In celebration of Macula Month, Dr Narme Deva joins us on the RANZCO blog to share some important advice about macula health. Dr Deva is a Consultant Ophthalmologist in New Zealand and a Medical Retinal Sub-Specialist. Following completion of her training in New Zealand, she spent several years at the prestigious Moorfields Eye Hospital in London. She also holds a Doctorate of Medicine from the University of Auckland for research into ocular wound healing modification.
This month RANZCO is celebrating Macula Month. Can you start by telling us why the macula is such an important part of a person’s sight?
The macula is part of the back of your eye that is responsible for your central vision, your colour vision and what allows you to perform fine detailed visual tasks. This is an important part of the eye as the macula is what allows you to recognise your family and friend’s faces.
What diseases commonly affect the macula?
The diseases that most commonly affect the macula include diseases that are inherited. Often a problem with the macula is one that you are born with. The most common condition that affects the macula is Age Related Macular Degeneration (AMD), and as the name suggests, this is a condition that increases in incidence as you get older. If left untreated, AMD can have devastating consequences for your vision. The other group of conditions that commonly affect the macula are due to blood vessel problems in the back of the eye from conditions like diabetes or high blood pressure. These can cause leakage of fluid at the macula and can also cause vision loss or blindness.
When you first started out in medicine what inspired you to lean towards macula and retina related ophthalmology?
The macula is rather beautiful to look at. There is also a vast array of problems that can happen to the macula and retina. Many diseases that affect the body manifest in the retina and indicate a larger problem. It is quite an intellectual sub-speciality and we can manage a lot of problems now that we couldn’t before! I find the work very rewarding.
Why is raising awareness during macula month so important?
It is crucial that conditions of the macula are caught early as many can be treated and the treatments are considerably more effective if the condition is recognised in its early stages. A small amount of pathology at the macula can have a big impact on vision. It is important to spread the word about good macula health, talk to your family and friends about their experiences and be aware of family history of any diseases that particularly affect the eyes.
What is the most important advice that you give to your patients about macula health?
It’s never too early to be concerned about looking after your health. The most important advice I can give my patients about macula health is please don’t smoke, try to eat a diet that is rich in green leafy vegetables and regularly wear sun protection for your eyes.
When in a person’s life should someone start considering the health of their macula?
It is particularly important from your 50s onwards and if you have a family history of macula problems to be looking after your eye health. Additionally, if you have any other general health issues like diabetes or blood pressure it’s also important to consider your macula health and have regular eye checks.
What are the most important signs that a person needs to have their macula checked by an eye care professional?
If you notice any distortion with straight lines or letters in a word appearing slightly tilted, it’s very important to get your vision checked. Also, dark grey patches in your central vision is another important symptom that should prompt you to get your macula checked by an eye professional.
Today (Tuesday 27/05/2019) the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) officially celebrates 50 years as a college.
The College in Australia was formed in order to bring together the numerous and varied ophthalmology qualifications that were available at the time into a single, high quality, training program and examinations system. With this is mind, the College’s predecessor organisation, the Ophthalmological Society of Australia, was disbanded and reformed, being officially incorporated on the 27 May 1969 as the Australian College of Ophthalmologists.
The College was granted the title of Royal College, becoming the Royal Australian College of Ophthalmologists (RACO), in 1977.
While negotiations had been going on for a number of years, it was not until 1997 that the Ophthalmological Society of New Zealand amalgamated with RAZCO to form a trans-Tasman college for ophthalmologists. For the next few years, the College was known as the Royal Australian College of Ophthalmology incorporating the Ophthalmological Society of New Zealand.
Finally, in 2000, the College moved to fully properly recognise New Zealand in its and the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) came into being.
RANZCO CEO Dr David Andrews states that “While RANZCO is one of the smaller specialty colleges in Australia and New Zealand, over 50 years we have had an enormous impact in the region. Ophthalmologists undoubtably change people’s lives for the better and RANZCO is proud of our history in training, education and across all areas of eye care. We look forward exciting developments in the future.”
While there have been a number of significant dates in the formation of the College, the 27 May 1969 is particularly notable. Today we celebrate 50 years of being a College. Later in the year, on 8 October, we will celebrate 50 years since the first official meeting of the College. Through 1969 and the 50 following years there have been a large number of notable moments for the College – when New Zealand joined being a particularly important one – and we will aim to celebrate the anniversaries of these dates in the future, as well as look ahead to what the next 50 years of the College and of ophthalmology will bring. Please continue to look out for interesting events and information celebrating our 50th year, including an e-publication history of the College.
A/Prof Adrian Fung joins us on the RANZCO blog to look at why macula health is so important
This May is Macula Month run by Macular Disease Foundation Australia. Macular disease is currently the leading cause of blindness and severe vision loss in Australia. Macula Month focuses on urging people to learn about their risk and take action to protect their sight. A/Prof Adrian Fung joins us on the RANZCO blog to look at why macula health is so important.
Can you start by telling us why the macula is such an important part of a person’s sight?
The macula is the centre of the retina, the nerve tissue that lines the inside of the eye. It acts like the “film” in the camera and is one of the most important structures in the eye for sight. It’s particularly important for central, reading and colour vision under lighted conditions.
What diseases commonly affect the macula?
The most common cause of visual loss in elderly patients is Age-related Macular Degeneration (AMD). This disease specifically affects the macula. There are two forms: a “dry” form which is a wearing down of the macula with loss of cells and a “wet” form where there is bleeding underneath the retina. Other than AMD, there are many other diseases that affect the macula. The most common of these would include swelling of the macula caused by diabetes (diabetic macular oedema) or blockages (occlusions) of the retinal veins.
When you first started out in medicine what inspired you to lean towards macular and retina related ophthalmology?
The first time I ever saw the retina I was struck by its beauty! A structure that is not much thicker than a piece of paper can capture all the images, memories and emotions that we see over a lifetime. Here is an organ that we can see in microscopic detail with the aid of only some lenses and a light source. Although there are many diseases that affect the retina, many of these are treatable with new medications and surgical techniques. This is perhaps the most rewarding part of being a retinal physician; restoring sight to patients and seeing how it can transform their lives.
Why is raising awareness during macula month so important?
In general, there is a poor awareness in the community of what the macula is and the consequences to vision that diseases to the macular can cause. Vision is a major determinant of quality of life, and currently there are good treatments for many macular diseases. The earlier that patients present, the better the final prognosis will be.
What is the most important advice that you give to your patients about macula health?
1. Don’t smoke
2. If you have diabetes look after your blood sugar levels and blood pressure.
3. If you notice blurring of vision, don’t delay seeing an eyecare professional.
When in a person’s life should someone start considering the health of their macula?
People of all ages can develop diseases of the macula from newborns to patients over 100 years old, so everyone should seek professional advice if they notice a deterioration in their vision. Patients who are diabetic should have an eye check when first diagnosed with diabetes and then at least every 1-2 years thereafter. AMD (“macular degeneration”) occurs in older people over the age of 50 years.
What are the most important signs that a person needs to have their macular checked by an eye care professional?
Blurred vision, difficulty reading, distortion (straight lines becoming wavy) and difficulty judging distances.
If there anything else that you would like to add or tell us about?
Contrary to popular belief, reading or watching the TV does not harm your eyes!
By Prof Nitin Verma
Ophthalmology has changed dramatically over the past 50 years. Ophthalmologists are now treating and managing conditions proactively rather than reactively, as was the case in the past. A prime example was the timing of cataract surgery. A few decades ago cataract surgery was performed only when the patient was severely visually disabled, with the philosophy being that it was best to intervene surgically only when the patient would have nothing to lose if the cataract surgery went wrong. Techniques for intracapsular cataract extraction included “tumbling”, the Smith Indian technique, instrument assisted extraction with the erysiphake, capsule forceps or cryotherapy with or without the use of zonulysis. Even when cataract surgery was performed, it was very often without the use of a microscope using 8-0 silk sutures to close the wound and leaving the patient aphakic. By today’s standards, the visual results were often poor and the complication rates were high.
With the advent of intraocular lenses, small incision cataract surgery with phacoemulsification, better intraocular lens power calculation formulae, cataract surgery has evolved into refractive surgery, which is being offered earlier and earlier to patients once they start complaining of visual disability. Cataracts are often in much earlier stages in their development when surgical intervention is planned.
As you would expect, looking more broadly we can see that, in every area of ophthalmology, the treatments and methods we use today produce significantly better results than were achieved 50 years ago.
The ophthalmic therapeutic armament was very limited and most of the drugs that ophthalmologists used had serious side-effects. An example of this was the use of topical Pilocarpine and Eserine in the management of glaucoma. These were often made in hospital pharmacies. Surgical techniques in the earlier days included cyclodialysis, iridenclesis and sector iridectomy. The complications of these medical and surgical therapies were very serious and were well known.
Screening programs for diseases such as glaucoma, diabetic retinopathy and childhood eye disorders were limited and very often by the time disease was detected, it was fairly advanced. In addition, blindness from infectious diseases such as tuberculosis, syphilis and leprosy were common.
Over the years a lot of disruptive medical technologies have come in (“disruptive” is a word used to define a technology that radically changes the way we do things; in this instance the way we practice ophthalmology). Examples of disruptive ophthalmic technologies include Optical Coherence Tomography, phacoemulsification and the use of intravitreal anti-VEGF agents for the management of ocular diseases. The YAG and Argon lasers are other examples of disruptive technologies that have come into common use over the past few decades.
From being a specialty that not many people were interested in and being low on the “scale” of popular medical disciplines, ophthalmology now is a sought after field of specialisation.
To enter the training program today is a very competitive process simply because the specialty has evolved to a very precise art and the results that we can achieve today are nothing short of spectacular.
With the advent and incorporation of artificial intelligence in an ophthalmologist’s day-to-day work, this will only make things better for patients, the profession and, of course, the community at large. A/Prof Nitin
Prof Nitin Verma will be further exploring this topic, including looking ahead to what the next 50 years of ophthalmology might bring, in RANZCO’s member magazine, Eye2Eye , later in the year.
Recently, RANZCO made two submissions to the Therapeutic Goods Administration (TGA) proposing changes that would help to improve eye health care. The submissions included the following:
RANZCO submission to consultation: Proposed changes to the classification of active implantable medical devices and their accessories – RANZCO recently made a submission to TGA supporting the re-classification of active implantable medical devices and their accessories in a category called Class III (Medical devices). Changing this classification would mean that active implantable medical devices (AIMD) is defined as Class III and RANZCO is therefore in agreement to re-classify AIMD and their accessories.
RANZCO submission to consultation: Proposed new medical device classification for substances introduced into the body via a body orifice or applied to the skin – RANZCO recently made a submission to TGA advising of appropriate emergency eye irrigation solution use. The appropriate emergency eye irrigation solution at the time and place of chemical eye injury, usually before transfer to a healthcare facility, is tap water which of course does not require TGA classification. Should proprietary eye irrigation solutions be necessary at other times and places for chemical injury and any other indication, RANZCO believes they should remain as “Class I sterile” since they are not intended for absorption into the body, the particular feature that would require reclassification.
For more information please contact Stephanie Mulholland via smulholland@ranzco.edu or on +61 2 9690 1001.
Spring has sprung in earnest, finally. But along with the blooming flowers and the warmer weather comes the risk of swooping magpies. Eye health experts are warning people to beware and to protect their eyes from these springtime pests. Parents of young children are being warned to be especially ware, as our research has found that spring, dubbed ‘magpie swooping season’, can be a dangerous time for children playing outdoors.
This was a lesson learned the hard way for one Western Australia mother and her young son. Around this time last year, two-year-old Will* was playing in a park near his home in WA , when a magpie attacked him, pecking at his left eye. It happened so quickly that, by the time the family were able to react, the damage had been done. Will was rushed to hospital with significant injuries to his eye.
Will was diagnosed with a corneal laceration and underwent emergency surgery. The injury was extensive and resulted in the onset of traumatic cataract and the loss of iris tissue. Approximately a month later, Will underwent a secondary procedure to implant an intraocular lens and remove corneal sutures. He now has significant corneal astigmatism and wears glasses to correct the refractive error in his injured eye. He has needed ongoing visual rehabilitation including patching , which works by covering the eye with normal vision so that the vision in the problematic eye improves. Will’s treating ophthalmologist describes patching therapy as “extremely challenging” in a child of his age because compliance can be such a problem.
A year later, Will’s vision is still poor in his injured eye and any further improvement will depend on the extent of his visual rehabilitation. It is expected that Will will suffer from lazy eye (amblyopia) and he will live with the impact and trauma of the injury all of his life.
Experts in the field of eye research estimate that each year approximately 250,000 children sustain serious eye injuries globally. Raising awareness through public education and by promoting simple protective behaviours and measures, such as using eye protection, can help prevent up to 90 per cent of eye injuries.1
*The patient’s name has been changed to protect his privacy.
1 Hoskin, A. (2014) Study to focus on children’s eye injuries. Medicus, May found at: https://search.informit.com.au/documentSummary;dn=585904964848706;res=IELHEA
Look at the sugar!
I have always felt very privileged to be an eye surgeon. The part of my job that I love the most is talking to patients the day after surgery and listening to their stories. Many of the stories are similar ‘I had no idea how dusty my house was’ or ‘I didn’t know I had so many wrinkles!’ People frequently remark on the brightness of colours, or the ability to see individual leaves on trees. They often say they had no idea how bad their sight had been and how much they had been missing. I never tire of hearing these stories no matter how often I have heard them.
One story, however, stands out in my mind. Some years ago, I operated on a young man in his 20’s. When I saw him the following day he didn’t say very much, and I wondered if he had noticed much of a difference in his vision. That’s when his wife spoke up and told me about their morning. While they sat at the table eating their breakfast he suddenly shouted ‘Look at the sugar! Look at the sugar!’ She had no idea what he meant and wondered if there might be ants or something in the bowl. He explained that he could see individual grains of sugar, instead of the usual vague hazy blob on the table. I myself, don’t recall when was the last time I became excited by something as simple as a grain of sugar, but this story has always reminded me just how precious the gift of sight is.
Dr Brian Kent-Smith
Worldwide, Retinopathy of Prematurity (ROP) continues to be a leading cause of childhood blindness. It is a potentially blinding eye disorder that primarily affects premature babies. This disorder, which usually develops in both eyes, is one of the most common causes of vision loss in childhood and can lead to lifelong vision impairment and blindness.
Recently, RANZCO teamed up with the University of Papua New Guinea and UNICEF to conduct a workshop on Retinopathy of Prematurity at the Port Moresby General Hospital. The workshop aims were to upskill eye care professionals, pediatricians and nursing staff in the identification and treatment of retinopathy of prematurity.
Through funding available from the Australian and New Zealand Eye Foundation (ANZEF), an indirect ophthalmoscope – the traditional standard of care for ROP, has been donated to the Hospital. The availability of this equipment enabled workshop participants to be upskilled in the use of indirect ophthalmoscopy to detect ROP. Special care nurses and neonatologists have also been upskilled in oxygen administration and resuscitation procedures for premature infants.
“We had an amazing team from Australia – a specialist neonatal nurse from the Royal Children’s Hospital, Melissa Stewart, and a neonatologist from the Monash Children’s Hospital, Risha Bhatia, together with myself, an ophthalmologist at the Royal Children’s Hospital and Royal Victorian Eye and Ear Hospital in Melbourne. The medical and nursing staff in Port Moresby are passionate about providing the best possible care for their newborn patients and they were smart and keen to learn as much as possible. For my team, we were overwhelmed with their thirst for knowledge. The experience for us was tremendous and we hope to return to give a refresher course next year, and also to visit other provinces.” Says Associate Professor Susan Carden
“Preventing newborns from blindness is one of the most important things that we can do. Teaching ophthalmologists in developing countries, such as Papua New Guinea, how to examine newborns’ eyes is incredibly rewarding. It means that there is the potential for a sustainable management of newborn eye health and the prevention of lifetimes of blindness”.
This initial workshop was the first of a proposed wider program aimed at addressing the eye health of newborns in Papua New Guinea and the Pacific islands region.
The first workshop on Retinopathy of Prematurity held at the Port Moresby General Hospital.
Professor Helen Danesh-Meyer
The old maxim ‘behind every great man there’s a better woman’ might still have some truth in it – although now women are now also beside and ahead. But perhaps a better truism is ‘behind every great woman is her mother’.
FMHS Professor of Ophthalmology, Helen Danesh-Meyer is certainly one person who attributes her success to both her parents, particularly her mother.
“My mother inspired me to do medicine. As one of the first women to attend medical school in Iran, she was a trail-blazer. Her philosophy was that obstacles were only challenges waiting to be conquered! And to challenge the establishment she’d do things like wearing mini-skirts to classes.”
Helen, did her undergraduate studies at Otago and her fellowship training at the Wills Eye Hospital in Philadelphia. She then joined the University of Auckland and completed both a Doctorate of Medicine (MD) and Doctorate of Philosophy (PhD). She was appointed the youngest professor in the medical school in 2008 and the first female Professor of Ophthalmology in New Zealand. She divides her work time between eye surgery, research and teaching. And with her equally busy periodontal surgeon husband she’s parenting two daughters.
Getting the balance right can be a struggle.
“I thrive on multi-tasking, which helped enormously as I balanced raising a young family in parallel with pursuing a surgical and academic career,” she said.
“My young daughters would frequently join me in lectures and on post-operative ward rounds. Once, near the end of a lecture I was giving, my three-year old quietly got off her chair, came to the podium, pulled at the hem of my skirt, and said: ‘Mum, I think we have all had enough!’ She was probably right.”
Prioritizing parenting hasn’t always been easy. When one of her girls was small she had a relatively serious accident at school and needed to be taken to emergency.
“I know all she’ll have wanted was her mother. But I was operating. So I didn’t even know she was injured for several hours.”
Fortunately, there is more than one path available today she believes.
“Surgical training has traditionally been all-consuming: unusually prolonged and intense, and not amenable to part-time activity. However, attitudes and the configuration of training programmes are changing, reducing some of the challenges for both men and women who seek balanced lives.”
Helen says she is grateful for the support people like her Head of Department, Professor Charles McGhee have provided her.
“Professor McGhee prioritizes academic excellence it in a way that allows achievement by different individuals through different paths and in differing timeframes. Such imaginative excellence-led thinking should be at the core of solutions to achieve greater diversity in leadership at our institutions.”
And for the young women following in her footsteps including, perhaps, her daughters, Helen has this advice.
“Ignore people who attempt to set you limitations. Create your own path. And do it on your terms – embrace your feminine qualities on the way.”
This article first appeared in the September 2018 issue of the University of Auckland’s UniNews.
The team from Westmead Hospital with a Fundus camera that is sure to save many lives in the ED
A camera the size of a hairdryer can quickly identify symptoms that can threaten a person’s vision or life. Within the first two months of using Fundus photography in the emergency department, two people received lifesaving surgery as the camera made it possible to see what was going on inside the eye.
“It’s really important that we can diagnose problems in the brain by looking at the back of the eye,” Westmead Hospital head of ophthalmology Professor Andrew White said.
“Historically people haven’t been very good at that because it has been quite hard to put in place proper training and supervision. Having the camera in the emergency department lets us reliably look at the back of the eye in real time and transmit those images.”
This technology allows for images to be captured, uploaded to the eMR and reviewed by an ophthalmologist within 24 hours. This is a great leap forward in identifying life and vision threatening pathologies quickly in an emergency situation.
