that person needs to be under care. Fantastic. The finer details of all the fancy toys and everything else that comes along with it, I have spent five years at university and then another many, many years doing CPD and reading articles. I would like to think I know a reasonable amount of eyeballs. I am amazed at how much GPs know and how much you are expected to know. I would not expect you to know everything there is to know about the minutiae of diabetic eye disease, but absolutely. The better we can work together, the better it is for everybody.
Jessica
Thank you for answering that one. The next one is for adults who are already high myopic. Is there anything they can do to prevent or delay maculopathy?
Michael Yapp
A lot of the research is around early intervention. There is some emerging evidence, but it is not strong yet about myopia control later in life. Ultimately, it is worth a shot to tell you the truth. The evidence is not quite there, but the optometrist will be able to talk through the different methodologies that are available to try and slow it down, and then if it is appropriate for that particular patient, it may be worth a try.
Jessica
Fantastic. There is two here about prescribing GLP-1 RA. Sorry, I do not know the exact term for that, but are there any precautions around prescribing that with Ozempic in patients with diabetic retinopathy and then what is your advice on starting it?
Michael Yapp
The GLP-1 RA or the GIP, those are the newest ones. There is no direct inherent link between that and the worsening of the diabetic retinopathy that we have found. There is a trial out there called the SUSTAIN-6 trial, which was run with Ozempic, and ultimately where we are seeing that there is a potential problem is in the dramatic reduction of the blood sugars or of the HbA1c, so typically there would be any other association between changes in blood sugar levels, we are seeing somewhat there for a potential to be a change in the diabetic retinopathy, but it is certainly not causative, more correlated.
Jessica
Thank you. Next one is with high triglycerides. Is it helpful to use the new medication icosapent to reduce triglyceride instead of fenofibrate?
Michael Yapp
I have to admit I have not come across that one myself personally. I do not know of any trials as yet from that perspective in terms of the eyes, but I will definitely read up on that one, and I will get some information back. I do not know of any studies that have looked at it, but I am sure someone already is, but I have not seen anything published on that as yet.
Jessica
Okay, just a couple more to go. What can we look out for in regards to early recognition of retinitis pigmentosa in GP?
Michael Yapp
You are doing well, Jessica, with pulling out some of these names. I am impressed. Symptoms is the first, family history is the second. One of the most diagnostic tools is something called autofluorescence which a lot of optometrists will have in their practices. It looks at how the retinal pigment itself is functioning. The most diagnostic test is electrophysiology where we connect up and look at how the retina is transmitting messages. It is hard to find. They are only in big centres, but that can be diagnostic from the age of 7. For people that have a family history, you can pretty much say from that age whether or not people are likely to develop it later in life. Ultimately, it comes down to poor night vision, symptoms along those lines and family histories.
Then, the appropriate diagnostic imaging tests will be able to pick it up much sooner than most things. A lot of the diagnoses are actually made incidentally using imaging before the patient is even aware they have got a problem. RP is a really challenging one because of the diagnosis, essentially being you are probably going to go blind, but yes, it is about trying to get the right imaging done. As an optometrist, I tend to refer them into retinal ophthalmologists for appropriate counselling because it is really important they get the appropriate, both mental health counselings and genetic counselings once the diagnosis is made. I could talk about that one for quite a while in a different area.
Jessica
No problem. Thank you. For those with late diagnosis of wet macular degeneration, how much vision do they get back from injection treatments?
Michael Yapp
Alex, you want to have a go at this?
Alex Craig
I can talk just based on what I have seen. I tend to see probably a 1 or 2 line improvement. It really just depends on when the intervention happens. Mike, do you have a specific study that you can quote?
Michael Yapp
Yeah, there is there is an enormous amount of research on this and lots of different studies being published about which treatment, when, how often and so on. In terms of how much they get back and how much it stays, I am not sure off the top of my head, but you have got to get it before it causes scarring. Once fibrosis kicks in, then the retina is not going to come back because it is the fluid that we are getting rid of with the anti-VEGF and drying up the blood vessels. If the vision has been damaged courtesy of scarring, the chances of recovery is very small.
If it is fluid leakage, the fluid will mostly go away once the injections have done their job. Most of these patients do not end up where they started, so they are not usually going to go back right to 20/20 vision or 6/6 if you want to be metric, but they generally held fairly well around about the driving standard or better.
Jessica
Excellent. Thank you. Last couple and then we will close it up. Is there any course for GPs to upskill on how to use biometry or retinal scans for example GPs upskilling using ultrasound?
Michael Yapp
The ultrasound for the eye is a fairly unique device given the dimensions of the eye itself. We are looking at a 21 mm object that has a particular type of B-scan ultrasound. It is not something that is commonly found in many optometric practices, let alone in your standard imaging centres either. Photography, absolutely. OCT imaging, you are looking at about $75,000 for an OCT device. If you want to go out and buy one, fantastic, but they are not exactly something that is going to be in regular use. I have forgotten what the question was, to tell you the truth, in my ramblings.
Jessica
I need to refer back to it. Are there any courses to upskill in biometry or retinal scans, for example, GPs upskilling using ultrasound?
Michael Yapp
Yeah. Lots of courses out there for diabetic retinopathy, interpretation of photography. Not a whole lot otherwise in terms of interpreting OCTs, lots of CPD available for that, but more aimed at ophthalmology, orthoptist and optometrists. That does not mean necessarily that we should not look at it. If you think it is an area that GPs are interested in, absolutely, we can start putting together courses on those areas for you.
Jessica
Excellent. I am going to be very bad at pronouncing the next one. Is posterior blepharitis difficult to treat?
Michael Yapp
Blepharitis comes in many shapes and forms. It falls into the whole dry eye scheme of things because essentially blepharitis is going to cause the same symptoms and actually cause dry eye as well. This is where what we talked about before, the macrolides and the tetracyclines kick in. Posterior blepharitis is meibomian gland disease, so when we are talking about treating that, often we have to resort to other methods that include things like hot compresses that include things like IPL which is a specific treatment for those glands. Alex, are you offering those sort of treatments in WA.
Alex Craig
Yeah, absolutely, and I think also the GP link here is that and especially as we move towards optometrists potentially having access to prescribing some oral medications is your doxycycline and your azithromycin. So, understanding that being able to take and fix and treat the bacterial load or the excess bacterial load at the Mongolian glands makes a very, very big difference, but, we use IPL so we run a dry eye clinic, a specific dry eye clinic, so we use tools like BlephEx, which is essentially like a Dremen with a cotton tip on the end that debrides the lid margin, we use that in combination with IPL. Now the one downside of IPL is that you cannot use it with doxycycline, obviously because of the photosensitivity effects of it. Our preference is to ask GP's to prescribe azithromycin in combination with IPL treatment for severe posterior blepharitis.
Jessica
Thank you for that. Last two questions. Comment. Great talk. Many thanks. If a patient with low grade myopia seeks Lasik treatment, how might this procedure affect their future risk of developing long term ocular complications? Are there any preventative medicines or vaccines available for eye diseases? Alternatively, is there any vaccine associated with major eye related conditions? Are there any private insurance or is there any private insurance that works best for treatment for eye conditions in private settings e.g. BUPA?
Michael Yapp
You have thrown a couple of beauties at us. It is getting late, but we will see how we go. In terms of Lasik treatment, ultimately the problem with myopia is the stretching of the eyeball. It is the staphyloma and the stretching which causes the problem. The higher the degree of myopia, the more likely they are to have a problem. Lasik basically covers what they have by reshaping the front surface of the cornea. It does not change the back of the eye, which is where the damage is being done.
Ultimately Lasik will improve their vision, but if the eye continues to progress in terms of their myopia, then that same cascade of events continues to happen, and just because they have gotten rid of their myopia through Lasik does not change the risk of having these diseases occur later in life based on the amount of myopia they had in the first place. So while Lasik is a fantastic process and treatment, ultimately what we want to do is try and slow down the progression of myopia regardless of where they are to stop it going as much as possible.
Alex Craig
I was going to say the one thing that I would comment on there is that because Lasik does thin the cornea and we typically are using either non-contact or even contact tonometry this can sometimes affect the intervention point for diseases like glaucoma. If the corneal thickness is too thin then obviously the adjudication of pressure can also potentially be affected there.
Michael Yapp
I think the other questions in terms of vaccines is probably a conversation for another time, if you do not mind. Jessica it is a big topic, and if we start on that one, that will be a little bit outside the scope of what tonight was about.
Jessica
No problem. All right. Let us move on to the last one. What is the definition of severe myopia that could increase the risk of AMD in terms of minus numbers.
Michael Yapp
One of the key points here is the difference between age related macular degeneration and AMD or myopic macular degeneration. They are not mutually exclusive. You can get both, but myopic macular degeneration is a very different process and a very different disease pathophysiology. Ultimately, the higher the number, the worse. Once you start, it used to be defined as greater than -6 was when you started to get into high myopia. We know now from the studies, though, that even low myopia can still cause problems, but the percentages are lower.
What the term they have moved away from now in terms of high myopia is pathological myopia, so essentially what we are talking about now is it does not matter what the number is, it is a matter of whether that number is the wrong number for that eyeball to the point where the stretching is causing damage. So ultimately the lower the better. If you want a number -6 and higher is when we really start standing up and taking notice and saying this is someone that is much more likely to have problems, but ultimately those problems can happen at -1 as well.
Jessica
Fantastic. Thank you so much. We have gone through all the questions which I think is quite impressive actually, so thank you Michael and Alex again for that fantastic presentation. Lots of great feedback already. Just a quick reminder to everyone that is still online with us, if you could complete the evaluation that pops up after the webinar closes that would be great. Your certificates of attendance will become available on your CPD statements within the next few days, but if you are not an RACGP member and you would like a certificate of attendance, please email us at rural@racgp.org.au, and finally, I would just like to invite you to join us for our next free webinar, which is happening next month on chronic wound management in rural communities.
This is going to be a great one to get a bit of an understanding from Australia's first wound nurse practitioner and provide valuable insights into the practical management and best practice for treating high risk groups. I will just put the link in the chat now if anyone does want to come along to that one, and aside from that, we have reached the end of this session. Thanks again for attending. Thank you so much again to our presenters. I hope everyone has a great night.