Re:Vision speakers: (back row, L-R) Drs Paul Rosser, Simon Dean, Trevor Gray, Hussain Patel and (front row, L-R) Jo Sims, Aki Gokul, Mo Ziaei and Clairton de Souza

With perfect seminar weather blustering outside, Re:Vision’s co-management conference got underway following a hearty breakfast, with doughnuts!

Eleven 15-minute presentations were delivered in just under four hours with Re:Vision’s ophthalmologists Drs Trevor Gray, Mo Ziaei and, the newest member of the team, Dr Simon Dean, deftly handling the majority of presenting duties. These were intermingled with talks from Re:Vision associate ophthalmologists Drs Hussain Patel, Clairton de Souza, Paul Rosser and Jo Sims and optometrist Dr Aki Gokul, who each presented on their specialties.

Re:Vision's Drs Mo Ziaei, Trevor Gray and Simon Dean

With a focus on co-management strategies with optometrists, subjects ranged from glaucoma and cataract post-surgery woes to the importance of prepping a patient’s ocular surface before surgery, watery eyes and a fascinating talk by Dr Gray on how the health of our gut microbiome is being increasingly linked to eye diseases.

Post-surgery blues

If a patient presents with severe pain and loss of vision in their post-glaucoma-surgery eye, coupled with nausea and high intraocular pressure (IOP), it’s likely to be a suprachoroidal haemorrhage, said Dr Patel. Immediate treatment includes IOP and pain management then drainage by the vitreoretinal team following clot lysis (10-plus days). Other post-surgical issues for high-IOP patients without pain or vision loss include encapsulated blebs, tight flaps and blocked ostia, while low IOP signals over-filtration, bleb leak or ciliary body shutdown. For those who present with a red and/or painful eye and blurry vision who’ve had a trabeculectomy in the past, seriously consider infection, said Dr Patel, as this can occur at any time from early post-op to years later and requires urgent referral.

Dr Clairton de Souza

Also relatively rare, post-surgery complications can occur in up to 5% of cataract patients, the most common being posterior capsule ruptures (risk: 0.4-5.2%), luxation/subluxation of the lens or IOL (0.05-3%) and retinal detachment (0.4-1%). These risks are far lower than they were, however, following the introduction of improved and new surgical techniques, said Dr de Souza, noting posterior chamber IOL implantation techniques appear better than anterior chamber options.

Jeremy Wong and Dr Hussain Patel

Many factors increase the risk of interoperative complications for cataract patients, said Dr Dean, including trauma, small pupils, floppy irises, posterior polar opacity, deep-set eyes or a patient’s own anxiety levels. A team approach and managing expectations is key to a happy patient, he said. For example, never promise spectacle freedom, said Dr Ziaei in his talk on surgical options for presbyopia. Although 90% of patients are happy with their vision post-surgery, those who do best tend to be older, myopes and are content to wear specs for distance vision and night driving, so want to be glasses-free most of the time. Contact lens trials and visual simulators (which are increasingly employed) are a good way to help patients understand what to expect post-surgery, he said, adding optometrists can help ophthalmologists select the right IOLs for their patients by providing detailed pre-consultation notes about their lifestyle.

Sob stories

Dr Rosser’s ‘Eyes and cries’ talk both amused and informed the audience as he discussed epiphora versus dry eye and the various treatment protocols and preferences for dealing with tear problems. A basic history and examination should differentiate lacrimal from pre-lacrimal pathology, he said, before providing a detailed guide to syringing. Patients should be referred if there’s punctal narrowing or occlusion, eyelid malposition or lacrimal outflow obstruction.

Isla Hills, Kerensa McCamish and Kylie Dreaver

The morning’s second half was kicked off by Dr Gokul, who discussed Auckland’s new crosslinking (CXL) service, which is proving very successful in both earlier referral, follow-up and treatment of keratoconics. He stressed the importance of early referral, since earlier treatment improves outcomes. Preliminary results from a pilot study to determine if post-CXL care can be better provided in a community setting, allowing appointments to be fewer and closer to home, were positive, with significantly more Māori and Pasifika attending follow-up appointments. However, despite the positive results, a grant application to extend the community trial was refused, he said.

Dr Aki Gokul

Dr Sims then shared some fascinating cases and tips for spotting uveitis red flags, while Dr Dean discussed the criteria for pterygium surgery and post-op care, and why some patients should steer clear of blepharoplasty, especially as they get older. This includes those with ocular surface disease (OSD), which can also cause complications and poorer outcomes in cataract surgery, explained Dr Ziaei. Sharing a recent study, he said while 50-77% of cataract patients had one or more symptoms of OSD when tested, only 22% had a dry eye diagnosis. So it’s important to test patients prior to surgery as the vast majority are asymptomatic, he said.

Bringing the formal presentations to a close, Dr Gray provided a refresher on steroids. Discussing when they should be used, how they work and should be administered, and how best to co-manage patients who are taking them, providing yet more talking points over a sumptuous co-shared late lunch!