Advanced Paediatric Optometry Insights

– [Amanda] Good evening, everyone. Welcome to the Deakin University
optometry alumni webinar. It’s our first webinar for the optometry
alumni and tonight we’re bringing to you Advanced Pediatric Optometry Insights. Tonight we have joining us Linda
Robertson, Hayley Birch, and Daniel Farrugia. I’m Amanda Edgar, your President for the
Deakin Optometry Alumni chapter. And tonight we’re broadcasting to you live
from the Deakin one point estate. Again, welcome to the optometry alumni
webinar. Tonight we’re presenting on Advanced Pediatric Optometry Insights
and our first speaker today is Linda Robinson. Linda graduated from Melbourne University
with a Bachelor of Science in optometry followed by a master’s in optometry. She has over 20 years
of experience in the field and is currently a clinical skills
lecturer at Deakin University. She also works in practice and owns
her own business in addition. Thank you for joining us today, Linda,
I’ll hand it over to you for your presentation. – [Linda] Thank you, Amanda. Okay, so the case that I’d like to present
tonight is a case of a little boy who presented with Accommodative esotropia and
subsequent amblyopia. We first saw him when he was only 12
months old, a little dot of a thing. And his mom was very
apprehensive when she came in. She had had a really bad experience
when she was a little girl. She was teased a lot at school
for wearing glasses. And she was really worried about the
possibility that her children might need to wear glasses. And at that visit, this little fellow
looked really quite good. He had moderate amount of hyperopia,
you know, which was normal for his age, his eyes did look straight. And so we scheduled just a regular
review for 12 months. He didn’t make it to 12 months later,
about 9 months later, his mom brought him back because his
parents had noticed his right eye was turning inward when he was very tired. So not all the time just on those odd
occasions when they’d noticed he was tired the eye would wander inwards. And at that age, it’s pretty difficult to
measure vision. But one of the techniques, of course,
that we can use is just covering the eye that we suspect is the good vision eye,
and to see whether the child reacts poorly. And he didn’t. He was quite happy
to have his left eye covered. The ret was coming up a bit higher than
it was nine months ago. And because there was an intermittent
turn, we recommended that he should perhaps wear glasses. But the mom, as we mentioned before, was
really resistant due to do to her own experiences. So we counseled her to watch closely to
see if that turn was increasing in frequency to return promptly if they
were concerned. Otherwise, due to his young age,
I was quite happy to let him go for another 12 months if they were. So he came back at almost three,
but now the right eye was tuning in pretty much all of the time. And we were able to get a visual acuity
measurement or vision measurement with single optotypes or pictures in this
case, and he was not doing too bad 6/7.5 and 6/9.6. And initially his eyes did look straight,
but when you really pushed him, got him to try and pay attention which is kind of
hard sometimes with little kiddies this age, but he did try really hard. And we did notice that
his right eye turned in. And it was just an interesting thing that
he seemed to have poor vision with his left eye. So I started wondering whether there was
an alternating turn and we just happened to be seeing that right eye turning today,
maybe the left eye was turning other times. And his dry ret we were still getting a
little bit more plus in the right eye. So I figured all that pretty much matched. So this time, I was a bit more strongly
recommending that he would need glasses. And the mom was really
still resisting treatment. So at that point, I offered a referral to
an ophthalmologist in order for her to have a second opinion from perhaps
somebody that she thought would be a bit more trustworthy. So we referred her to a local
ophthalmologist who happens to have lots of kids herself, so we knew she’d be
pretty good with dealing with a little fellow. And she confirmed that there was a right
convergence strabismus vision. She wrote back with 6/9 in each eye. She did a cycloplegic ret got about plus
5.00 and 4.50. And she made a note that she thought it
was interesting that she noticed a retraction of the right
globe on left gaze. I hadn’t noticed that,
but she wrote that that was what she found. So she recommended at this point to pop
him into plus 2.50s. And for them to return
to her in three months. But the patient didn’t get those glasses
made up and didn’t go back to the ophthalmologist,
or to myself at that point. So this is what we call loss to follow-up
which is rather sad. What the mom did is she’d heard of an
alternative treating optometrist that had moved into the Greater Geelong Region. And his theory was to try and wean
people out of needing glasses. So the glasses that he had when I saw him
next were plus 0.50 in each eye, with some microprisms in inverted
commas. So very, very tiny amounts of vertical and
horizontal prisms designed to make the eyes feel more comfortable. Not surprisingly, this was
not controlling the turn. So this is when I saw him next,
when he was 6 and a half. Now the mom was really concerned,
the eye seemed to be tuning in the whole time she even thought
the left eye was turning in also. So she was really upset, the vision in the
right eye had really dropped and there was no stereopsis. So once again, I recommended changing his
glasses to the highest script and to start patching. And once again she
wanted a second opinion. I suggested she return to the original
ophthalmologists, but she didn’t want to do that either. She was a bit embarrassed,
I believe, to go back to her. So I referred her to a very well-known
strabismus surgeon and specialist in Melbourne. And the reply I got from this
ophthalmologists was gorgeous. He enthused it was very good that this
young fellow had bounced back into mainstream eye care,
and that he’s diagnosed failed alternative treatment right esotropia a V-pattern or
an oblique muscle dysfunction which was obviously what was causing that retraction
of the globe on left gaze. Right amblyopia hyperopia
and latent hyperopia. He prescribed plus 4 for each eye and
patching of Atropine drops twice a week to the left eye with
a review in two months. So even though we thought that this would
be fine, it looked as if he was going to be straight with those wet ret results,
he still persisted with the right esotropia, even
with his full correction. And so ultimately surgery
was performed in 2012. The vision in the right eye proved to be
very variable at different times, he would respond well to the Atropine in
the left eye the vision would come up in the right eye,
but then decreased again when the Atropine was withdrawn. And my feeling is this is that if we’ve
got onto this a lot earlier, and had some chance of him having
binocular vision earlier, that there wouldn’t be as much regression with
patching at this age. So I saw him again caught up again when he
was few months shy of 8, he needed just a new referral. Because he just finished a course of
Atropine drops to the left eye and was heading back to see
the surgeon in Melbourne. He’s still having a bit of an alternating
esotropia at this point. So my initial thought that there might be
that alternation turned out to be true. And at this point mom was quite happy with
his progress, he was looking straight to her in the distance
with the glasses on. It continues we’re going up and down like
a roller coaster with this little fellow. The vision in the right eye dropped again
to 6/12 only weak sensory fusion present. And so we commenced Atropine drops again. By 8, we’re still bouncing up and down
about 200 seconds of arc but fairly good vision. And almost 9 it’s dropping down
again in the right eye. So at this point, even though
he looked straight at distance, we gave him a little bit more plus at near
so we gave him some progressive lenses. And we recommenced Atropine drops or we
recommended recommencing Atropine drops. But patient’s mom decided enough was
enough she’d had it with these drops and decided that 6/9 vision
was good enough for her. So luckily he remains about 6/9 we’ve kept
him in the progressive lenses because he still gets a fairly decent
esphoria without the lag. And even though you know he’s still
only about 6/9, mom’s still declining further amblyopia therapy.
I think this might… no I saw him a couple more times,
one time when he broke his glasses. And then another time when he came in and
wanted contact lenses for football and soccer. And another time when
he wanted some new glasses. So look, it goes on these people aren’t
like, see them, treat them, that’s it. I mean, that’s a whole relationship with
that family that we’ve had with their ups and downs. So little bit of theory,
what causes unilateral amblyopia? Well, it can be an anisometropia, primary
strabismus or stimulus deprivation. So in this case, it was the latent
hyperopia causing the strabismus. They also had this muscle imbalance which
ultimately required extraocular muscle surgery. So treatment of patients like this is
the first step is to give their full refractive correction. So we either go for the wet ret results
for hyperopes or a partial refraction, which gives them ortho at distance. The debate about whether full corrections
interferes with the emmetropization process is quite strong. There are conflicting results in the
literature, you might like to have a look at that reference that I’ve given there to
prescribe or not to prescribe. And it really sort of goes up and down as
to whether or not you should give a partial correction because that way,
at least you’re letting the child accommodate a bit, which is the normal
state for most mildly hyperopic children. So sometimes full corrections they feel
can be a problem. But in this case, we had to push
that full correction otherwise, we’re never going to control the term,
we’re never going to get anywhere with trying to keep him straight. And therefore to treat the amblyopia and
get some sort of binocular vision. Second step to your
treatment is to review. Typically after a month… I know when I trained we sort of used the
rule of thumb of one week per year of age, but I think these days
the PEDIG says one month. And what you’ll find is that there will be
some improvement in amblyopia with just the refractive correction. I tend to see more when they’re
anisometropic rather than strabismic. And I tend to see more when they’re
younger, but there will be some improvement. And it’s worth not starting patching
straightaway, but to let them wear their glasses for that first month to see what
improvement you’re going to have. The third step for your treatment
is the occlusion therapy. And the results of the PEDIG
studies are quite interesting. When I look at two hours occlusion,
it’s the same as six hours occlusion for moderate amblyopes,
and six hours is the same as all day occlusion for severe amblyopes. So we don’t actually need as much
occlusion as we… you know, back once again when I trained
as we used to think we did. But you do need more
occlusion for older children and for strabismic
versus anisometropic patients, so keep that in mind. If you’ve got somebody with quite a big
turn, and they’re older like this child was then they need far more time occluded
or penalized with the Atropine than you would if you had a 2-year-old that just
had anisometropic amblyopia. Some of the PEDIG studies found that two
hours with near work worked better than two hours of occlusion alone,
and some found no difference. So I think the jury’s still out on whether
we use near work. I certainly don’t think it hurts. I think that when the child’s patched if
they’re given something that they really like doing up close,
then that might distract them a little bit and keep them a bit more interested in
keeping the patch on. So I don’t think it hurts to be
recommending near work, but I don’t think it matters if they do
other things without the near… like patch on without near work as well. So what about recurrence?
This young fellow in my case definitely had a huge amount of recurrence. Every time he stopped
the Atropine, he would start decreasing in vision again. So the statistics are it’s between 13 to
24% of people will decrease by about two or more lines in the first year after
ceasing treatment. However, there’s no good evidence to
support the weaning of occlusion. Even though there’s no good evidence to
support the weaning of occlusion in young patients, I tend to do that. I’ll go from four hours a day to two hours
a day, to one hour a day while that vision is remaining stable to
one hour, every second day, to one hour a week, you know,
just so that they’re not stopping occlusion altogether. It’s when you stop occlusion altogether,
and they’re still in that period of time where they could become amblyopic that
they may recur a little bit. So what about the critical period? So we used to think that amblyopia could
only actually be treated up to about eight years of age and after that
we should abandon trying. But 50% of children in the 7 to
17-year-old age group will benefit from occlusion therapy. So it’s certainly something that you can
offer patients keeping in mind that they’ll need fairly aggressive occlusion
compared to if they were younger than seven.
And what about at Atropine? I never used to use Atropine but that was
because I wasn’t allowed to prescribe it when I first graduated. But now that I can, it’s a wonderful
second option, it certainly is something that once the drop’s in,
the child can’t pull the patch off. And it seems to work really well for
school-aged children. Because once again, after they’re seven,
you want to have more hours of occlusion. But that’s really, really hard with a
child that’s at school all day. At this age, children once
they’re at school, you can pop the drops in on a Friday afternoon after school,
spend most of the weekend really quite effectively Atropined. And then by the time they’re about
midweek, they’re seeing fairly normally, and they get most of their school week,
able to cope quite nicely. It blurs the vision to around 6/30. So that’s pretty rough if that’s your good
eye and your amblyopic eye is also about 6/30 that can be pretty poor vision. But fortunately,
it does work fairly quickly. And so it’s only a few weeks before the
child’s noticing that it’s not as difficult to cope. There is a gap in the research,
we need to have a little bit more research into whether it’s effective
for severe amblyopia. So if the child is worse than 6/30,
in their poor eye is this blurring them enough in the good eye
to actually make it work. And we also need a bit more
research for that older-aged child. So the take home message from this case is
we know which treatments are going to work. The trick is to get the parents to
actually agree to do them. And as this case illustrates,
it’s a long journey from the first diagnosis as a toddler to careful
maintenance as a teenager. And don’t be afraid to
ask for second opinions. As in this case, it took an optometrist
and two ophthalmologists to convince the parents of the right course of action. And now thank you very much,
are there any questions? – Great. So thanks so much
for your insightful presentation, Linda. That was a great way to get this
webinar started. And you guys out there listening,
we now have the opportunity for you to ask any questions, we’ll start
the discussion with Linda. So please feel free to use that question
box that we had last time, open for you and we’d love
to hear from you. So our first question that we have for
you, Linda, today is that you mentioned there’s a chance of recurrence in
amblyopia, how frequently do you review these patients? Is it is age-dependent or dependent
on the amblyopic factor? – That’s a good question because I
don’t know that I have a strict rule. I think it depends on how often
I’ve been seeing them originally. I can recall a case of a little tot who’s
about three, and I was seeing her every three months during
her amblyopia treatment. So I’ve continued to see her every three
months, until we get that stabilization of the vision, and then I’ll probably drop
it back to six months. – Okay, thank you, Linda. There’s another good question there. How do you decide what you’re going to
prescribe for infants or young children? – Once again, it depends on whether
there is strabismus there or not. If there’s no strabismus,
then you’re going to go for pretty much their dry retinoscopy because
we’re trying to provide good acuity. However, if there is a strabismus,
and it’s an esotropia, we want to give enough plus to actually
straighten the eye up. So I’ll probably go for more
the wet ret result in that case. – Great. That’s a good answer, Linda,
and there’s another good question for us. Do you use anything to aid binocular
fusion and stereopsis when you’re treating amblyopia? – So EG, opaque patching,
what do you think that next word is? – Blurring.
– Blurring the good eye. Look, when I was preparing this I actually
looked at a paper that was looking at opaque patching, and the results aren’t
quite as good as at Atropine penalization or total occlusion patching. But if it helps the patient cope better
and the other options aren’t working, then it’s definitely something that you
could do as part of your approach. Yeah, certainly wouldn’t say it was
something I would not do. – So we have another question. Is there a rule of thumb you use to
calculate the hours of occlusion based on age? – I generally start with four hours a
day, for children under seven, if they’re over seven, I’m going to
try and get them six to eight hours. If the amblyopia is moderate. If it’s very mild, then it’s going to be
slightly less than that. And if it’s very severe,
it’s going to be a bit more than that. So about four hours is my starting point
for moderate cases. – Great, Linda,
and how often would you consider doing a cycloplegic refraction in your follow-ups? – I must admit,
I generally only do cycloes at the start because I’m interested in what’s there. But I’m not so worried about
doing a cyclo at follow-ups. I’m really then trying to see
how much plus I can push to maintain good
vision, but still keep the eyes straight. – So we’ve had a few questions about
the percentage of Atropine that we’re using in amblyopic treatment. If you’d like to confirm
that for the audience. – It’s 1% Atropine. – Great.
And we’re just going through… we’ve got a lot of questions
coming up from you guys. So thank you for all the interaction
that’s going on. So we’ve got another question here from
Zara. “If you found that there was less plus gave better vision but did not
control the turn and more plus caused blur when a child is older,
which would you choose to prescribe?” That’s a quite complicated questions Zara,
so I’m glad you asked. – Yeah. So she’s gone for example,
right eye plus 2 giving 6/7.5 and the lift eye if we gave them plus 3 they’d
get 6/9 but still a left esotropia or plus 4 giving 15,
but only a 4 or no turn. Zara, I’d give it a plus 4,
we definitely need to control that turn. And in your example here their plus two is
still fine if it’s still getting 6/7.5 in the right eye. So they’re actually not going to notice
that that plus four gives slightly worse vision. What’s going to happen is that because the
eye is straight now that vision will quickly improve, especially with patching. – Great, thanks,
everyone for all these questions. And thank you again, Linda,
for your presentation and time tonight, it was great having you on board. We’ve got our next presenter
coming up now. And she’s from our very own alumni. So we’re very excited to have her here
with us today. We’ve got Hayley Birch. So Hayley graduated from the 2015 cohort
and is now working part-time as an optometrist and also part-time here
at Deakin University as a clinical skills tutor. – Hi, everyone,
hope you’re enjoying the webinar so far. So tonight, I’ll be delving into a bit of
pediatric optometry so myopia which is a hot topic at the moment. Just to give bit of background as to why
this is such an important area for us. A study in 2010 found that myopia
currently affects 1.9 billion people worldwide, so that’s about 28% of
the world’s population. But projected that by 2050, myopia will be
affecting almost 5 billion people. So that’s about half the world’s
population. So pretty significant figures when we
think about the pathology that can come along with myopia. So I’ll be talking you through an Ortho K
case study that I’ve had at my work. We’ve been fortunate enough to have most
of the evidence-based myopia control options available to us. And after recently purchasing a
typographer we’re able to do Ortho K as well.
So I think… beautiful. So our patient today is a 12-year-old
Caucasian male. He’s been seen in our practice for the
past six years. And currently, he’s about minus 3/2.5 in
both sides, with not much [inaudible]. The next slide I’ll show you is a table
of his progression bio so far. But before we delve into that,
I just thought we’d go over the sort of risk factors that we need to consider
in our young progressing myopes. So the first one being younger age of
onset, so anyone nine years old or less is at a higher risk. Parental myopia, so one parent will
increase your risk by about three times, and two parents six times risk. Other things that we know are common are
East Asian descent where 80 to 90% of the population are myopic. Any binocular vision dysfunction
particularly is esphoria and accommodative lag. And there’s also a consideration for time
spent outdoors versus time spent doing near work. So outdoor time less than one half hours a
day, or near work greater than two and a half hour a day can increase the risk. The mechanism behind that is a little bit
interesting so rather that being outdoors is protective, it’s not the activity
level, it’s rather associated with high alert levels. The lacks of natural light,
smaller pupils, [inaudible] accommodation, and [inaudible]
variation, which may be involved. So I’ve just popped up the table there of
his prescription year by year. So as you can see you back at age
seven, was when we first found him with mild myopia. And things just moved quite slowly,
only changing by 0.75 in the next four years. And then in May of last year, huge jump. So we had him 0.75 change
in about six months. Then again, another 0.75 change
six months after that. So in May 2018, we started talking about
myopia control as an option for this patient. But his parents opted to wait another six
months and see what happens and look what happened. So fast progression is generally defined
as a change of 0.75 or more per year. So as you can see there,
we’ve got about a 1.5 optic change in a year. So he’s going pretty quickly along there. So we talked about some good myopia
control options in November for this patient.
So I’ve put four up there. Others we’ve excluded, just based on
they weren’t suitable for this patient because of his presentation. He only had the young age of onset and one
parent with myopia, but his BB was totally normal. And he’s a reasonably active kid,
he has a lot of time outdoors and he’s not a big reader either.
So that was pretty good. So we gave him orthokeratology
as an option. Low dose Atropine, multifocal subcontacts,
he was already an existing spherical contact lens wearer. Or they can do nothing again and wait
another six months and see what happens. So out of those options,
I’ve just touched here a little bit on the efficacy of each of those,
and this is just pulling some figures from a meta-analysis. And some numbers also from the lovely
Kate Giffords’ papers she’s put out. So Ortho K and Atropine seem
to be fairly similar. There is a huge range of variance from
study to study about how effective each of these treatments are for myopia. Multifocal subcontacts a little bit
less and doing nothing obviously doesn’t help us very much
to control myopia progression. Other things that we think about,
of course, progressive addition lenses, so multifocals, executive bifocals,
and peripheral defocus specs, so [inaudible] vision. So we opted not to do any of those three
options for this patient because he doesn’t have esophoria
or accommodative lag. We don’t generally fit executive bifocal,
and a 12-year-old really didn’t want to wear it because of cosmesis. And we don’t have access,
unfortunately to the peripheral defocus spectacles. So the patient actually choose
orthokeratology, he loved the idea of being glasses-free during the day. As I said before, he was a big soccer fan,
so he thought it would be amazing. He currently played without glasses on and
remembering those are minus 3.25. So he was hoping to play a little bit
better with the lenses as well. So before we went ahead and agreed that
he’d be a suitable candidate for Ortho K, we had some primary criteria
that he had to meet. So I’ve just listed on here two sort of
areas of consideration. So to actually fit Ortho K,
and then other things that may be important. So myopia between 1 to 5 dioptre
is ideal. You can fit higher than that, but it becomes
a little bit more complicated. So certainly if you’re new to Ortho K, I
wouldn’t suggest you do that straight off the bat.
Corneal curvature. So we don’t want the eyes to be too flat
because there’s less cornea to flatten down and reshape in the middle. HVID about 11 millimeters which is about
average anyway, most people will have an HVID of 11 mill. Corneal eccentricity which relates to how
the apex of the cornea flattens or steepens all the way
down to the periphery. And that’s the value get off the corneal
typographer as an E value. So the higher it is, the more change there
is from the apex out to the peripheral cornea. Against-the-rule astigmatism starts out
at 90 degrees less than 0.75 dioptre cyl. With-The-Rule 1.50 and of course pupil
diameter comes into play as well. So if they’ve got bigger pupils, it’s more
likely that where the flattening of the cornea is happening may
cause a little bit of glare or halos, especially at night time. And then other things we’re thinking about
are the age of the patient. So doesn’t necessarily stop us from doing
if it the patient is younger. I know that there’s been some quite young
seven, eight-year- olds who have been successfully fit. We actually tried to fit a girl in her 20s
in practice, and she just couldn’t wear the lenses at all. So she, unfortunately,
didn’t go ahead with Ortho K. So maturity is a big thing, too. And this 12-year-old was very mature for
his age, he was excellent, great competency already with his soft
lenses, and good compliance in cleaning. So what do you need
to do Ortho K in your practice? I put right at the top there that a
corneal typographer is essential. In my opinion, I wouldn’t fit without it,
and you can, of course, fit empirically. This may be a little bit more difficult,
whether a keratometer might be a suitable option. But remembering that it only gives us that
central 3 millimeters, whereas a topographer gives you about
8 to 10 millimeters of cornea. You’ve got more accurate follow-up,
and you can do a few different graphs [inaudible] showing you how much
refractive change there has been. Helps you look at the centration as well. So other things that we all have access to
already is a baseline refraction, that’s fairly straightforward. Would a cycloplegic refraction
be arguably better? Yeah, possibly. We’ve had a couple of Ortho K
patients who we’ve given the lenses to and they’ve actually come up being a little
bit over-corrected in their glasses, and we’ve had to reduce
the power of the Ortho K. We’ve all got slit lamps, so
we’re able to do those precorneal checks. We can all measure HVID quite easily. And we’ve got awesome people at the ACL
and Gelflex who can really help us out. So for this patient,
we did the fitting of the lenses, and then a review after night one, week
one, month one, and three months later as well.
So this was his typography. So this was about two weeks in. So as you can see there,
just on the top left-hand side is before we’d done any Ortho K,
so that was sort of mid-November. And then this two is weeks later down the
bottom, just about three weeks on, so it’s just the first week of December there. And so you can see that
central flattening of the cornea. It does look on that graph like it’s
slightly [inaudible]. However, where those spots are is just
where the topographers filled in where it couldn’t read the placido
rings very well. And if you look at the colors down the
side, we can see we’ve had about of refractive change of 3.5 dioptres. And again, just reminding you that he’s
about a 3.25 to start with. With Ortho K, we’re aiming for them
to be about plus 0.50 in the morning. So we were pretty happy with that. All righty, and so here are just a couple
of things that I thought were quite interesting on my journey
of fitting Ortho K. So for some reason, I didn’t realize that
when you initially inserted the Ortho K lens that they would be able to see. I
thought they would have to wait a few nights before that cornea has been
reshaped before you get good vision. However, the lenses actually have
prescription built in so your patient should be 6/6 or better. And this will give you an idea of what you
could expect vision-wise, once Ortho K has finally set in. And the other thing that was interesting
too, is that the cornea changes. So it was first theorized that epithelium
cells actually migrated to the peripheral cornea. But new studies have shown that it
could be a change in the cytoplasm. That’s the sort of liquid that fills up
our cells so that being less dense in the center [inaudible] peripherally.
So that was interesting, too. So just to let you know how the patient is
going, after night one he was about 2 dioptres less myopic,
so only about a minus 1.25, now. So we just gave him some daily lenses to
get him all the way through the day. And then after, as I said, about two weeks
later, he was about 6/4.8 unaided, so really, really good vision,
with only a slight hyperbolic refraction in the morning.
And he’s maintained that since December. And so far pleased to report
there’s been no progression. So it is certainly early days for him. But going off his rate of progressing
1.5 dioptres in 16 months, we would expect about a 3.75 dioptre
progression in the 4 months since he was fitted.
And there has been no change. So that’s maybe all the
evidence we need so far. And that’s everything.
Thank you, guys. – And thank you, Hayley,
it’s been great to have you along, tonight and a great addition to our
pediatric webinar tonight. So again, it’s time to ask Hayley some
questions. If you have any burning questions about Ortho K,
we’d love to hear from you. To get started, Hayley, what advice would
you give one of the alumni members who’s looking to start getting into Ortho K? – So I think if it’s your own
practice, obviously, the best advice would be getting a corneal
typographer, if you don’t have one already. If you’re working with other optometrists,
perhaps speaking with your boss to see if that is an option as well,
that would be fantastic. But it’s definitely a good thing that we
should be giving our patients the opportunity to have. It works really well, there’s a lot of
evidence-base behind it. So I think just diving right in, picking
some patients that fit that criteria first would be really useful. So don’t do the most complicated patient
first, pick someone who’s a minus 1 to a minus 5, and has all those other
criteria that we like and go from there. – So when you first started,
did you have a patient in mind to offer it to them as an option?
– Pretty much. So we had that sort of criteria written
down in the back of our mind. And then as we saw patients pop up,
and they’re progressing myopes and they fit that, we gave
them the option there. So that’s pretty much how it started. And now we’ve fitted a few more in the
clinic that are high myopes and or just, you know, they just want the refractive
correction without being in glasses or being in subcontracts. They just want to be, yeah,
spectacle free during the day. – And here’s the big question,
I think how much does Ortho K cost? And you can talk about the range
the range that’s out there. – Yes, I look at my practice,
it’s $1,150. And that covers their lenses,
and all their follow-up treatments as well. So I think that’s a little bit less than
other clinics, I’ve seen them up to $2,000 at some practices in Melbourne. In terms of cost price,
the lenses will cost you about $300 a lens. So you’ve certainly got to think about
that when you’re starting out as well. So you’ve got to cover that baseline cost
and the chair time going on from there. – That’s great, Hayley,
really good. So we’ve got a question here about what
age range do you think is most studied. And I suppose that’s referring to Ortho K
in terms of controlling myopia prevention? – Yeah. So in terms of [inaudible] if
you’re talking about myopia progression, you want to get them while they’re young
and progressing. It’s interesting, nowadays,
we’re still seeing people with myopia progression into their 20s as well. And although there’s not a lot of research
to support Ortho K slowing down progression at that age range, it doesn’t hurt to give you patients the
option and to try. I am fitting currently at 24-year-old who
is progressing about 0.75 every 6 months as well, and she’s
doing really, really good. – So we also had a question about
whether you take IOP before you fit Ortho K and the effect that might have
on intraocular pressure? – Yes, certainly. So absolutely want to check
IOP before you start. It would be good to measure it, you know,
your corneal thickness once [inaudible] so there is that thinning of the
epithelium. It doesn’t change the thickness as much as you would expect. So it’s only about a mil overall,
depending on the level of myopia. Obviously, the higher levels it’ll be more
of a corneal of flattening there, too. So absolutely, check your
IOPs before you start. – And now we’ve had that long
discussion about Atropine [inaudible] is Ortho K now a preferred method for
controlling myopia when you talk to patients? – At the moment it is and only
because anecdotally, we’ve had quite a few patients who we’ve
had on Atropine for a long time, so six months to a year, and they’re still
progressing at the same rate. So in which case, we’ve opted to give them
the option of doing Ortho K, as well. – Okay, thank you so much,
Hayley, again for joining us. – You’re welcome
– That was an excellent addition, like I said, to our presentation,
and we look forward to seeing you at other Deakin alumni events in the future. – Thank you very much, Amanda.
Thanks, everyone. – So next up, we have joining us
Daniel Farrugia. – [Daniel] Farrugia.
– Farrugia. …get that one wrong. So Daniel’s worked in private
practice in Werribee for the last 14 years in Victoria. He supervises students in the
Deakin… University on their clinical residency placement. And he occasionally speaks to community
groups and students and has a lot of experience managing pediatric patients. He’s also hoping to get around to
finishing his [inaudible] fellowship sometime soon.
So welcome, Daniel, and I’ll hand it over to you. – Thank you. Thank you. So I’m actually presenting three cases,
I’m going to burn through these as quickly as I can. So I frequently get people referred to me
as being the second opinion, I thought that would be an interesting
take on things. Now, some of you will know who I am
that I’m involved with a Deakin course in some degree. So I put an obligatory photo of my family.
There I am with my wife. Don’t be fooled by how adorable my
children are, my eldest son is actually punching that plush koala in that photo. But there they all are,
so you can visualize me, I’m the one on the very left. So let’s look at PP,
who’s a 13-year-old female who was brought in to see us. So she’d been seen by another
optometrist who’d actually referred to us to possibly do some VT for this patient. So vision wasn’t great. She was having difficulty refocusing,
going from distance to near, sometimes getting double vision. And the referring optometrist thought the
best way to deal with that would be to do some VT. Now, there are my findings,
nothing particularly exciting there. Oh, have I gone backwards?
No, I have two. So when we did some of the BV tests there,
that’s what we were getting on blur function, reasonably,
steep AC/A ratio, there. I want to draw attention to we had a very
good PRC, MEM was a little bit tight. I probably should talk a little bit about
what a blur function is. Because my experience is that not a lot of
the students we have through actually know what one is. So I’m quickly going to talk about blur
function, I’m not going to read everything out there you can look at
the slides later. But it’s essentially a technique
where you put… you over-plus the person,
and then you wind it down until they get to 6/6. And then you do a balance between the two
eyes at that point when you get to 6/6. You can plot that on a graph. And it should look like that when you plot the lens power against the
minimum angle of resolution, which is not the log ma, it’s the…
before it’s had that conversion. It should be a straight line,
when it’s not a straight line, there’s something very wrong with what the
patient’s eyes are doing. So looking at that patient… I’m going to try and keep this as
interactive as I can. These are possible ways we could treat it.
Is it near point stress and you treat with a low plus
and a single vision near form? Is it near point stress and you treat it
with a low plus in multifocal with some Yoked prism? Or would you do the VT that the referring
optom. had suggested, or what you’re seeing is actually early
myopia and you should commence on myopia control options. Or maybe it’s E, what are you talking
about with near point stress. I’m going to take a little
tangent again for this. So essentially, near point stress theory
is a way of thinking about the visual system, as… basically,
it’s under stress, you get changes
that happen to try and allow the individual to cope with the
tasks that they’re having to do. It puts undue strain and concentration
that they have to exert. But then you get these long term
adaptations that happen over weeks and months to try and maintain function and you eventually get fatigue and
breakdown, which manifests as double vision and sore eyes, and in
some cases, avoidance entirely. So I could do a whole lecture on that,
but I’m just going to leave it with this little table. And you can basically classify it as
situations where you’ve got the patient being better at converging,
so they use that to try and drive the system. And you’ve got a lag and accommodation,
or vice versa with a bit of accommodating. So they accommodate to try and
drag the convergence in. So going back to our question,
how would you treat this patient? Well, I went with C.
No I didn’t, I didn’t go with C. I didn’t go with VT at all. Okay, I actually went with B,
that’s my bad. Sorry about that everyone. So I put them into a multifocal
with some Yoked prism. and they actually responded
pretty well to that. They were finding it easy to refocus. The patient really noticed when they
didn’t have their glasses, they noticed a difference. And their unaided acuity
was actually a little better. So there are the patient’s BV results,
they had a little bit less [inaudible] there. Now, these are all results
when they were unaided. So we’re comparing… the goal is that you’re
comparing like, for like. We were getting a bit of MEM unaided once
again, it was starting to look a little bit more natural there. And I didn’t do any VT
for that patient at all. So someone may ask
why we do Yoked prism. The theory behind Yoked prism is
that by shifting the image upwards, things that are close up look like they’re
actually a little bit further away. And so it reduces the stimulus for
accommodation and convergence. And so it’s generally advocated as a
way to treat an esodeviation at near. And now, in terms of the data on that,
there isn’t a lot that I can point to. Steve Leslie does a really nice summary
about everything to do with Yoked prism on the ACBO website. So if you’ve got access to that,
you can check it out. If you don’t, you can email me after the
presentation, and I’ll be happy to send that out to you. But there isn’t a lot of good evidence
that I can point to and say, yes, this is why it’s done.
Other than you shouldn’t go too much. And you shouldn’t go a little,
which is why I tend to do two base down Yoked. So the take-home message from this case,
I thought was, the person you’re referring to won’t necessarily do the thing you’re
asking for, and that’s okay. Because sometimes the reason you’re
referring them is because you’re not actually 100% sure what
you should be doing. So I have another case report,
which I’m actually just not going to do because we don’t have time for it. And it’s very similar to that first case.
It’s just a different flavor. This one is a bit more interesting. Now, you’ll notice this isn’t technically
a child, but it was interesting enough. And it was kind of dealing with similar
issues and I thought I’d include it. So this patient presented to me,
they’d been getting blur intermittently, far away, close up, it had been going on
for a while. They were getting sore eyes and burning eyes. Sometimes they got a headache,
sometimes behind their ears. And they had been seen by another
optometrist who was going to refer them on to an ophthalmologist. And with those sorts of acuities,
you can understand why because there’s nothing to see in this patient. They had unremarkable internals,
maybe a little bit of SPK, but certainly, nothing to reduce their vision to 6/120. They had on cover tests
at near, they had a left esotropia. But excursions were normal. The ret was really, really unstable,
and I couldn’t actually obtain a result. Now as a new graduate, you
might feel like, “Oh maybe I’m just not very good with this ret
and that’s why I can’t do it.” I never feel like that. If I can’t get a ret result there’s no ret
result to be gotten. So I was pretty confident that we were
just getting some really wet numbers because it seemed to be
swinging around everywhere. So what would you do?
Now looking down that list there, you might laugh at B,
but this case was presented as a clinical conundrum by one of
my students to a Deakin cohort. And the supervisor actually went,
“I don’t know what I’d do, maybe I’d just give a placebo.” And so I hope he was joking, I’m not sure. But that may be something
that someone considers. I can’t really do F if I’m going to refer
for another optometrist’s opinion, I’d probably go to an ophthalmologist at
that stage, particularly with pediatric stuff.
So I did D. So this is all basically everything that
I’ve circled, it’s going to be the one above because
it hasn’t transferred across. At least I can work out which one it is. So I did D, not E, I actually dilated her
with cyclo. And cycloplegia was magical,
where’s the slide? Oh, no. There it is. So I got her back on another visit,
and we found that with cyclo and her vision improved to 6/24
with my cycloplegic ret. Subjectively, we got her to 6/9
from 600, from 6/120. So clearly, there’s something really crazy
going on with this young woman’s accommodation when she’s not under cyclo. So this is what I gave her. I gave her
this really Mickey Mouse script with a really Mickey Mouse,
add a bit of Yoked prism, put in a multifocal form and said, “Okay,
I want you to wear this full-time.” I don’t often get kids
to wear their glasses full-time. But this was such a bizarre case
I thought I needed to. And we said we’d see her in a month,
and we saw her in a month. Now she’s saying that the vision still
goes blurry occasionally, not as often. But when it does go blurry,
it goes blurry for longer. Wasn’t getting any headaches
or sore eyes anymore. And the unaided acuity had improved to
6/60 in that left eye, which you might not be thrilled about. But I thought it was
a pretty big improvement. She was esophoric in the distance. Those of you who are paying attention will
note that I said esotropic at near. So those results don’t necessarily
contradict each other in terms of being an improvement. And now we’re actually able to start
getting some numbers with our ret. Left eye was still really unstable,
but at least we could get some measurements now. At three months vision with glasses had
improved to 6/9, at five months, she was 6/7. So this is one of those cases that we were
really happy with this. This young lady actually was in the
practice, I think only a couple of weeks ago, she’s doing fine. No regression, unfortunately,
at one of the visits to me, her dad found out that she dropped out of
her correspondence course at uni. But otherwise, she’s doing really well,
she did have to have a very serious discussion with her dad after that. So the take home message that I’ve got
from this is that adults can get BV issues as well. Children with BV issues that aren’t
treated become adults with more complicated BV issues. They can be more entrenched,
and because they’re entrenched, they take longer to resolve. The longer it takes for them to get where
they are, the longer it’s going to take them to recover. So one more, very much a child, case. So this is a very recent one for us. EL was brought into us after being seen by
multiple other optometrists with diagnoses including myopia, astigmatism,
and amblyopia. She had been prescribed glasses,
but she didn’t wear them. This was her unaided acuity.
Internals were pretty normal. Everything about her BV results was pretty
normal. No movement on cover test. But then with ret, we had a little bit of
minus in the dry ret. And subjectively, you know,
little bit of minus and still gave us an improvement but not much. Certainly not an amount
that you’d consider embryogenic. So what I want to point out, though,
is that when we were doing ret, we noticed a central opacity
in the red reflex. And so I don’t often get kids on the slit
lamp, I’m not ashamed to say that. I do when I’m concerned and
this was one of those times. So when we did that, we saw this. So we saw this area of little opacities in
the cornea centrally with… they were kind of bluish in appearance. It was really hard to get a look at them
because initially, she was very… she blinked a lot while we were having her
on the slit lamp, probably because I was shining a light into that opacity. And I initially thought it was a posterior
cataract, something congenital. But no, it was staining with fluoresceine. And so I went, okay,
maybe we’ll treat this as a dry eye. And my take-home message from this whole
case is #gdustoffyourret. This was a hashtag that Kate Gifford
champion at the SRC a year ago. And it is such an important piece of
equipment, I cannot stress enough how important is to do ret,
you find out things that you’re not going to find with an autorefractor or just
doing things subjectively. So I haven’t done a multiple choice for
this one because it was so wacky. I’m still not frankly,
sure exactly what we’re dealing with. But my tentative diagnosis is that it was
a Unilateral Thygeson’s keratitis because I thought it looked
a little bit like that. So we put her on if FML four times a day.
Saw her again in a week. In a week’s time, maybe the staining
looked worse, continued with FML… sorry two weeks, the staining was over a
larger area, but less concentrated in the middle. We saw her at three weeks and the staining
was small again, it was still less dense. We thought, great we’ve
kicked some goals here. But we were thinking maybe we’re getting a
bit of a toxic response with the FML. And the vision hadn’t really improved. So we switched to Genteal, which is a
fairly gentle lubricating gel three times a day. And we saw her at a month and the staining
looked better, but the vision was still 6/12. It wasn’t improving. And when I have these situations,
I start getting suspicious, so I’m going to do,
a topography map on this patient. And we saw this. And that is a crazy looking cornea there,
and you can kind of understand why she’s not getting 6/12,
and why we’re getting the cyl. So when I saw that I went, right,
let’s put an RGP on this patient and see what effect it has. Not for the long term,
just diagnostically. And when we did that,
we were able to improve the vision to 6/6. So at this point, I’m kind of fist pumping
the air because I thought… and I’ve sorted out what’s going on. We know that your child
doesn’t have amblyopia. And so, you know, we’re happy with this,
let’s just continue with the lubricants. And we’ll see you in three weeks. So we saw her at what was now the
two-month mark, vision still wasn’t great. Dryness didn’t…
like we still had this staining centrally. And at this point… so meanwhile, the parents have been coming
in with their other daughter, who’s a doctor.
I didn’t mention that at the start. This is something that’s come in recently,
and they’ve decided, look, we want to see an ophthalmologist for a
second opinion, just for our own peace of mind, we understand
that things are okay. But you know, having said that,
they still said we want to come and see you again in three weeks time to get you
to do the follow-up, but they just wanted this extra opinion.
I completely respect that. So when she saw the ophthalmologist,
the ophthalmologist really didn’t have anything to add, she did do a corneal swab
to rule out infective keratitis, which is negative. She was on the fence about the Thygeson’s,
but acknowledged that it could look different at the initial presentation. And said, just keep doing
what you’re doing. Go and see, Daniel. So the take-home message from this one
really is dust off your ret. And children can have pathology as well. Now, I saw this patient yesterday,
and she hadn’t really gotten much better. But at that visit, the doctor sister said,
“Could it be an allergy?” And I said, Are you getting any itching? “No,” you’re not getting any itching,
probably not an allergy. The opthal had mentioned
maybe it was an allergy. Then after I had a look at her inferior
lid and inverted it, I went, “That could be mild papillae.”
Let’s try treating that. Then the sister who’s a doctors
volunteers, “I had the same thing as a child, vision dropped in one eye,
didn’t have it treated properly until I started getting the itching. And then we treated it as hay fever
and it got better.” And all I could think was, “Why didn’t you
volunteer this to me when we started? This could have been
a much shorter process.” Anyway, so yep, children can have
pathology too, make sure you use your ret. It does tell you a lot more than just
giving you a refraction and a number. Sometimes you can see stuff that
you would otherwise miss. So thank you very much. There’s my email address if you want to
get copies of slides from me, and I think we’re going to take some
questions now. – Yeah. Great.
Thanks so much for that presentation, Daniel, it was very
interesting, indeed. So if you have any questions for Daniel,
we’d love to hear from you. We’ve got a question first up for Daniel. “You’ve mentioned that for near point
stress, you prescribe vision therapy. Can you describe the regime that you would
use for this type of treatment?” – I try and avoid VT whenever I can
because I’m a time-poor parent and I try and do the thing that’s going to
get the best results because it requires the least work from the parent. But when I do do VT, it is always
because the patient has convergence insufficiency,
they have an exo-type deviation because that’s been shown to respond
really well to VT. I think, if you’re trying to do stuff for
accommodation, or for an esodeviation, I think you’re going to be
struggling to make that work. And oddly enough, that first case that I
was referring to the patient did have an esodeviation. So there really was no indicator for VT,
so for him or her I can’t remember anymore. But we do stuff with Brock string,
making them more aware of the… giving them an awareness of diplopia. But you know, Brock string is probably
your bread and butter for doing convergence training.
– Okay, great. And how do you decide exactly how much
plus that you give a patient when prescribing in near eye? – I get asked this by students all
the time. I generally would err rewards plus 0.7. That’s my kind of baseline
measurement; I’m going to give plus 0.75 for a child. If they have a tendency to
over-accommodate, you might want to ease back on that a bit. There have been a few patients that I’ve
needed to go a bit more than that. I’d say, take your ret out, do a near ret,
and try your proposed add in a trial frame and see what that does to
what the reflex looks like; whether it changes their position of
focusing, and use that to guide what you would go with. – That’s great.
Thanks so much, Daniel. And that’s probably all
we have time for tonight. So thank you very much for your
presentation today, we really enjoyed it. And everyone, we’ll just tidy up
with some housekeeping now. So what we do have to bring to you is the
next alumni event, which will be happening on the 14th of June.
So that will be our annual reunion and we’d love to see you there.
So stop by if you’re in town. It’s going to be at Blackman’s Brewery
this year again because we had such a fantastic time last year. So pop that in your calendar. And there’s also an opportunity for people
who graduate in 2015 and 2016, to get involved in our
clinical residency program. So to become a supervisor,
if you’re interested, send David Hammond or myself an email just
to register your interest or see what else is involved. It has changed a bit since you guys
would h ave gone through the program, but we’d love to hear from you,
even if it’s just to flag interest. So now the benefits of being involved is
that you do get access to the Deakin University website. So the library, all its resources, the
optometry and ophthalmology journals. You get recognition amongst your peers
that you’re going to be a supervisor. And this year, we’re also offering a
mentor training program. So that can be related to staff at the
optometry practice as well as students that you’re involved in.
So a good thing to pop down in your CV. And of course, that satisfaction and
recognition that you’re involved in the course again.
So we’d love to hear from you. We’re all about alumni,
supporting alumni here at the alumni committee. So let us know your ideas for the next
webinar. We’re going to be sending out a Survey Monkey feedback survey to you guys,
and we’d love to hear what you’d like to get… showing
at the next webinar. One thing I heard the other day was
diplopia was a topic which could be fairly interesting. So there’s anything else that scratches
your brain, let us know. Also, we’d love to hear from you if
you’re doing some interesting research or you’re involved in a project that other
alumni members might benefit from hearing from because we want this to be a platform for
you to get involved and get some recognition in what you’re doing, too. So finally, we come to
InteDashboard. So this is what we’ll be using for
your CPD activity for this webinar. So you’ll get two points
for the CPD activity. But completing this quiz means that you’ll
get that extra point, so a total of three points. Like I said, you’ll have received an email
from InteDashboard at the end of last week. If you’ve lost that, check your trash
file or your junk mail file, and if you’re totally at a loss you can
contact one of us here Jack, Lacey, Ash or myself and we can reset your
password for you. But remember, we’ll be using this moving
forward for all our optometry alumni events and even any CPD events
at Deakin University. So if you are registering in future
events, please use the same email address and that means you won’t have to create a
new password every time you sign up, and we can use the same one. So thank you again,
everyone, for joining us. It was fantastic to have you all here and
we’re looking forward to next time. Until then.

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