The XXIXth ICO
The XXIXth International Congress of Ophthalmology took place at the Sydney Convention Centre in the last week of April 2002. It was a big event, attended by a number of Kiwi ophthalmologists and optometrists, in addition to about four thousand international delegates from around ninety different countries. Being a ?local? meeting, the largest contingent were Aussies, followed by American and British delegates. The Saturday immediately preceding the opening on Sunday was characterised by a number of independent meetings timed to coincide with this large gathering of ophthalmologists, optometrists, ophthalmic nurses, technicians, orthoptists and other scientists and academics in related fields. It would be impossible to provide any real detail as to what was covered at this meeting as it was only physically possible to attend five or ten percent of the concurrent sessions, with up to twenty one taking place in different rooms at any one time!
I don't know about you but I have never really enjoyed conferences that have concurrent sessions and much prefer meetings that are either targeted at a broad audience, or alternatively aimed specifically at a group or sub speciality.
I was wearing a number of different hats at this meeting but my main focus was on contact lenses and in particular scouting for a final keynote speaker for our NZSCLP meeting in Taupo, February 6th to 9th 2003. I think we found one. I?ll keep you posted. For this reason I was unable to attend many presentations that caught my eye, although I did manage a few. There were many excellent contact lens presentations but not much earth shattering stuff. Indeed many delegates felt the same about the lectures and workshops they attended in their area of speciality. Most felt that if you keep up-to-date with CE and reading of journals then there was not much new. We all agreed however that no matter how much you know there will always be a few pearls that one takes home from just about any meeting one attends. This can be said not only for knowledge gleaned from presentations but as importantly from interaction and discussion with colleagues.
that's what It's all about.
There seemed to be a good balance between academic research and clinical presentations.
One of the pre-congress meetings on Saturday was the International Myopia Workshop. As we already know there's a major myopia epidemic taking place in the world, with some far reaching ramifications. Another thing I learnt was that those concerned that LASER refractive surgery [LRS] is going to put optometrists ?out of businesses?, can relax. A leading US refractive surgeon even stated that contact lenses still account for around 40% or 50% of their work. Most responsible refractive surgeons will also not ?treat? unstable progressive myopes, nor those with thin or irregular corneas.
To illustrate this point, consider the stats from a Taiwanese study: Myopia was prevalent in 20% of 7 year olds, 61% of 12 yr olds and 81% of 15 year olds. By age 18, myopia over 6D was found in 24% of girls and 18% of boys. Even rural Finland shows an almost doubling of myopia prevalence in thirteen years. So I guess that means a sharp growth in spectacle and contact lens prescribing. Reports indicate Ortho K is also growing significantly.
We already know that regular RGPs can also slow myopic progression.
Millions are being spent on myopia research. More and more chemical mediators are being studied and more and more genes are being detected with diet and environment also receiving attention. 180 different genetic disorders have been linked with myopia.
There is a ton of information out there and a lot more to come. Keep your eye out for papers in journals - but don't overdo it and don?t forget that ?plus at near? or you may end up as another myopia statistic.
A study just presented at ARVO showed an increase in myopia of ?up to several dioptres? in monkeys that performed prolonged near work for two years - which reinforces what behavioral optometrists have touted for decades.
I guess It's a case of monkey see, monkey do, monkey myopic?
Classic.
There were numerous other pre-congress meetings, some dealing with custom wavefront guided ablations, with many more refractive surgery sessions during the main meeting too. Now that the hype has died down, more realistic expectations are being touted. Gone is the talk of 20/05 vision by 2005 and even 20/10 by 2010, is no longer the catchphrase. What surgeons with access to wavefront guided LASIK/PRK tell you is that patients report that the eye that had a custom ablation does indeed provide ?better quality? vision than the other eye that had regular LASIK or PRK.
There was much well lubricated talk about Zernike polynomials and the various order aberrations ? late into the night.
Some researchers show that flap-induced aberrations do however reduce the potential benefits of correcting some of the other ocular aberrations.
The conference proper kicked off with a most impressive opening ceremony ala the 2000 Olympics, albeit on a much smaller scale. There was a great multimedia presentation on the history of ophthalmology. The international conference of ophthalmology also holds the distinction of being the longest running international medical meeting. There was dancing, music, singers, performers, acrobatics and gymnastics and numerous medal presentations and speeches. As one colleague commented, you?d be hard pressed to find more intellectual horsepower among any group of people anywhere - nor might I add, economic clout. A report at the time in the local press stated that a forthcoming conference on cardiology was likely to inject something like $67 million into the Australian economy from the 8000 delegates. I reckon the per capita spend of the ophthalmologists would have been similar.
Monday?s contact lens sessions didn't do much for me, however I did attend a most illuminating presentation on the use of an Excimer LASER for trephination in penetrating keratoplasty [PKP]. It's still experimental but studies indicate that it could lead to a reduction by as much as 50% in post op astigmatism, following suture removal. Maybe more, once perfected. The goal it would seem is for a perfect, ?waterproof? junction between the host and donor with small locating and orientating ?notches?. A sutureless technique is envisioned. Specialist contact lens practitioners would welcome this I am sure, as there are not many more difficult fittings than grafts that sit proud of the host, or those that are ?tilted? or simply those with ten or more dioptres of corneal astigmatism!
One fellow that attended a keratoconus workshop was less than impressed when the presenter suggested that a mono or bicurve lens was reportedly the first choice and that fitting precision was critical. ?Not too steep and not too flat? was apparently the advice given.
Duh.
Party Time
I can?t say that the evening entertainment was disappointing. ALCON threw a party of all parties with a seemingly endless supply of excellent food and drink, with a fashion show, lecture on glaucoma, two bands, entertainers and a fun-fair-like bunch of stalls providing karaoke, fruit juice, beach activities and much more. A great night was had by all. We did see one delegate leaving on a stretcher. After that one of the local optometrists took a couple of us out on the town?
Being a staunch bunch we somehow made it to lectures the next day.
Tuesday provided what was, in my humble opinion, a better range and relevance of contact lens presentations. My only problem was that now we were faced with two or three concurrent contact lens lectures ? never mind the other seventeen odd sub specialities ranging from path, glaucoma, paediatrics and retina, to epidemiology and deeply technical and intellectual dissertations on document and data standards, inter-platform compatibility and quality eyecare standards. Oculoplastics, anterior segment, neuro and strab were also covered.
Hectic.
So what does a contact lens practitioner choose? Silicone-hydrogels or presbyopia management? UV or sclerals? CL complications or paediatric fitting?
I tried to flip flop between sessions and lectures and managed to juggle the most important lectures pretty well, but did miss a few I wanted to hear.
There have apparently been a ?few? MK?s in high Dk Extended Wear [EW]. Some, 3 or 4, possibly related to swimming in Melbourne last summer. I still advocate a conservative 6-night EW policy, as do a number of like-minded colleagues. Compliance is still a factor in a number of complications with EW.
I?ll be interested to see some real numbers in a ?controlled? study of long-term ?complications? of EW vs. LRS?
Accommodating IOLs are another big item for the future. Current results indicate reasonable potential but I wouldn?t go for any of the current techniques. there's a lot of work going on and a lot still needs to be done. there's a potentially massive market for treating presbyopia surgically with accommodating IOLs before cataract onset. Other research points to slowing or delaying the development of cataracts. One poster dealt with a significant increase in cataracts from ionising radiation that is becoming evident in Iraq 7-10 years after the US used armour piercing anti tank weapons. These weapons have metal containing ?spent? or depleted Uranium that makes them extremely hard.
Spent my eye! Not with Uranium?s half-life of between a quarter of a million years and four billion years.
The incidence of cataract is apparently related to the distance soldiers and civilians were from the battlefield. There are also other medical problems being studied under the umbrella of the so-called ?Gulf war syndrome??
Space age and frightening but there was even more futuristic stuff to come.
Tuesday night arrived and many attended what was apparently a fantastic performance of Ballet at the Opera House. Some complained about the food, or lack thereof.
Some always do.
The Plenary Sessions
Wednesday was great as it featured the plenary sessions in the main auditorium and thus one got to hear what would surely represent the cr?me de la cr?me of the ophthalmology world - with one eye on the past, one on the present and a third on the future.
Triclopian vision?
The focus is on the future with various programs such as ICEE and Vision 2020 gaining momentum and the important support and funding needed. Fortunately there are many dedicated people in ophthalmology and eye care and major strides are being taken toward the goal of eliminating avoidable blindness by 2020. A noble goal and one which shall surely benefit millions of people and provide the gift of sight where otherwise they may not have had it.
Visionaries.
?Genetics' is a big part of the future and quite possibly plays a role in widening the scope of ?preventable? blindness to the genetic level. There are amazing discoveries taking place. One presenter showed a graphic of eye related ?defects? on the human genome we knew about in 1994. With dramatic strides in genetic research since then, an updated image from 2002 showed many more eye related genetic defects.
As with myopia, many other eye diseases show a multi-gene nature with many complexities - sometimes intertwined with other maladies. Genetic engineering, gene therapy and stem cells are quite probably a big part of the future, with some current research techniques using adenoviral-type vectors. Microsurgery, with the benefit of micro-machines, robotics and electro optical wizardry is also being talked about. We already have electronic retinal chip implants that reportedly impart ?light perception?.
Hell, these days one can even swallow a ?pill-cam? that takes and transmits photos of your entire digestive tract as it passes through.
Most of the plenary presentations were quite simply well presented talks on the current state-of-the-art of the sub specialities previously mentioned. Even more mundane things like standards and records were dealt with including XML, DICOM, GEHR, NLP, WC3, HL7 and more. Look them up on your favourite search engine.
The lay press of course focussed on many of the more esoteric, futuristic items - like successful cloning of frog?s eyes - and the Sydney media appeared to give many aspects of the meeting wide coverage.
In addition to the lectures, there were also around one hundred courses and workshops with over one thousand posters that alternated on the hanging space available in the massive and extremely impressive exhibition area. There was a complex schedule of days and times for presenters to attend their posters. Most only had one short exposure. I could see some presenters also got confused and there was a pile of ?removed? posters growing on the floor, behind the scenes.
I had signed up for two workshops. Unfortunately one was cancelled. I attended the remaining one entitled ?Ophthalmic Pathology ? Hands on Review of Slides with the Experts?. Expecting a Gordon Sanderson style quiz I confidently strolled into the lecture room ? albeit a bit late. I was confronted with two stern professors at the front and was immediately ushered to a lab style desk by an official looking usher. When I sat down and looked around I noted a few serious looking Japanese chaps with their eyes firmly glued to Olympus microscopes.
Aha, I now realised what sort of pathology this was. The ?Hands On? bit should have alerted me.
It's been over twenty years since I did biochem pracs, but I was relieved to see I could still find my way around a microscope. Within seconds I had loaded one of the excellently prepared and stained slides. I had a great image too. One slide was a histological section from the eye of a deceased AIDS sufferer. I think I saw a cell that had been invaded with cytomegalovirus? Another was from a person whose eyes were enucleated ten years after suffering bilateral panophthalmitis. I wasn't sure what I was looking at but there were some pretty interesting cells to be seen. I think I recognised a few white blood cells?
I viewed all six slides and read the accompanying case histories, but as the session clashed with a major contact lens presentation, I happily excused myself.
I got a few more strange looks and then I was gone.
So much for a cruisy, Sanderson style quiz!
Anyone for Coffee?
Espresso machines are now de rigueur on stands at international conferences and trade exhibitions. Medical meetings appear to be no exception. Although there was plenty of ?conference? tea and coffee there seemed to be an endless number of people at the companies that had a coffee stand. Some revelled in it, yet I heard one staff member at another whinge about people treating them ?like a coffee bar?. What did she expect?
There was also a twenty-four-computer, email stand that provided fast enough computers and download speeds for email. One could view and buy a seemingly unlimited amount of ophthalmic equipment, books, surgical tools and instruments. I purchased a great pair of ?epilation? tweezers but had to hold back on the titanium pair costing well over $500.00! Others spent hundreds of thousands on wavefront guided LASER and topographic workstations.
There was no shortage of food on Wednesday night at the official conference party. Nor drink. Nor entertainment. Everyone present seemed to have an absolute blast. Even before we got on the bus I could see we were in for quite a night. On arrival there were hundreds of performers in movie-studio-splendour and all manner of apparatus, stilts, trombones, stock whips, real Aussie Cobbers, bushmen, surfers, fairies and more. There were dodgem cars too and I saw at least two senior Auckland ophthalmologists having a great time. There were also climbing walls, food stalls with fantastic food and numerous bands and performers including South American dancers and a group of ?Beatle clones? resplendent in their ?Sergeant Peppers Lonely Hearts? uniforms. They played a marvellous set of Beatles classics. I saw a lot of fellow Kiwi?s having a really good time, as were the thousands in the audience dancing, watching or just listening. Those outdoors and in the other halls and outdoor areas were also having a marvellous time.
As a result of all the frivolity there were definitely fewer delegates at the early morning sessions on Thursday, however to be fair it was ANZAC day and a number of delegates chose to rather attend ANZAC day parades. There were some good presentations on tears and dry eye, Ortho-K, implantable ?contact? lenses and artificial corneas. One promising development from Australia is a HEMA based artificial cornea, which understandably received good press coverage. Although promising results are coming to the fore, I wonder how long it will be before we see GPC? If it happened with contact lenses I don't see why it won?t happen with a HEMA ?cornea?. I suppose though that GPC and long-term treatment for it, is a better alternative to being blind? There were a few more interesting lectures on corneal topography, corneal shape, aberrations and viral diseases and then as often happens, the meeting ended.
Anticlimactically.
In summary one would have to say that the meeting was well organised, ran smoothly with a fantastic array of presentations and an outstanding exhibition. The Kiwi contingent delivered around half a dozen lectures in their specific fields and we also had one optometrist present a contact lens lecture. There were also a few other technical and scientific papers from NZ based presenters in complimentary fields. When Grant Watters asked Brien Holden a question about the ?fit? of a lens, Brien replied ?For those of you who don't understand Grant is speaking New Zealand English and what he means by ?futt? is actually referring to the ?feet? of the lens?. For those readers who are neither Aussie nor Kiwi what they both meant was ?fit??
My compliments to all those involved in the thousands of hours of work and years of planning that meetings of this magnitude involve.
Sydney has benefited greatly from the Olympics. Now that the major pressure is off, the upgrades to Sydney are being enjoyed by locals and visitors alike. The facilities are excellent and It's all run with slick efficiency. It's also great when different, yet complimentary professions can meet in such a positive fashion.
As it should be.
Many thanks to ophthalmology for including us in this great meeting.
Last Word.
As I said last month, the only way to make up for losing out on the rugby world cup co-hosting is for the ABs to take the cup at Olympic stadium in Seedknee. Lets hope the Crusaders drubbing of the Waratahs 96-19 is an indicator of things to come, but I suspect the Aussies will come back strong. As we go to press, it is pleasing to see a Crusaders vs. Brumbies final. By the time you read this it should be all over. Lets hope our boys remain staunch and don't throw it in the last minute, as we seem to have done all too often these past few years!
96-19 has such a nice ring to it?
For more information or any comments email Alan at incontact@optom.co.nz.