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2010 ISSUE 1
newsletter
Welcome
Welcome to the inaugural issue of IMAGE, Centre for Eye Health’s (CFEH)
newsletter for optometrists registered with the Centre.
Centre Update
It has been an exciting
period for CFEH,
where we went
from completion of
building works to
being operational in
less than five months.
The Centre was
officially opened on November 4, 2009.
Since then we have assessed more than
100 clients and currently have over 150
registered practitioners: a mixture of
optometrists and ophthalmologists.
A formal agreement with the South
Eastern Sydney Illawarra Area Health
Service means that consultant
ophthalmology services are available
within the Centre. As a result, CFEH is
in a position to provide a full spectrum
of service delivery: from individual visual
testing and suites of tests (targeting
suspected diseases), through to
diagnostic services.
CFEH offers services and advanced ophthalmic instrumentation that will
better enable optometrists to manage their patients. IMAGE aims to assist
referrers in better understanding the range and application of testing,
equipment and services available at the Centre. Each issue will contain
updates on the Centre’s activities, an interesting case report and information
on a specific eye condition. We will also include educational inserts from
time to time on specific tests or equipment available at the Centre. This
issue we feature our Optical Coherence Tomographers (OCT).
Case Report
Fred is having difficulty reading the newspaper
Fred, a 47-year-old male, presented
to his optometrist complaining
of trouble reading the newspaper.
Visual acuity was 6/6 in each eye
and N5 print could be read with a
small near addition.
External examination and
binocular vision assessments were
unremarkable.
Fundus examination was
unremarkable in the left eye.
The posterior pole of the right
eye is shown below (Figure 1).
An Amsler grid showed a small
area of distortion superior
to fixation. The small area of
disturbance inferior to the
right fovea had been noted on
a previous examination (three
years earlier). The highly reflective
area superior to the fovea was
not noted on the previous
examination.
Issues to consider
1. Given the above
appearance and
information, what are
your differential
diagnoses?
One of our main aims in the coming year
is to streamline Centre operations to
ensure we are meeting the needs of our
stakeholders. A key strategy in achieving
this is to provide our registered
practitioners with activity updates and
useful clinical information through
IMAGE newsletters.
Prof. Michael Kalloniatis
Director
2. Based upon the
available information,
do you predict that the
foveal pit is unaffected?
Figure 1: Fundus photograph of posterior pole of
the right eye (Photograph courtesy of N. Delaveris)
cfeh.com.au
3. What test results
from CFEH would be
useful to you to assist
with the management
of this patient?
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Case Report (continued)
newsletter
Results and Discussion
Differential diagnoses of the area
superior to the fovea could include:
macular oedema, chorioretinal
disturbance, epiretinal membrane,
drusen, solar keratopathy, white-dot
syndrome and cotton-wool spot.
The normal visual acuity suggests an
undisturbed foveal-pit region.
In light of the metamorphopsia, and
the new, reflective changes superior
to the fovea, Fred was referred
to CFEH for optical coherence
tomography (OCT) of the macula.
The Heidelberg Spectralis uses
spectral domain OCT to assess
the layers of the retina. It utilises
a scanning laser ophthalmoscope
to image the fundus and, as such,
the images provide a different
perspective (Figure 2) to traditional
digital fundus photography (Figure 1).
The anatomical image across the
foveal pit appears normal (Panel 2a),
which is consistent with the finding
of unaltered visual acuity. The
OCT images superior to the fovea
clearly demonstrate an epiretinal
membrane (ERM) (Panel 2b: a
reverse contrast image is used in
the presented case to enhance the
areas of interest). The ERM causes
a wrinkling of the retinal surface
(pucker) (Panel 2c), leading to the
reflective area and faint traction
lines superior to the fovea in the
photographic image (Figure 1). OCT
images of the inferior macula show
disturbances at the level of the
retinal pigment epithelial level and
adjacent photoreceptor layer loss
(Panel 2d).
Imaging of the posterior pole:
■ Aided in diagnosis and
management of the patient;
■ Established that the area inferior
to the fovea is a dry, deep retinal
disturbance of unknown aetiology
that required no further action.
The epiretinal membrane was not
affecting the central vision at this
point in time. An ophthalmologist
was consulted and confirmed that
no further action was necessary at
this point.
A six-monthly review was
recommended.
Figure 2: Four panels showing laser scanning ophthalmoscope image of the posterior
pole and corresponding OCT cross section of the retina.
Vitreous base attached at the fovea
Panel 2a: OCT imaging with the Spectralis showed a clear central fovea with
attached vitreous
Panel 2b: Sections of the volume scan superior to the fovea show apparent
vitreoretinal traction and an epiretinal membrane.
Panel 2c: Wrinkling of retinal surface superior to the fovea.
Photoreceptor dropout
The ERM causes a wrinkling
of the retinal surface (pucker),
leading to the reflective area
and faint traction lines
superior to the fovea in the
photographic image.
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Disorganised RPE
Panel 2d: The macular hypo-pigmented area shows some drop out of the adjacent
photoreceptor outer segments with an unbroken but disorganised RPE.
Prepared by: Michael Yapp, CFEH Principal Optometrist.
Acknowledgement: We thank Nikki Delaveris for referring this client to the Centre.
cfeh.com.au
Eye-Condition Spotlight
Epiretinal Membranes (ERMs)
Epiretinal membranes (ERMs) are
comprised of glial cells migrating
through breaks in the internal limiting
membrane. These can occur where
the membrane is normally thin or
discontinuous, such as at the optic
nerve head, the macula, along blood
vessels and at retinal tufts. ERMs
can also occur at acquired sites
such as retinal holes and lattice(1).
The majority of ERMs are idiopathic,
and are bilateral in up to 10% of
cases. Secondary membranes are
associated with other retinal surgery,
retinal vascular disease, intraocular
inflammation and trauma(2)(3).
OCT imaging of patients with ERMs
can assist in clinical management
- through both detection and
recording the extent and severity of
the membrane - and also whether
tractional forces are affecting retinal
thickness (Figure 3). The ability to
perform subsequent exams with
overlay of the results can also greatly
assist in monitoring change with time.
Treatment for ERMs is generally
not indicated unless the patient is
concerned by visual symptoms such as
decreased acuity and metamorphopsia
as a result of macular pucker.
Figure 3: A volume scan of a patient with an epiretinal membrane showing traction
lines and corresponding retinal thickening.
There are many synonyms for ERMs
with or without macular pucker
including: cellophane maculopathy,
surface wrinkling retinopathy,
preretinal fibrosis, preretinal
membranes, epimacular membranes
and preretinal gliosis.
If required, treatment for ERMs
traditionally involves vitrectomy
with peeling of the membrane.
Current surgical techniques also
allow for sutureless vitrectomy(4),
as well as peeling of a membrane
without prior vitrectomy. Indications
for surgery are strongly influenced
by the potential benefits of surgery
weighed against the risk of
surgical complications.
These complications include infection,
intraoperative haemorrhage, retinal
tears, detachments caused by retinal
tears, postoperative progressive
nuclear sclerosis, macular oedema and
retinal pigmentary epitheliopathy(5).
Studies have shown that vitrectomy for
epiretinal membranes is beneficial in
eyes with relatively good preoperative
visual acuities, but cataract surgery is
necessary in phakic eyes to achieve
long-term visual-acuity improvement(6).
Epiretinal membranes
(ERMs) are comprised of
glial cells migrating through
breaks in the internal
limiting membrane.
STAFF PROFILE
Michael Yapp joined Centre for Eye
Health (CFEH) in September 2009
as a Principal Optometrist.
Prior to CFEH, Michael worked
in a variety of roles, from an
ophthalmology practice and
optometric private practice, to
teaching at The University of New
South Wales and running the
Australian arm of Luxottica Group’s
charity program.
“Working at CFEH is a brilliant
opportunity,” Michael says. “I can be at
the forefront of optometry by having
access to the latest technology while
also helping the community and our
profession.”
There are many benefits to referring
patients to CFEH, Michael notes.
“The Centre can help practitioners
to best manage their patients,” he
explains. “There’s also a cost saving
for patients - elsewhere these tests
can cost hundreds of dollars, but
here they’re free.”
1300 421 960
Michael Yapp
Principal Optometrist
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References
Next Issue
1. Wilkinson CP. Retina. St. Louis, London, Philadelphia, Sydney, Toronto: Mosby, 2001( 3rd Edition).
2. Kanski JJ. Clinical Ophthalmology. Edinburgh, London, New York, Oxford, Philadelphia, St Louis, Sydney, Toronto.
3. Kanski JJ, Milewski SA, Damato BE, Tanner V. Diseases of the Ocular Fundus. Edinburgh, London, New York, Oxford, Philadelphia, St Louis, Sydney, Toronto: Elsevier Mosby,
2005 1st Edition, Pg 116.
4. Warrier SK, Jain R, Gilhotra RS, Newland HS. Sutureless vitrectomy. Indian Journal of Ophthalmology.
2008;56:453-458.
5. Donati G, Kapetanios AD, Pournaras CJ. Complications
of surgery for epiretinal membranes. Graefe’s Archive for
Clinical and Experimental Ophthalmology. 1998;236:739-746.
6. Thompson JT.Vitrectomy for epiretinal membranes with good visual acuity. Transactions of the American Ophthalmological Society 2004;102:97-106.
Case Report – George is having
problems with his glasses
Thirty-year-old George presented to his
optometrist with blurry vision in his left eye.
His last eye examination was 18 months ago.
George has had glasses on a number of occasions
in the past. However, he has always found it difficult
to adapt to new glasses and so hasn’t persisted
with wearing them. What could be the problem?
Instrument for discussion
The Pentacam HR is an instrument that is very
useful for the examination of the anterior eye.
For more information on its application and
interpretation, see the next issue of IMAGE.
Centre For Eye Health
CFEH is a free referral service assisting eye-care practitioners to optimally manage their patients.
With 24 state-of-the-art instruments in one location, the Centre offers a range of advanced eye
imaging and visual assessment services.
Contact Details
Our Clinical Staff
Centre for Eye Health
Professor Michael Kalloniatis, Director BSc Optom, MSc Optom, PhD, GradCertOcTher
The University of New South
Wales
Rupert Myers Building (south
wing), Kensington NSW 2052
Associate Professor David Pye, Deputy Director BOptom (Hons), MOptom, FCLSA
Ph: (02) 8115 0700/1300 421 960
Fax: (02) 8115 0799
Email: [email protected]
Paula Katalinic, Principal Optometrist BOptom (Hons), MOptom, GradCertOcTher
Consultant ophthalmologists through South Eastern Sydney Illawarra
Area Health Service
Anna Delmadoros, Principal Optometrist BOptom (Hons), MOptom
Dr Andrew Whatham, Principal Optometrist BOptom (Hons), DPhil, GradCertOcTher
Michael Yapp, Principal Optometrist BOptom (Hons), MOptom, GradCertOcTher
Agnes Choi, Optometrist BOptom, GradCertOcTher
George Rennie, Optometrist BOptom (Hons)
Disclaimer: This newsletter is not intended to provide or substitute advice through the appropriate health service providers. Although every
care is taken by CFEH to ensure that this newsletter is free from any error or inaccuracy, CFEH does not make any representation or
warranty regarding the currency, accuracy or completeness of this newsletter.
Copyright: © 2010, Centre for Eye Health Limited. All images and content in this letter are the property of Centre for Eye Health Limited and
cannot be reproduced without prior written permission of the Director, Centre for Eye Health Limited.
Printed: February 2010 on recycled paper.
Centre for Eye Health is an initiative of Guide Dogs NSW/ACT and The University of New South Wales
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cfeh.com.au