Dr Vincent Lee - News

Recent Publications in Glaucoma

Mon, 29 Dec 2025 23:25:17 GMT

clement_et_al_longitudinal_outcomes_of_istent_inject.pdf
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tan_et_al_impact_of_different_intraocular_pressure_and_medication_endpoint_criteria.pdf
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Should eye care professionals be wearing Personal Protective Equipment?

Sun, 05 Apr 2020 02:09:54 GMT

In the current CoVid-19 situation, many may be wondering how far we go in protecting ourselves and our staff in our day-to-day work. Some of us remain in operation, seeing urgent cases and this may involve patients with acute problems including red eyes, epiphora, allergies, "conjunctivitis" and other ocular presentations which themselves may be a small part of the spectrum of symptoms experienced by patients with CoVid-19. Or, these or other symptoms, may co-exist in patients who have more mainstream features of the disease (hopefully, these latter patients would have been screened out by procedures detailed in my previous post, and have been referred to the local hospital for further assessment).

In any case, what protective equipment should we be donning to shield ourselves from potential infection?

The following is information from RANZCO, which I think applies to most Optometrists in the South West and Western Districts of Victoria, most of whom practice clinical Optometry to an extent that, I think exposes you to some risk. Hopefully you will find this of some help (for 'ophthalmologist', read 'optometrist'):

When should I use PPE?
The use of PPE by ophthalmologists seeing asymptomatic patients remains contentious. Thus far the Australian Government Department of Health has only recommended use of PPE for healthcare workers caring for suspect or confirmed COVID-19 cases. New Zealand has similar advice. There is strong evidence from other respiratory viral epidemics that wearing PPE (including mask and eye protection) minimizes the risk of infection.1-3 It is likely ophthalmologists are at higher risk of being infected by SARS-CoV-2 compared to the general population. This is based on the following:

1. COVID-19 is known to cause conjunctival congestion. In a large Chinese cohort of 1099 patients with laboratory confirmed COVID-19, this was reported in 0.8% of patients.4 In a smaller cohort from Hubei, China, 12 out of 38 (31.6%) of COVID-19 patients had ocular manifestations consistent with conjunctivitis. 5

2. SARS-CoV-2 has been isolated in tear and conjunctival secretions (although this is infrequent and one study failed to detect it in tears of 17 patients with COVID-19). 6

3. The virus has shown viability in aerosols for hours and surfaces for days.2

4. Infected patients can be asymptomatic. 3,7,8. In a testing of the entire population of Vo, Italy, almost 3% of residents tested COVID-19 positive and most were asymptomatic.9 In Yokohama, Japan, within a cruise ship holding 3711 passengers, 634 passengers tested positive for COVID-19. It was estimated that 17.6% of these were asymptomatic.10 One paper has suggested an undocumented infection rate of up to 86%. 11

5. Ophthalmologists come into close contact with our patients, closer than the 1.5m or 2m social distancing that is being recommended by the Australian and New Zealand governments respectively. This occurs at the slit lamp and for longer periods whilst operating.

6. Ophthalmologists have died from COVID-19, and at least 3 from the Central Hospital of Wuhan, including one after contact with an asymptomatic patient.11-14

Given the fact that ophthalmologists may themselves be asymptomatic carriers and see multiple patients, mask-wearing may prevent infection of patients. This is particularly relevant for our patients who tend to be older and co-morbid (the most vulnerable to COVID-19).

A retrospective review of 493 medical staff at Zhongnan Hospital of Wuhan University found none of 278 staff became infected by SARS-CoV-2 when wearing N95 respirators versus 10 of 213 staff who were infected when they did not wear a mask. This is despite the fact that the non-mask wearers worked in departments that were considered to be of lower risk than the group that wore N95 masks (who worked in the Departments of Respiratory Medicine, ICU and Infectious Disease).15

Surgical masks are currently recommended for ophthalmologists seeing asymptomatic routine patients in the following countries: USA, UK, China, Italy, South Korea and Singapore.16 They are recommended in some, but not all Local Health Districts in Australia for health care workers caring for patients in a vicinity closer than 1.5m.

When face to face consultations are required, ophthalmologists are advised to use their own judgement regarding use of PPE in asymptomatic, routine patients. They should be able to assess infection risk on a case by case basis, taking into consideration RANZCO guidance about how to assess patients, and be permitted to wear their own PPE if they feel this is clinically justified. Any decision should acknowledge the need to preserve critically low supplies of PPE in Australia and New Zealand.

References
1. Yu Jun IS, Anderson DE, Zheng Kang AE, et al. Assessing Viral Shedding and Infectivity of Tears in
Coronavirus Disease 2019 (COVID-19) Patients. . Ophthalmology 2020.
2. van Doremalen N, Bushmaker T, Morris DH. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med 2020 2020;28.
3. Lauer SA GK, Bi Q, et al. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med 2020;10.
4. Guan W, Ni Z, Liang W, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020;28:28 2020.
5. Wu P, Duan F, Luo C, et al. Characteristics of Ocular Findings of Patients With Coronavirus Disease 2019 (COVID-19) in Hubei Province, China. JAMA Ophthalmology 2020.
6. Xia J, Tong J, Liu M, Shen Y, D G. Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection. J Med Virol 2020;26:26.
7. Lee K, J. Coronavirus kills Chinese whistleblower ophthalmologist. American Academy of Ophthalmology 2020.
8. Bai Y, Yao L, Wei T, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. . Jama;21.
9. Crisante A, Crisone A. Coronavirus outbreak: In one Italian town, we showed mass testing could eradicate the coronavirus. Guardian 2020 8/03/2020.
10. Mizumoto K, Kagaya K, Zarebski A, G. C. Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship, Yokohama, Japan, 2019. Euro Surveill 2020;25.
11. Cai J. Wuhan doctor who worked with whistle-blower Li Wenliang dies after contracting coronavirus on front line. South China Morning Post 2020 03/03/2020.
12. Parrish RK n, Stewart MW, Duncan Powers SL. Ophthalmologists Are More Than Eye Doctors-In Memoriam Li Wenliang. Am J Ophthalmol 2020;;09.
13. Green AL. Obituary Wenliang. Lancet 2020;295.
14. Global Times 2020 09/03/2020.
15. Healthcare Infection Society. Association between 2019-nCoV transmission and N95 respirator use. Journal of Hospital Infection. Letters to the Editor 2020:2020. https://doi.org/10.1016/j.jhin.2020.02.021
16. Li J, Shantha J, Wong Y, et al. Preparedness of Ophthalmologists during and beyond COVID-19 pandemic. Ophthalmology 2020.

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COVID-19: Update for eye care professionals

Sat, 07 Mar 2020 07:13:55 GMT

I share with you some important eyecare-specific information, from the American Academy of Ophthalmology and the Royal Australian and New Zealand College of Ophthalmology, related to the novel coronavirus, referred to as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The highly contagious virus can cause a severe respiratory disease known as Corona Virus Disease - 2019 (COVID-19). (My region-specific advice for South West and Western Victoria are included in red))

Background information on COVID-19:
Symptoms can appear as soon as 2 days or as long as 14 days after exposure.
The virus is believed to spread primarily via person-to-person through respiratory droplets produced when an infected person coughs or sneezes. It also could be spread if people touch an object or surface with virus present from an infected person, and then touch their mouth, nose or eyes. Viral RNA has also been found in stool samples from infected patients, raising the possibility of transmission through the fecal/oral route.
There is a possibility of asymptomatic transmission. A Feb. 21 report in JAMA details a case of an asymptomatic carrier who possibly infected 5 family members despite having normal chest computed tomography (CT) findings. These reports, however, are preliminary.

What you need to know

Several reports suggest the virus can cause conjunctivitis and possibly be transmitted by aerosol contact with conjunctiva.

Patients who present to ophthalmologists/optometrists for conjunctivitis who also have fever and respiratory symptoms including cough and shortness of breath, and who have recently traveled internationally, or with family members recently back from overseas, could represent cases of COVID-19.

Countries and regions considered to pose a higher risk of COVID- 19 transmission

As of 4 March 2020, the Australian Government Department of Health has named the following countries as being of higher risk of COVID-19:
• Mainland China
• Iran
• Italy
• South Korea

Those at moderate risk are:
• Cambodia
• Hong Kong
• Indonesia
• Japan
• Singapore
• Thailand

As the new evidence is emerging, information regarding current countries and particular areas within those countries of concern can be found at:

Health Alert Travelers and Visitors

COVID-19 countries

Steps to take:
1. Routinely ask all patients before their appointment and again on arrival at the practice:

a. if they have returned from any of the countries, listed above, affected by outbreaks of the coronavirus (COVID-19) in the past two weeksand

b. if they have respiratory symptoms (note: symptoms may occur between 2-14 days after infection - this means asymptomatic patients cannot be excluded)

2. Follow all recommended guidelines for protecting yourself and protecting your work environment against infection. Click button below

Guidelines Infection Control

Note: Symptoms can appear 2-14 days after exposure. Ask patients if they have symptoms suggestive of COVID-19 including fever, respiratory symptoms (cough, sputum, shortness of breath), fatigue, myalgia, headache.
Most patients presenting with viral conjunctivitis will have adenovirus. However, a study by Guan W et al. indicated conjunctival congestion was present in 0.8% of the Chinese cohort of 1099 patients with laboratory confirmed COVID-19. There is some evidence that the virus can cause conjunctivitis and be spread by aerosol contact with conjunctiva. (AAO, Xia et al.).

a. Non-urgent eye problem

Patients with a non-urgent eye problem who have travelled in a higher or moderate risk COVID-19 country within the last 14 days
OR
Patients who have been in close contact with a confirmed case of COVID-19 in the last 14 days
OR
Patients with symptoms suggestive of COVID-19

Should have their eye appointment postponed for 14 days until COVID-19 has been excluded.
The patient should be referred to an appropriate clinical centre for testing (South West Health Care Warrnambool, Colac Area Health or Western District Health Service Hamilton).

The current interim advice from the Australian Government Department of Health (click link below) suggests:

Telephone the doctor or hospital emergency department to notify the patient will be referred
If the patient experiences severe symptoms, call 000 and advise the operator that the patient is in self-quarantine because of COVID-19 risk.

Outpatient Care of suspected or confirmed cases

b. Urgent eye problem

Ophthalmologists/ optometrists seeing a patient with an urgent eye problem who is at risk or has symptoms suggestive of COVID-19 will need to use their discretion to triage the relative urgency of each condition.

i) If the eye condition can wait, the patient should be referred to an appropriate clinical centre for testing (South West Health Care Warrnambool, Colac Area Health or Western District Health Service Hamilton). See above link for guidelines on referral

ii) If the eye condition cannot wait (*see note below), the current interim advice from the Australian Government Department of Health should be followed including:

Immediately give the patient a N95/P2 (surgical if N95/P2 is not available) mask and ensure they put it on correctly.
Direct them to a single room, whether or not respiratory symptoms are present.
If this is the first contact with a health care provider, contact the local public health unit or state/territory communicable disease branch for advice if you are uncertain about the need for testing.
Standard precautions, including hand hygiene (5 Moments), should be observed for all patients. Patients and staff should observe cough etiquette and respiratory hygiene.
Contact and droplet precautions should be used for clinical assessment and collection of specimens from a patient under investigation.
Perform hand hygiene before putting on Personal Protective Equipment (PPE):
gown, gloves, eye protection (goggles or face shield) and N95/P2 mask. All assistants should do the same.
To collect eye swabs, stand slightly to the side of the patient to avoid exposure to respiratory secretions, should the patient cough or sneeze.
After the consultation, remove PPE and perform hand hygiene.
Any contacted/contaminated surfaces should be wiped with detergent/disinfectant by a person wearing gloves, surgical mask and eye protection.
Note that, for droplet precautions, a negative pressure room is not required, and the room does not need to be left empty after sample collection.

iii) Any patient with severe symptoms suggestive of pneumonia should be transferred to and managed in hospital. Call 000 and advise the operator that the patient is in self- quarantine because of COVID-19 risk.

*NOTE: I expect that most, if not all, Optometry (and Ophthalmology) practices will be unable to implement the above procedures and as such, my advice is to refer all suspected patients (ie those at risk or who have symptoms suggestive of COVID-19) to an appropriate clinical centre for testing (South West Health Care Warrnambool, Colac Area Health or Western District Health Service Hamilton). The eye problem can then be assessed and treated at a facility where all the appropriate resources are available.

References

Guan,W,Ni,Z,Liang,W,Ou,C,He,J,Liu,L,Shan,H,Lei,C,Hui,D,Du,B,Li, L. Clinical Characteristics of Coronavirus Disease 2019 in China" (2020) The New England Journal of Medicine. Feb 28, 2020. DOI: 10.1056/NEJMoa2002032 https://www.nejm.org/doi/full/10.1056/NEJMoa2002032
American Academy of Ophthalmology: https://www.aao.org/headline/alert-important-coronavirus-context
Xia J1,Tong J1,Liu M1, Shen Y1,Guo D1. Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection. J Med Virol.2020 Feb 26. doi: 10.1002/jmv.25725. [Epub ahead of print]. https://www.ncbi.nlm.nih.gov/pubmed/32100876
World Health Organisation: https://www.who.int/health-topics/coronavirus
Australian government: https://www.health.gov.au/resources/publications/interim-advice-on-non-inpatient-care-of-persons-with-suspected-or-confirmed-coronavirus-disease-2019-covid-19- including-use-of-personal-protective-equipment-ppe
www.health.gov.au
https://www.healthdirect.gov.au/notification-of-illness-and-disease

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Here today, gone tomorrow...

Sat, 15 Feb 2020 00:09:24 GMT

I report two interesting cases referred to South West Eye Surgery

CASE 1:
A 38 year old woman was referred by her Optometrist with symptoms of flashes and floaters in her left eye over the previous 10 days. There was no reported reduction in vision and her Optometrist observed a small temporal retinal haemorrhage and left choroiditis. She had been well and reported no prior illness.

The patient's visual acuity was measured at 6/6 in both eyes. Her fundus examination revealed a small left retinal haemorrhage in the far left temporal periphery and multiple small flat white lesions in the posterior pole outside the macular area in the left eye.

Fundus photography showed the lesions to be hyperautofluorescent and revealed further lesions, not easily seen on clinical examination and colour photography, extending out into the mid-periphery and mainly in the left eye.

A fluorescein angiogram was performed and this showed early hyper fluorescence of the punctate lesions with late staining. There was also some staining noted in the left disc in the late frames of the angiogram.

CASE 2:

A 32 year old South American primigravid woman presented to her GP at 23 weeks gestation with a 5 day history of a left central visual field defect, associated with a mild headache occurring at the end of each day. This patient was a moderately severe myope with an -8.00 dioptre correction. She reported that she had suffered from a mild head cold about two weeks before.

Visual acuity was 6/9 right and 6/60 left, corrected.

The left fundus contained multiple grey/white spots in and around the macula and surrounding the left optic disc.

Fundus autofluorescence demonstrated a mix of central hypo-autofluorescent and peripheral hyper-autofluorescent lesions affecting the posterior pole on the left.

The Optical Coherence Tomography scan revealed subretinal fluid around multiple dome shaped hyper-reflective lesions in the subretinal space.

DIAGNOSIS, TREATMENT AND CLINICAL COURSE:

Both patients were diagnosed with Multiple Evanescent White Dot Syndrome (MEWDS) and managed conservatively.

At 2 week review, Case 1 reported no more photopsia or floaters and vision remained 6/6 bilaterally. In Case 2, by 2 weeks, vision had improved in the left eye to 6/9 and, by week 4, was back to 6/6 corrected. The central scotoma fully resolved.

Multiple Evanescent White Dot Syndrome (MEWDS):

MEWDS is one in a group of white dot syndromes. It was first described in 1984 by Jampol and colleagues (1).

It is thought to result from inflammation of the retina and choroid of unknown cause. It occurs commonly in otherwise healthy, young, myopic females. Typically, it has an acute presentation in one eye, but bilateral cases do occur rarely. In a third of cases, there can be a preceding viral-like illness.

The retinal haemorrhage in Case 1 is a rare associated feature in MEWDS.

The syndrome is self-limiting and the prognosis is excellent. Most patients recover full visual acuity and visual field over a period of one to two months. Extremely rarely, chorioretinal scarring and choroidal neovascularisation or progression to AZOOR (acute zonal occult outer retinopathy) can occur (2).

Jampol, Lee M. “Multiple Evanescent White Dot Syndrome: I. Clinical Findings.” Archives of Ophthalmology 102, no. 5 (May 1, 1984): 671. doi:10.1001/archopht.1984.01040030527008.
Fine HF, Spaide RF, Ryan E H Jnr et al. Acute Zonal Occult Outer Retinopathy in patients with Multiple Evanescent White Dot Syndrome. Arch Ophthalmol 2009;127(1):66-70

Further reading:

MEWDS

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A mulberry in the bush

Wed, 27 Nov 2019 13:00:00 GMT

An otherwise well 65 year old man, during a routine examination for spectacles, was found by an Optometrist to have a lesion in the right fundus that had not been previously documented. There was no relevant past history of any ocular or systemic conditions.

The lesion appears raised, white and multinodular, with a scalloped edge and patchy calcification - reminiscent of optic nerve head drusen, but in a peripheral location.

On OCT, the lesion appears to have a multi cystic structure, each "cyst" consisting of a hyper reflective edge, casting an optical shadow, with an optically empty centre.

This is a typical astrocytic hamartoma or "mulberry lesion" - a benign retinal tumour composed of glial cells (connective tissue cells of the nervous system), predominantly astrocytes. It can occur singly or in multiple locations. It is most often associated with tuberous sclerosis (TS) or Bourneville's Disease, but may also be found rarely in patients with neurofibromatosis. Although the finding may point toward a systemic association, it can also be found incidentally on retinal examination as an idiopathic and spontaneous lesion, as in this case.

Apart from recommending the patient have his retina examined periodically in the future, no treatment was required.

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RANZCO Congress 2019

Thu, 07 Nov 2019 13:00:00 GMT

The 51st Annual Congress of the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) was held in Sydney over 5 days in November. Celebrating the 50 year anniversary of RANZCO, the meeting showcased top national and international speakers delivering topics covering current and emerging practices in eye disease diagnostics, technology, surgical and medical treatment, including gene therapy. Highlights included presentations on the Bionic Eye* project at the Centre for Eye Research Australia (CERA) and the evolution of laser treatment in the eye, by Prof John Marshall, inventor of the excimer laser used in refractive eye surgery and of the new sub threshold nanosecond laser, or 2RT, now in use for treatment of dry AMD and diabetic macular swelling.

*Associate Professor Penny Allen is delivering the 2019 Gerard Crock Lecture on the Bionic Eye Project on Thursday 21 November in Melbourne. To register for this Free Event click this button:

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Blurred awakening

Wed, 06 Nov 2019 13:00:00 GMT

A 21 year old male was referred to South West Eye Surgery by his GP with blurred vision and a central visual field defect (a blurred patch) in his right eye. He had awoken 2 days previously with a headache, fatigue and bloodshot eyes.

On examination, visual acuities were Right 6/12 and Left 6/5. He had bilateral conjunctival hyperaemia (red eyes), but little anterior or posterior uveitis (internal eye inflammation) of note.

The ultra wide field fundus picture showed subtle grey/white lesions inferior and temporal to (below and to the next to) the macula in the right but also in the left eye. There was associated elevation (lift or detachment) of the retina below the macula on the right.

There were no autofluorescence features of note, other than the overlying retinal folds consistent with a neurosensory (a layer of the retina) detachment beneath and involving the right macula.

Optical Coherence Tomography revealed sub retinal fluid (fluid under the retina) on the right, causing a serous neuroretinal (the nerve layer of retina) detachment.

Intravenous fluorescein angiography showed early hyper fluorescent lesions that later enhanced and leaked fluorescein, associated with an intensely hyperfluorescent left optic disc (injected dye leaked into the areas of the eye affected).

The patient was immediately admitted to hospital and commenced on intravenous methyl prednisolone. He made a rapid recovery and by day 3 of his hospital stay, his right vision had improved back to 6/5 and repeat scans showed steady resolution of the fundal lesions and sub retinal fluid.

The diagnosis is Vogt-Koyanagi-Harada disease - a systemic illness resulting from inflammation around melanocytes (the pigment producing cells of the body), melanin (the body's pigment material) and retinal pigment epithelium (a support layer of the retina). It is thought to be an auto-immune disease in which some of the body's white cells (T-cells) attack areas in which these cells and material exist. Therefore, patients develop problems in their skin (vitiligo, alopecia), ears (hearing loss) and eyes (inflammation, and vision loss). Urgent treatment with immune-suppressant agents is required to prevent permanent loss of vision.

The patient is now on a reducing dose of steroids over the next few months and is looking forward to a full recovery, but may require long term immune suppression.

Fore more information on V-K-H disease, click the button below:

V-K-H disease

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EURETINA Congress 5-8th September

Sat, 07 Sep 2019 14:00:00 GMT

I attended the 19th Congress of the European Society of Retina Specialists in Paris, early this month.

A gathering of the top minds from Europe, USA, Asia and the rest of the world in the stunning setting of the City of Lights, made for an enlightening meeting .

The latest research work and technologies were brought to the fore. New treatment paradigms were debated and consensus reached on the most effective therapy for the most common retinal diseases.

I was invited to the 2RT (Subthreshold Nanosecond Laser) User Group Meeting and was the only Ophthalmologist to represent Australia. The meeting was chaired by Prof John Marshall, inventor of the 2RT laser (as well as of the excimer laser, commonly used in LASIK, PRK and FLACS) and was attended by about 10 Ophthalmologists hailing from France, Switzerland, USA and Canada. Current and future applications of 2RT were presented as well as results obtained by individual practitioners.

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Warrnambool Winter Symposium

Wed, 21 Aug 2019 14:00:00 GMT

It was a privilege and a pleasure to host the Warrnambool Winter Symposium on the 22nd of August 2019. A gathering of 20 regional optometrists (representing all the Optometry practices in the Southwest and Western Districts of Victoria), clinical staff and industry representatives assembled for a cosy dinner on a cold August evening, at the Lady Bay Hotel Warrnambool, to hear about the latest developments in treatment of Age-related Macular Degeneration (or AMD, as well as Diabetic Macular Oedema and Retinal Vein Occlusions) and Refractive Surgery. The meeting was approved for 2 CPD points by Optometry Australia.

Symposium attendees were brought up to date with the imminent arrival of more efficient, quicker and longer acting antiVEGF drugs, as well as slow release devices which promise less frequent visits to the ophthalmologists rooms for ongoing treatment. The advent of modern antiVEGF treatment has made possible rapid gains in vision in diseases resulting in swelling of the macula. This treatment is able to maintain visual improvement indefinitely in the vast majority of patients. However a commitment to ongoing therapy is required creating a heavy burden on patients, carers, eye practitioners and the heath care system. I discussed some of the current research in AMD, which now centres around methods of reducing the burden of treatment (which involves repeat visits for eye injections).

I was also delighted to present recently released research data about 2RT (Retinal Rejuvenation Therapy), one of the more exciting developments to emerge in the last 12 months. This new sub-threshold nanosecond laser treatment can reduce or even potentially eliminate the need for eye injections. Attendees were interested to learn about the recently published results of the LEAD Study which showed a decrease in the progression of Dry AMD after treatment with 2RT laser in the majority of patients with AMD. Although not all patients with AMD are suitable for this treatment, the majority of those with intermediate dry AMD, without more severe retinal changes, are nearly 80% less likely to advance to the late stages of AMD, including wet AMD.

While we look forward to the arrival, late next year and beyond, of more efficient therapies to reduce the burden of ongoing eye injections for wet AMD, sub threshold restorative nanosecond laser in the form of 2RT is now available in South West Victoria and many patients have availed themselves of this therapy, since its introduction in April 2019

On a different note (and over dessert), I presented symposium delegates with information about 2 new refractive surgery options now available locally, that free patients from having to wear glasses, contact lenses or spectacles.

The Intraocular Collamer Lens (ICL), also known as the Intraocular Contact Lens or Phakic Intraocular Lens - a thin lens inserted into the eyes of younger people - has had the benefit of many years of development. It was recently implanted, for the first time in South West Victoria - this patient now no longer needs to wear the thick spectacles she has worn since she was a young girl. While laser operatio,ns like LASIK and PRK have been used in the past, ICL surgery has distinct advantages, the most important of which are the increased quality of vision and reversibility of the procedure (the implant can be removed and/ or replaced, though this is hardly ever needed).

Finally, I introduced the audience to the IC-8 - a new small aperture lens implant that improves depth of focus over conventional multifocal lenses used in cataract surgery. The IC-8 increases contrast sensitivity and reduces glare symptoms, yet allows patients to enjoy a smooth transition of vision in the near to intermediate range. It can be more confidently used in individuals who have previously had laser refractive surgery (such as LASIK and PRK) in whom conventional multifocal lenses can prove problematic.

For further information regarding some of the topics above, click the links below:

2RT

ICL

AMD

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Diabetic Retinopathy Insight Meeting

Mon, 29 Jul 2019 14:00:00 GMT

I was invited to present a lecture on the management of Diabetic Retinopathy (DR) at the Lady Bay Conference Centre at the end of July. The meeting was attended by GPs in Warrnambool and surrounding districts, as well as industry representatives.

The intent of the DR Insight meeting is to accelerate awareness amongst General Practititioners about DR screening pathways in primary care settings. Welch Allyn and Mylan Pharmaceuticals, as part of the Keep-Sight program https://www.keepsight.org.au/, host multiple educational events across regional Australia. The educational events include a presentation delivered by an Ophthalmologist and an Endocrinologist (Dr Shannon McCarthy, Epworth Geelong) along with hands on experience with the RetinaVue device to increase awareness of DR screening & demonstrate the unique telehealth component of the RetinaVue camera.

Meeting Objectives
The objective of these educational meetings is to:

Clarify GP’s role in screening & treatment of the diabetic patient
Educate GPs on specific DR treatment options
Establish the impact of early intervention, screening and treatment
Encourage GPs to screen patients at the point of consultation

I had the opportunity to see and use the RetinaVue - it is a compact device with excellent ergonomics and importantly, provides a clear image of the central retina. It is geared to easily display the image to the practitioner to enable ease of screening and can be transmitted to specialists as part of a telehealth consultation, if required. The pictures can conveniently be captured by non clinical staff using the RetinaVue and stored in the patients' electronic file to be viewed by the GP during the subsequent consultation. There is now Medicare funding for retinal imaging by GPs to facilitate the uptake of this technology. I hope that this is adopted by all general practices as a way of easily examining the fundi of all patients with diabetes.

I would be happy to discuss any aspect in the implementation of this program.

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ICL (Implantable Collamer Lens) vision correction surgery gives patient "High Definition TV" vision

Tue, 07 May 2019 14:00:00 GMT

View Video

ICL

In what is likely to be the first operation of its kind in regional Australia, a 32 year old patient from Hamilton last week received an Implantable Collamer Lens (ICL or Intraocular Contact Lens or Phakic Intraocular Lens) at St John of God Hospital in Warrnambool.
The 20 minute operation was performed by Warrnambool Eye Specialist Dr Vincent Lee and involved inserting a very thin lens into each of the patient's eyes to remove the need for glasses or contact lenses.
The patient made a rapid recovery. Immediately after the operation, she was able to see well enough for the first time to walk around safely without thick spectacles or contact lenses. By the next morning, the patient's vision in each eye was excellent, measuring 6/9, without the help of spectacles. On day 2, she reported that her vision was so clear it was like she was "watching a High Definition television". At the 1 week check, her vision was effortlessly 6/6 or 20/20.
The Implantable Collamer Lens or ICL is like a contact lens but, rather than sitting in front of the eye on the cornea, it is placed inside the eye and therefore, is permanent and does not have to be removed each night or each week.
The patient is a young professional who had required very thick spectacles (-11.00 diopters) for severe myopia or short sight from the age of 6 years. She said that by the time she was in high school,

she had moved to Contact Lenses which gave her new freedoms, but she soon discovered the high maintenance contact lenses required in cleaning and sterilising. This improved with disposable contact lenses but she still found she was not able to wear them for long periods due to discomfort, irritation and redness from prolonged wear. They were also hard to put on and take off. So, for the last 20 years, she has alternated between spectacles for daily wear and contact lenses for special occasions. Needless to say, she was ecstatic about the "amazing" operation and the brilliant result.
The ICL is a relatively new vision correction solution and is different to laser surgery that most people have heard of, for example LASIK or PRK/ ASLA. The ICL has several advantages over the older Laser operations:

In contrast to laser operations which reshape the eye by cutting away corneal tissue from the front of the eye, ICL surgery does not cause destruction of any part of the eye.
The operation is fully reversible. Because a lens is implanted, it can easily be removed and changed to a different power, although this is almost never needed
The quality of vision experienced after an ICL operation is usually extremely good and distinctly better than with LASIK or PRK.
The operation does not cause as much postoperative pain, as PRK/ ASLA, or long term Dry Eye symptoms, as LASIK.
Because the shape or structure of the eye is not changed, the ICL operation does not limit your options when newer technology surgery becomes available, unlike laser procedures
Very high refractive errors from -20.00 to +8.00 diopters and astigmatism of up to 6.00 diopters can be treated with ICLs
ICLs can be implanted in patients with thin corneas, who cannot have laser procedures like LASIK and PRK/ ASLA. Of course, it can also be used in people with adequately thick corneas but who wish to have the ICL instead for all the benefits over laser surgery as detailed above.

As the technology is now available in Warrnambool, regional patients no longer need to travel to the city over multiple pre- and post-operative visits to access this service.
For more information on the ICL, click or tap the button below:

ICL

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Revolutionary 2RT laser for early Macular Degeneration (AMD) and Diabetic CSME is here

Sat, 23 Mar 2019 13:06:43 GMT

Drusen in a patient with AMD before (A) and after (B) 2RT 3 ns pulse laser therapy

Warrnambool is the first regional city in Australia to receive the revolutionary 2RT laser for the treatment of age-related macular degeneration (AMD) and diabetic CSME (vision-threatening swelling of the macular in diabetes), with the installation of a new laser machine at South West Eye Surgery in Koroit Street.

The sub threshold nanosecond laser, known as 2RT - Retinal Rejuvenation Therapy, is the first laser shown to be able to safely reverse the early signs of AMD and slow down progression to the late stages of the disease, which leads to vision loss and the need for eye injections. The 2RT laser is also able to treat diabetic CSME without the associated collateral damage to adjacent retina as seen with laser retinal photocoagulation.

In AMD, despite the advent of improved screening tools, which has enabled eye physicians to diagnose the disease in its earlier stages, treatment options have remained limited to the late, wet stage of the disease only. Whilst anti-VEGF injections have proven to be a highly effective treatment option in cases of wet AMD, we haven’t been able to treat the large number of patients diagnosed with the disease in its earlier stages. It is estimated that early-intermediate AMD accounts for 85% of all cases of AMD.

Recently, a multi-centre clinical trial at the Centre for Eye Research Australia (CERA), has demonstrated the efficacy of nanosecond laser in slowing the rate of progression from intermediate AMD to late stage AMD in selected patients and therefore reducing the risk of needing life-long eye injections.

The Laser Intervention in Age-Related Macular Degeneration (LEAD) trial enrolled 292 patients with intermediate AMD (bilateral large drusen ≥125 microns. or pigment changes with medium drusen 63-125 microns) and no signs of late AMD over a 36-month period. Patients were randomised to receive 6-monthly treatment with 2RT or sham (placebo) treatment.

The results of the LEAD trial showed that selected people with intermediate AMD without signs of more advanced macular disease demonstrated a 77% reduction in the rate of progression to late stage disease at three years, a highly statistically significant result.

Intermediate AMD is the stage of AMD showing signs of:

Medium drusen (63-125 microns) with pigment, or

Large (>125 microns) drusen

Importantly, there were no reported significant complications or adverse events in this trial, a result that is consistent with all previous pre-clinical and clinical studies dating back to 2010.

Based on the results of this three-year multi-centre trial, 2RT offers the potential to intervene earlier in the treatment of selected patients with intermediate age-related macular degeneration (AMD).

The 3 nanosecond pulse laser energy delivered to the retina with the 2RT laser stimulates a biological healing response that improves the permeability of Bruch’s membrane and thereby restores the transport of fluid across it. As illustrated in the image above, this does not cause photoreceptor damage. By restoring metabolite flow to retinal cells, 2RT may also reduce the production of endothelial growth factors and other precursors of neovascularization.

In Diabetes, conventional treatment for vision threatening macular swelling or CSME consists of regular eye injections. In the past, laser retinal photocoagulation was used but, while this treatment is effective at treating CSME, maintaining vision and reducing macular swelling, the treatment results in collateral damage to the parts of the retina crucial to vision.

2RT is capable of achieving the same degree of clinical efficacy as conventional laser retinal photocoagulation but without damage to the overlying neurosensory retina (specifically, no damage is caused to the photoreceptors or light sensitive cells of the retina).

In addition, a smaller randomized clinical trial has demonstrated the improved safety profile and efficacy of 2RT in patients with CSME compared to traditional retinal photocoagulation.

2RT is therefore an alternative treatment for CSME, particularly in cases where eye injections are not tolerated or where they are ineffective.

2RT - Retinal Rejuvenation Therapy rejuvenates the aged, compromised retinal pigment epithelium (RPE), a layer of support cells behind the macula – without damage to the overlying neurosensory retina, the cells surrounding the RPE that enable vision.

Research conducted by Professor Erica L. Fletcher MScOptom, PhD (Department of Anatomy and Neuroscience, The University of Melbourne, Australia) and colleagues has shown that the integrity of the human RPE remains intact following treatment with 2RT. There was no inducement of CNV or upregulation of vasoproliferative or inflammatory factors (which means there were no changes to cause a risk of progression to wet AMD). An analysis of human retinal structure post-2RT at both clinical and suprathreshold levels demonstrated that the procedure does not alter retinal structure.

Listen to Professor Fletcher speak about 2RT:

Prof Fletcher speaks about 2RT

It is also important to note that, owing to its unique nanosecond pulse duration and proprietary pixelated beam profile, the results of 2RT as demonstrated by the LEAD trial cannot be extrapolated to other forms of subthreshold laser treatment. 2RT has a uniquely different method of action.

I encourage you to review the information on the 2RT page, by clicking the button below, to better understand the benefits of 2RT Retinal Rejuvenation Therapy.

2RT

In AMD, with careful diagnosis and patient selection, the 2RT has the potential to provide an effective treatment for the majority of people with intermediate AMD (ie, those with bilateral large drusen ≥125 microns and/or medium sized drusen 63-125 microns with pigment changes) with no signs of late AMD.

In diabetes, patients with diabetic CSME may be suitable for 2RT, particularly those not responsive to antiVEGF treatment or those who are not compliant with this treatment.

If you are interested in finding out more about 2RT Retinal Rejuvenation, please do not hesitate to contact us at South West Eye Surgery.

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Laser is better than drops for glaucoma - SLT (Selective Laser Trabeculoplasty) is first line treatment in Moorfields study

Fri, 08 Mar 2019 13:00:00 GMT

SLT induced cellular response within the drainage channels of the eye (trabecular meshwork)

A major new study has shown that SLT, a non invasive, pain-free laser that has been in use for many years, is better at controlling pressure in patients with open angle glaucoma than conventional eye drops.

Dr Gus Gazzard and colleagues at the world famous Moorfields Eye Hospital in London, UK reported the results of the LiGHT Study, which compared SLT to glaucoma eye drops as first-line therapy in a multi centre randomised controlled trial, in The Lancet journal.

KEY POINTS:

STUDY NUMBERS / IOP REDUCTION: 718 patients (1,235 eyes). Intraocular pressure (IOP) reduction was similar for those treated with SLT (356 patients, 613 eyes) and medication (362 patients, 622 eyes) after 36-months follow-up.
EYE DROP USE: 78.2% of SLT patients did not need drops to maintain target IOP at 36-months. Further, patients who received SLT were within IOP target for more visits compared with medicated group (93.0% vs 91.3%).
NO SURGERY REQUIRED: No patients who received SLT required surgery to lower IOP, versus 11 eye drop patients.
ADVERSE EVENTS: There were 5 times less medication-drop related adverse events* with SLT (30) compared to eye drops (150).
COST PER PATIENT: The average cost per patient for all ophthalmology expenses was significantly less in the SLT group compared to eye drops (p<0.001).

Not only was the laser treatment better at reducing eye pressure and therefore controlling glaucoma than eye drops, it was also shown reduce the need for surgery and to be more cost-effective in the long term than eye drops. Patients tolerated the SLT laser treatment well and the decreased and more stable eye pressure that resulted from the treatment freed them from the burden of daily eye drops and their side effects.

As reported in The Guardian

For the full text article of the LiGHT study as reported in The Lancet, clink this link:

As reported in The Lancet

From the Moorfields Eye Hospital website:

From the Moorfields Eye Hospital website

Dr Vincent Lee has performed SLT laser treatment for glaucoma at South West Eye Surgery in Warrnambool for nearly 2 decades now with excellent results. A full eye check is necessary to determine suitability for SLT laser treatment.

To find out more about glaucoma and the use of SLT and other laser treatments in glaucoma, click the link below:

Glaucoma: treatment with SLT and other lasers

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Angle closure can be missed by Van Herick technique

Mon, 19 Nov 2018 12:25:58 GMT

While simple to perform and generally fairly accurate, a recent study has shown that the Van Herick technique for estimating anterior chamber angle depth can be unreliable in some circumstances.

This applies to males and myopes (people with short sight). The other risk factors are when this technique is performed on individuals of Asian and black race.

Click the button to read an abstract of the study:

Missed diagnosis with Van Herick technique

As such, it is recommended that when examining people in this demographic, a more reliable test is gonioscopy, especially when performed in a dark room.

One system of grading the anterior chamber angle depth is the Shaffer grading system, as depicted below:

Zovirax eye ointment discontinued

Fri, 02 Nov 2018 09:40:05 GMT

Zovirax® (aciclovir) 3% eye ointment will be discontinued and deleted from the market in February 2019 after GSK ceased manufacturing in the 3rd quarter of 2018.

When existing supplies of Zovirax® (aciclovir) 3% eye ointment are exhausted the following options may be considered:

Alternate brand aciclovir 3% eye ointment. AciVision® has been temporarily approved for supply under Section 19A of the Therapeutic Goods Act 1989 (exemption in the event of shortage or product unavailability) until 31 August 2019. This means that SAS approval is currently not required to supply this product, and it is now available in the community. AciVision® is not a TGA registered product and currently not subsidised on the Pharmaceutical Benefits Scheme (PBS). It will be necessary to check with individual pharmacies for availability and cost. (*see footnote below)
Oral valaciclovir 500mg bd or tds orally, combined with epithelial debridement, and chloramphenicol ointment. Dose reduction to 500mg daily is recommended in patients with renal impairment where creatinine clearance is less than 15mL/min. Note that Valaciclovir is not listed in the PBS for HSV keratitis. Oral aciclovir is recommended in paediatric patients.
Ganciclovir 0.15% (Virgan®) gel, three times per day. Virgan gel requires SAS Category B approval

*Please note that I have made arrangements for the Pharmacy Departments at St John of God Hospital and South West Health Care to ensure they carry stocks of AciVision® for prescribers in Warrnambool. Patients will simply need to present their prescriptions to access the drug. I will be speaking to Pharmacy Departments in Colac and Hamilton soon to ensure this brand of aciclovir is made available. If prescribers have difficulty accessing this drug for their patients, please contact me directly - Dr Vincent Lee.

LASIK vs ICL (or Phakic IOL) for myopia

Fri, 26 Oct 2018 13:00:00 GMT

For short sighted people who want a permanent solution to get rid of their spectacles, LASIK has been a go-to choice for a long time.

However, many are not suitable for LASIK - their level of shortsightedness may be too high or their corneas too thin, or too irregular, or too dry. There are also a proportion of patients in whom shortsightedness returns after their LASIK procedure. Furthermore - a process termed regression, LASIK is tissue-destructive - a thin layer of cornea is removed in reshaping its surface and it cannot be repeated more than once, if an incorrect result is obtained at the first attempt. Finally, when cataracts eventually develop, post-LASIK patients, will find that their options are limited when it comes to whether they can have premium Intra Ocular Lenses (IOLs) to enable them to remain spectacle free after cataract surgery. This is due to the higher order aberrations created by the laser procedure (from unpreventable tiny movements of the eye during the laser re-shaping process). So a procedure that frees you from glasses in your younger years may actually reduce your chances of being spectacle free in the second half of your life.

However, shortsighted people can choose another procedure, known as ICL (or Implantable Collamer Lens/ Intraocular Contact Lens or Phakic IOL). The ICL procedure does not have any of the above disadvantages of LASIK and has a number of additional benefits that may give it an advantage over LASIK, as explained yesterday at a meeting of the American Academy of Ophthalmology, in Chicago.

Click the button below to access the link to the AAO webpage:

LASIK vs ICL, American Academy of Ophthalmology

Click the button below to learn more about the ICL

ICL

Warrnambool patients are the first to receive MIGS Hydrus microstents in Victoria

Wed, 03 Oct 2018 14:00:00 GMT

View Video

Today, 2 of our patients became the first to receive a Hydrus Microstent implant in Victoria. The Hydrus is the latest MIGS device to be approved for use in Australia by the TGA (Therapeutic Goods Administration).

MIGS or, Minimally Invasive Glaucoma Surgery, is a new class of surgery which is considerably less invasive than traditional glaucoma surgery. The use of microstents and other MIGS procedures has greatly reduced the burden of eye drops in glaucoma sufferers with nearly all patients experiencing a reduction in the need for glaucoma eye drops following this type of surgery and many patients not requiring any drops at all.

The surgery was performed by Dr Vincent Lee at St John of God Health Care in Warrnambool.

The Hydrus is the world’s first intracanalicular scaffold. The device is inserted into the drain of the eye (Schlemms canal) and is designed to open up the channel to allow blocked fluid to flow more freely, thus reducing high eye pressure. The microstent is made from nitinol (a nickel-titanium alloy), which is a well-proven biomaterial used in over 1 million implants in a variety of medical devices to date. The Hydrus microstent is designed for patients with moderate glaucoma and is performed at the time of cataract surgery. Eye pressure can be expected to decrease by up to 30% and 70% of patients can expect to be free from eye drops after the surgery.

The Hydrus is one of three new MIGS devices made available by the TGA in Australia, the other two being the iStent (for mild to moderate glaucoma and the Xen stent (for moderate to severe glaucoma).

For further information go to MIGS section in the Glaucoma page or click the button below:

GLAUCOMA

New laser for Dry AMD

Thu, 20 Sep 2018 14:00:00 GMT

A highlight of the EURETINA Congress held in Vienna in September was the announcement, for the first time, of the results of a study which showed that a new laser treatment - known as Retinal Rejuvenation Therapy or 2RT - reverses the ageing changes in Macular Degeneration (AMD) and leads to a substantial reduction in advancement to the late stages of AMD, including Wet AMD.

Up until this time, there has been no treatment for Dry AMD and the worry for many with this disease has been that there was no preventive therapy that could reduce their chances of progressing to the late stages of Wet AMD.

It now appears likely that there will soon be a laser that, simply and painlessly applied to the eye in the clinic over a few minutes, could prevent the late stages of AMD and the risk of requiring monthly eye injections for life!

It is very pleasing that the study was conducted in our Victorian capital city of Melbourne, at the Royal Victorian Eye and Ear Hospital, and that the new laser is built just across our state border, in Adelaide!

The LEAD (Laser Intervention in Early Age-related Macular Degeneration) trial was conducted at the Centre for Eye Research Australia (CERA) in Melbourne. The treatment consists of a sub-threshold laser (using energy settings so low as to not cause visible damage to the retina). Each laser pulse is delivered over a very short time - measured in nanoseconds (or billionths (1/1,000,000,000s) of a second). The 2RT laser is made by Ellex Medical Lasers in Adelaide, SA.

Click the button below to find out more about the 2RT laser:

2RT Laser

Click the button to access the link to the CERA webpage:

CERA LEAD Study

It has been shown that the laser causes microscopic changes to the lining of the macula, the RPE or retinal pigment epithelial cells, which then regenerate. In the regeneration process, it is thought that high levels of enzymes, known a MMPs (matrix metallo-proteinases), are produced which then clear up the waste products of cells, which collect under the macula in AMD.

The laser results in a reduction in the yellow spots under the macula, known as drusen, consisting of waste deposits that are unable to be cleared by the ageing cells that leads to early and intermediate AMD. However, the laser also results in a four fold reduction in many of the late signs of AMD that are known to progress to wet AMD.

While the results of this study need to be validated by future studies, these results are a very positive sign that very effective treatment for Dry AMD is just around the corner and that we may soon be able to prevent many people from needing eye injections.

These are very exciting times indeed!

Reducing eye injections for patients with macular disease

Wed, 19 Sep 2018 14:00:00 GMT

It was a privilege to attend the EURETINA Congress, a meeting of the European Society of Retina Specialists, held in Vienna in September. Apart from the simply awesome city which was the venue of the meeting, it was gratifying to learn that much of the latest technology available to the world, in terms of the diagnosis and treatment of retinal and macular diseases, is also currently available right here in the south west of Victoria.

Nevertheless, there was also much to discover in relation to new technology and treatment modalities that are just on the horizon.

For example, I was very excited to learn that a number of longer acting drugs and a slow release device are about to be introduced, which will mean that patients, who need regular eye injections for macular disease will soon see benefits in reduced frequency of injections and a longer interval between injections of up to 6 months!

Three new drugs - brolucizamab, abicipar pegol and conbercept are undergoing final trials and all show great promise as longer acting agents than the currently available ones, which only have, at best, 6-8 weekly dosing regimes (although a small number of fortunate patients can tolerate extensions of injection intervals longer than this). These three new drugs have been proven to be effective at 12 weekly dosing intervals, so may optimistically be extended in some to 4, or even 5, monthly dosing intervals, which will be a relief to very many patients in the region.

Additionally, a device that could delay the retreatment interval for 6 months or more may soon be available. The Port Delivery System or PDS, is an infusion device that is similar to a reservoir that is implanted in the eye, which is then filled with the active drug for treatment of macular diseases like macular degeneration and diabetic macular oedema (DMO). The results of a study completed earlier this year showed that 80% of patients fitted with this device went 6 months or more before requiring a refill. And the refill procedure is much less traumatic or troublesome than an eye injection (even if the eye injection is only minimally uncomfortable using modern anaesthetic techniques). This will surely be music to the ears (and eyes?) of both patients as well as their long suffering but wonderful carers!

For more details on the Port Delivery System, click the link below:

Port Delivery System

GP Update - Diabetic Eye Disease

Mon, 06 Aug 2018 14:00:00 GMT

Dr Vincent Lee was an invited speaker at a Bayer sponsored event - "The Health Challenges of an Ageing Population" held at the Quorum, Warrnambool on 7 August 2018. The meeting was attended by General Practitioners, Pharmacists and Nurses.

Dr Lee spoke about the skyrocketing prevalence of diabetes and its impact on the health of the population, not just the elderly, but also the young, due to Type 1 and Type 2 Diabetes.

Diabetic Retinopathy (DR) and Diabetic Macular Oedema (DMO) are the two main eye complications of the disease which can potentially lead to moderate to severe loss of vision if undetected and untreated

The treatment of DR and DMO has undergone tremendous change in the last 10-15 years with the development of drugs that can improve these conditions so much that vision can be restored and maintained at excellent levels for many years, sometimes for the life of the patient. Dr Lee explained how these drugs are used in the eye and showed clinical examples of the benefit of early detection and treatment and the danger of late detection and delayed treatment.

Because early disease can remain undetected for many years and because patients are unaware of the deterioration in their eye health without any hint of vision problems, pain or other symptoms, the important role of GPs is to refer diabetic patients after 3-5 years of Type 1 Diabetes and on diagnosis of Type 2 diabetes to an appropriate eye care professional. Initially, screenings can be performed by an Optometrist and follow ups continued until mild retinopathy is detected at which time referral to an Ophthalmologist is recommended. Because DMO can occur at any stage in the disease (from no retinopathy to severe retinopathy), there should be a low threshold to refer to a medical Eye Specialist even with minimal decrease in vision.

Glaucoma therapy, MIGS and BEYOND

Sat, 21 Jul 2018 14:00:00 GMT

The Allergan Beyond conference was held in Sydney on the 21-22 July 2018. An eminent group of world leaders in glaucoma was convened to present the latest information on MIGS, in particular the Xen Gel Stent.

The XEN® Gel Stent is a surgical implant consisting of a 6mm long gelatin stent designed to lower high eye pressure in open-angle glaucoma patients where previous surgical treatment has failed and/or medications alone were insufficient (also known as refractory glaucoma).

Dr Ike Ahmed from Toronto Canada, widely regarded as a 'guru' of MIGS, was present to pass on some invaluable tips on the use of the Xen stent and his views on the use of this and other MIGS devices.

Global Retinal Network Program

Sat, 23 Jun 2018 14:00:00 GMT

Dr Lee attended the Global Retinal Network Program held on the weekend of 23-24 June 2018 in Sydney.

Guest presenters included:

Prof Neil Bressler
A/Prof Gemmy Cheung (Singapore)
Prof Paul Mitchell
Jennifer Arnold
A/Prof Wilson Heriot
Mark Gillies

Important updates on the treatment of retinal disease were presented by an international group of experts.

For more on this meeting as reported in mivision:

GRNP Sydney 2018

ANZSRS Retina Symposium

Sat, 26 May 2018 14:00:00 GMT

Held on the 26-27 May 2018, The Australian and New Zealand Society of Retinal Specialists convened for their annual Retina Symposium in Melbourne. Attended by retinal specialists from Australia, New Zealand and beyond, the meeting was a great opportunity to catch up with developments in the field.

MIGS - New Hope for Glaucoma

Mon, 19 Mar 2018 13:00:00 GMT

MIGS arrives in Western Victoria

There is finally some relief in sight for glaucoma sufferers in Western Victoria with the arrival of Minimally Invasive Glaucoma Surgery (MIGS).

Dr Vincent Lee recently delivered a lecture on ‘MIGS Treatment Algorithms’ to a group of 15 Optometrists from the region. The lecture, on 20 March 2018, was organized through Optometry Victoria Director, Mr Jayson Ward of Warrnambool and Portland Eye Care, and held at the Lady Bay Resort in Warrnambool. Attending Optometrists received 3 CPD points, as approved by Optometry Victoria.

As Dr Lee explained, this class of surgery has been steadily evolving over the last 20 years and will soon make a difference to thousands of patients in our region. As its name implies, the big advantage of MIGS lies in the fact that there is a great reduction in the incisional surgery required as compared to traditional filtration operations such as trabeculectomy and insertion of drainage tubes that many glaucoma sufferers eventually require.

Similar to traditional surgery, MIGS targets both excessive production of aqueous as well as diminished drainage. However, due to advances in technique made possible by breakthroughs in technological development, MIGS procedures take a much shorter operating time and carry considerably less risk. And in terms of success rates, MIGS compares well with traditional surgery.

Presently, there are three new MIGS procedures that have been approved in Australia, with a fourth soon to be introduced. These procedures involve the implantation of devices that enhance outflow of aqueous, but each implant targets different outflow pathways.

The iStent Inject (Glaukos) was the first MIGS device to be approved in Australia in 2016 and provides a direct route for aqueous into Schlemm’s canal. It is the smallest medical device approved for use in humans and consists of a heparin-coated non-ferromagnetic, titanium stent measuring 360 microns by 230 microns. It is inserted into Schlemm’s canal through the trabecular meshwork, essentially bypassing it. Two stents are inserted in the nasal quadrant where there is an increased density of aqueous drainage veins thereby maximizing the efficacy of the shunt.

The Hydrus Microstent is a MIGS stent made of a super-elastic, biocompatible alloy (nitinol) that has been used in over 1 million implants to date. It is an intracanalicular scaffold - a type of support structure inserted into the primary fluid canal (known as Schlemms canal) to allow blocked fluid to flow more freely, therefore reducing eye pressure. It is often used in moderate glaucoma. The Hydrus microstent can be described under the category of MIGS procedures known as canaloplasty, in which the primary drainage canal inside the eye is improved in its function.

The Xen Gel Stent (Allergan) is a 6mm long gelatin stent. It is inserted via an ab interno approach through the scleral wall from the anterior chamber to the subconjuctival space. It results in a new trans-scleral aqueous outflow pathway into a low lying extraocular filtration bleb, similar to a mini-trabeculectomy.

To measure efficacy, clinical trials measured magnitude of unmedicated IOP reduction, proportion of patients not requiring medication and magnitude of decrease in medication use.

All three of these procedures result in a significant reduction in IOP (20-50%) as well a significant decrease in medication burden (50-85%). In addition, 40-80% of patients remained medication free postoperatively for the follow up periods of between 2-3 years. Follow up is continuing and there are numerous ongoing trials investigating these and other results.

New Glaucoma procedure - iStent Inject

Wed, 14 Dec 2016 13:00:00 GMT

The iStent Inject is expected to help glaucoma sufferers by reducing their dependence of eye drops and, in some cases, completely eliminate the need for them. This is the first, widely available MIGS (Minimally Invasive Glaucoma Surgery) device in Australia and was formally approved by the TGA (Therapeutic Goods Administration) Australia, earlier this year, in 2016.

At the invitation of Glaukos Australia, Dr Vincent Lee presented a lecture to Optometrists, GPs and other specialists, at Warrnambool's Lady Bay Resort, on the advent of MIGS and the iStent Inject.

MIGS is a new subclass of glaucoma surgery that is quicker, technically simpler and involves lower risk than traditional glaucoma surgery, following which recovery is more rapid with less down-time for patients. Whilst patients are restricted for many weeks following traditional glaucoma surgery, following MIGS, patients can expect to return to normal activity within a day or two!

The iStent Inject is a tiny heparin-coated non-ferromagnetic, titanium stent measuring 360 microns by 230 microns. It is inserted into Schlemm’s canal through the trabecular meshwork, essentially bypassing it.

The operation decreases eye pressure by 20-30%, reduces (and in many cases completely eliminates) the need for glaucoma eye drops and is expected to benefit very many patients with glaucoma, in the region.

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