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image 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? image 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. page 2 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 page 3 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 page 4 cfeh.com.au