YAG Laser Vitreolysis

Treating Floaters with YAG Laser Vitreolysis

Many people suffer from vitreous floaters, while benign in nature they can become quite frustrating and troublesome. Eye floaters can be clumpy or stringy; light or dark – they are caused by clumps or specks of undissolved vitreous gel floating in the dissolved gel-like fluid (vitreous) in the back of the eye, which then casts a shadow on the retina when light enters the eye. Taking the concerns of patients seriously, and treating them with either YAG laser vitreolysis or floater only pars plana vitrectomy, can make a significant improvement to their everyday quality of sight.

Though not new, YAG laser vitreolysis has advance to a degree that allows the successful relief of symptoms from troublesome floaters in many patients. The inability to superimpose the illuminating light source of the laser with the path of the laser beam has been a problem. The goal of treatment is to disrupt floaters into smaller fragments rather than vaporize them. However, a new design to the YAG laser, developed by Ellex in Australia, has combated this issue by allowing superimposition of the viewing, lighting and treating axes. The YAG laser causes optical breakdown of vitreous opacities converting them to gas which leaves the eye via the retinal venous vasculature. If remnants of the posterior capsule following capsulotomy are hit by a YAG laser, they fragment rather than vaporize. This is seen with direct visualisation as a solid chunk of matter becoming a gas bubble and rising in the vitreous cavity.

How the Procedure is Performed:

The pupil needs to be maximally dilated. Topical anaesthesia is used to allow a contact lens to be placed on the eye but the procedure itself is painless. No sedation is necessary. Generally, it takes about 10-15 minutes. There are no known long term risks with the YAG laser vitreolysis, however it is possible to damage the crystalline lens (causing an instant cataract), hit the retina (causing a retinal burn) or cause a rise in intraocular pressure.

If you suffer from floaters, we encourage you to come in for an assessment and speak to one of our highly trained professionals to determine if you are suitable for the treatment.


New treatment to fight against sight loss caused by AMD

Patients regain sight after being first to receive retinal tissue engineered from stem cells

  • Successful trial on patients using new stem cell based treatment for wet age-related macular degeneration (AMD).
  • Results from a clinical study suggest the treatment is safe and effective.
  • The study is a major milestone for the London Project to Cure Blindness and could lead to an ‘off-the-shelf’ treatment within five years.

The first patients to receive a new treatment derived from stem cells for people with wet age-related macular degeneration (AMD) have regained reading vision.

The results of this ground-breaking clinical study, published in Nature Biotech, described the implantation of a specially engineered patch of retinal pigment epithelium cells derived from stem cells to treat people with sudden severe sight loss from wet AMD. It is hoped that it will also help treat dry AMD in the future.

It’s the first description of a complete engineered tissue that has been successfully used in this way.

The study is a major milestone for the London Project to Cure Blindness, a partnership between Professor Pete Coffey from University College London and Professor Lyndon da Cruz, a retinal surgeon at Moorfields Eye Hospital NHS Foundation Trust.  The Project has also been supported by the UCL Institute of Ophthalmology and the National Institute for Health Research (NIHR).

AMD is the most common cause of sight loss in the UK, and can lead to a rapid loss of central (reading) vision. The two patients who underwent the procedure, a woman in her early 60s and a man in his 80s, had the severe form of the condition (wet AMD) and declining vision.

The study investigated whether the diseased cells at the back the patients’ affected eye could be replenished using the stem cell based patch. A specially engineered surgical tool was used to insert the patch under the retina in the affected eye of each patient in an operation lasting one to two hours.

The patients were monitored for 12 months and reported improvements to their vision. They went from not being able to read at all even with glasses, to reading 60-80 words per minute with normal reading glasses.

Photo of Douglas Waters, patient to receive trial treatment.

Douglas Waters, 86, from Croydon, London, was one of two people who had received the treatment at Moorfields Eye Hospital. He developed severe wet AMD in July 2015 and received the treatment three months later in his right eye. He says: “In the months before the operation my sight was really poor and I couldn’t see anything out of my right eye. I was struggling to see things clearly, even when up-close. After the surgery my eyesight improved to the point where I can now read the newspaper and help my wife out with the gardening. It’s brilliant what the team have done and I feel so lucky to have been given my sight back.”

Professor Lyndon da Cruz, consultant retinal surgeon at Moorfields Eye Hospital NHS Foundation Trust said:

“The results suggest that this new therapeutic approach is safe and provides good visual outcomes. The patients who received the treatment had very severe AMD, and their improved vision will go some way towards enhancing their quality of life. We recognise that this is a small group of patients, but we hope that what we have learned from this study will benefit many more in the future.”

Professor Pete Coffey, UCL Institute of Ophthalmology said:

“This study represents real progress in regenerative medicine and opens the door to new treatment options for people with age-related macular degeneration. We hope this will lead to an affordable ‘off-the-shelf’ therapy that could be made available to NHS patients within the next five years.”

Robert Dufton, chief executive of Moorfields Eye Charity said:

“The results from this trial are fantastic and the culmination of years of research by the London Project team. Philanthropy has played a critical role in the London Project since its inception and we are delighted that this support continues through Moorfields Eye Charity. This ground-breaking milestone demonstrates the real impact philanthropy plays in creating life-changing moments, such as helping someone regain their sight.”

Successful trials of new treatment at Moorfields in fight against sight loss caused by AMD

Glaucoma Research: A Year of Progress

Glaucoma Research: A Year of Progress
Dr. Simon Skalicky & Clin Assoc Prof Andrew White | 28 February 2018

Greater knowledge of disease risk factors, new approaches to detection and monitoring, and innovative treatments are positively impacting glaucoma outcomes.
Over the past year we’ve seen a continued shift towards surgical/laser management of glaucoma, coupled with depot preparation medication trials rather than drop therapy. A major prospective trial looking at the efficacy of depot bimatoprost intracamerally has just finished recruiting (ARTEMIS 1) and two more are still underway (ARTEMIS 2 and ATHENA). Other similar trials are underway as well as assessment of an ocular ring releasing bimatoprost.1,2

Should We Add Vitamin B3 to the Water?
The paper with the biggest potential therapeutic impact this year described the potentially protective role of Vitamin B3 in glaucoma. A team from the Jackson Labs in the US fed vitamin B3 to mice prone to ocular hypertension, resulting in a significant reduction in the risk of ganglion cell death. This effect was even greater than targeted gene therapy treating the proposed metabolic/inflammatory pathway implicated in the disease process.3 Small scale clinical trials have already started. Much like the findings from the Nurses Health Study and nitrates, there seems to be an increasing role for dietary and nutritional supplementation in preventing glaucoma and/or halting progression.4

Minimally Invasive Glaucoma Surgery
Undoubtedly in 2017, glaucoma clinical practice focused on minimally invasive glaucoma surgery (MIGS).

MIGS represents a broad group of small surgical devices characterised by minimal conjunctival dissection, short operating times, rapid recovery and a good safety profile. This is a rapidly expanding field with trans-trabecular devices (eg iStent, Glaukos), increasingly performed in conjunction with cataract surgery.

Other devices are available, with a growing body of supportive data, such as the Cypass (Alcon), which creates a cyclodialysis cleft and drains to the suprachoroidal space and the Hydrus microstent (Ivantis), a fenestrated curved tube that enters, passes through and dilates Schlemm’s canal.

Currently, Medicare restricts the use of these devices to only at the time of cataract surgery, although work is underway to expand the availability for the procedure to a wider body of glaucoma patients, and potentially allow stand-alone MIGS procedures.

There is still a scarcity of robust MIGS scientific data. A meta-analysis of all MIGS papers released up until 2016 found that while overall safety data from MIGS is reassuring, good head-to-head random clinical trials comparing MIGS devices to one another or to traditional glaucoma surgery is lacking.5 As clinicians in this field, it is imperative we collect quality local data that evaluates MIGS in real-world clinical practice, and audit through communal software platforms such as the Save Sight Registry.*

Hydrus was compared head-to-head with selective laser trabeculoplasty (SLT) in a small (n=56) case series. Hydrus resulted in a greater reduction in medication dependence than SLT at 12 months.6

Filtration Surgery
Glaucoma filtration surgery (eg. trabeculectomy, tube surgery) involves creating an aqueous drainage pathway from inside the eye to the subconjunctival space. Some preliminary results have been released for the Primary Trab vs. Tube Study (PTVT) that attempts to settle the question as to whether a primary drainage tube may be better than trabeculectomy as a first surgical procedure for glaucoma. In a word, no.7,8 IOP control was better in the trabeculectomy group, especially in those with lower starting IOP. The complication rate was similar despite more early complications/interventions in the trabeculectomy group.

The Xen Gel Implant (Allergan) is a soft collagen implant that is inserted, ab interno, from the anterior chamber into the subconjunctival space creating a bleb. In many ways it is more similar to traditional filtration surgery than to other MIGS devices. It is increasingly used as an alternative to trabeculectomy, although quality head-to-head studies comparing Xen to trabeculectomy are few.

The Xen was shown to be effective in uveitic glaucoma, despite the potential for sight-threatening complications of hypotony, bleb infection9 or suprachoroidal haemorrhage10 (ie similar complications to a trabeculectomy).

Lasers in Glaucoma
The efficacy and safety of SLT in the treatment of open angle glaucoma (OAG) continues to be supported by the literature. SLT was evaluated in Afro-Carribeans with primary OAG (POAG) and found to have a 12 month success rate of 78 per cent.11 In Belgium, SLT was evaluated as replacement therapy for medically controlled OAG; it was able to completely replace medical therapy in 77 per cent of eyes after 18 months12 and improved treatment related quality-of-life (QoL)13 with similar efficacy between phakic and pseudophakic eyes.14 However, when 24-hour IOP rhythm was evaluated by the contact lens sensor Triggerfish, SLT was not shown to alter the amplitude or pattern of the IOP rhythm.15

Angle Closure and Glaucoma
Angle closure is frequently missed, both among patients referred for cataract surgery who are often dilated without prior gonioscopy, and among patients with POAG who can develop phacomorphic angle closure with age. Two studies from Canada elegantly demonstrated this; of patients referred for cataract surgery, 1.5 per cent were found to have undetected narrow angles,16 and one in 11 patients, with a diagnosis of OAG referred to a tertiary glaucoma centre, were found to in fact have angle closure.17

Dysphotopsia is a rare but debilitating complication of laser peripheral iridotomy (LPI). Previous data suggested the frequency of this can be reduced by temporal placement of the LPI.18 However, a larger (n=595) Indian/US RCT found that location, LPI size, and amount of laser energy used did not affect the frequency of dysphotopsia reported.19

Another large Indian study confirmed that LPI hastens the development of cataract.20 These findings support the landmark EAGLE study that compared early clear lens extraction (CLE) to laser iridotomy in the management of primary angle closure glaucoma (PACG). CLE showed greater efficacy and was more cost-effective than laser iridotomy.21

Externally applied micropulse cyclophotocoagulation (M-CPC) is an alternative mode of laser delivery to continuous wave cyclophotocoagulation (CW-CPC). Micropulse has a high post-treatment inflammation rate (46 per cent after three months) and a similar but potentially lower complication profile than CW-CPC.22 More head-to-head studies are required comparing micropulse to continuous wavelength and to endoscopic CPC to better elucidate this rapidly developing technology.

Monitoring and Detection
We have yet to improve the 50 per cent undiagnosed glaucoma rate in Australia. However, new advances in diagnostic technology, a greater drive for optometry-led detection, and an emphasis on first-degree relative screening such as through the TARRGET study may improve the detection rate.

Australian-developed tablet-based perimetry has the potential to revolutionise glaucomatous monitoring, allowing home or waiting-room self-screening for glaucoma. It is easy to use and sensitive to glaucomatous progression.23,24

Three separate studies have confirmed the importance of central (eg 10-2) visual fields in glaucoma diagnosis to complement 24-2 fields; the latter might miss early glaucomatous defects. This trend persisted irrespective of the type of field machine used.25-27 Furthermore 10-2 changes had a greater impact on vision-related quality of life (QoL) than 24-2 changes.28

The frequency of monitoring for glaucoma patients continues to vex strained clinics. One study found twice yearly visual field testing had similar sensitivity to thrice yearly for detecting glaucoma progression, provided two quality baseline tests were available for reference.29 These findings support the UK Glaucoma Treatment Study, in which a few early visual fields established a firm baseline; this allowed sensitive detection despite greater intervals between later field tests.30

OCT-angiography (OCT-A) continues to be explored in glaucoma. Adding to vascular loss previously described at the optic nerve head, new studies have found macular vascular density declines in glaucoma.31,32 However this finding was not consistent; one study found the macular vessels were spared in glaucoma.33 In addition, the diagnostic sensitivity of OCT-A is lower than traditional OCT metrics (RNFL and MGC complex thickness).33

One drawback of OCT analysis glaucoma is a floor effect of the peripapillary RNFL (sensitivity is lost in advanced disease). In agreement with prior studies, the ganglion cell inner plexiform layer metric was again shown to be more sensitive for advanced glaucoma than the peripapillary RNFL and continued to demonstrate progression once the RNFL had reached its floor effect.34,35

More data has supported the water drinking test, finding IOP spikes induced by the water-imbibed challenge were predictive of future glaucomatous progression.36

The Genetics of Glaucoma
The last few years have seen an explosion of genes identified in glaucoma pathogenesis. Novel loci include: for POAG (ABCA1, AFAP1, GMDS, PMM2, TGFBR3, FNDC3B, ARHGEF12, GAS7, FOXC1, ATXN2, TXNRD2); PACG (EPDR1, CHAT, GLIS3, FERMT2, DPM2-FAM102); and pseudoexfoliation syndrome glaucoma (CACNA1A).37 There are so many genes implicated that work is beginning to move towards better phenotyping of glaucoma for targeted gene studies, and studies looking at the functionality of these genes and interactions with each other (ie. is it combinations of gene anomalies rather than a single gene that is causative?). Stay tuned.

Health, Socioeconomic and Lifestyle Factors
Smoking was the smoking gun for glaucoma in 2017. A Spanish cohort population study of 16,797 participants over 8.5 years demonstrated a direct association between current smokers and glaucoma incidence, and the risk increased with number of pack-years.38

Additionally, a retrospective study looking at risk factors for rapid glaucoma progression showed rapid progressors were older, had significantly lower baseline IOP and central corneal thickness, and significantly higher rates of cardiovascular disease and hypotension.39 Further prospective study needs to be done to better understand the pathophysiology behind this finding.

A Taiwanese study evaluated the influence of different socioeconomic factors on vision-related quality of life in glaucoma. A lower education – but not income – affected QoL detrimentally, suggesting the importance of additional counselling for patients with a lower educational level to help them cope with the disease.40

Other Medical Therapies
Drug development for new glaucoma therapies has been slow but continues.

Rhopressa (Netarsudil 0.02 per cent) is a once daily topical agent with two mechanisms of action and two targets. Rhopressa targets rho-kinase (ROCK) and a norepinephrine transporter (NET). Trial results (ROCKET1-4) yet to be published seem promising. The most common side effect was mild redness of the eyes.

A combination product, Roclatan, is a once daily, combination of netarsudil 0.02 per cent + latanoprost 0.005 per cent made by the same company (Aerie Pharmaceuticals). Initial results from two trials (Mercury 1 and 2) also seem promising.

A new pathway for treatment was discovered this year that may also show promise. The angiopoietin-Tie2 system is crucial in the development and maintenance of Schlemm’s canal and hence IOP control. Antibody mediated activation of Tie2 resulted in an increase in drainage apparatus in Schlemm’s canal when injected in mice. Further development of this pathway may lead to a new IOP lowering agent in the future.37

As clinical and laboratory science marches forward, we must stay nimble in our approach to clinical practice, and translate the new knowledge into better, more efficient and more inclusive glaucoma care delivery to all patients.

Clinical Associate Professor Andrew White is a clinician scientist ophthalmologist at Westmead Hospital with a subspecialty interest in glaucoma. He is a Clinical Senior Lecturer and has research affiliations with the University of Sydney at both the Save Sight Institute and Westmead Millennium Institute where he has an active laboratory. Clin.Assoc. Prof. White has multiple peer-reviewed scientific publications and published conference abstracts. He is a regular invited speaker at overseas conferences and is actively involved in training medical students, registrars and fellows in cataract and glaucoma. He also lectures optometrists and optometry students in Glaucoma.

Dr. Simon Skalicky, FRANZCO, PhD, BSc (Med), MPhil, MMed, MBBS (Hons 1) is a glaucoma subspecialist in Melbourne. He is a Clinical Senior Lecturer at the University of Sydney and University of Melbourne. Dr Skalicky is widely published and actively involved in teaching. He is a federal Councillor for Glaucoma Australia and Associate Advisory Board member for the World Glaucoma Association. Dr. Skalicky specialises in glaucoma and cataract surgery.

*To find out more about participating in the Save Sight Registrar Glaucoma module visit: https://frbresearch.org/au


FOCUS Progress

Thank you to everyone who attended our annual ophthalmic day surgery and consulting services education evening, FOCUS Progress last week! We hope you had a fantastic evening meeting new people and learning everything on offer at FOCUS Eye Centre from our team.


common eye myths

Busting Common Eye Myths

Can carrots help you see better?

I’m sure we’ve all heard it before, carrots are here to save the day and cure us of all our eyesight problems. But is it true?

We are busting this myth wide open and we are happy to report that yes carrots can contribute to better eye health. Eating carrots will provide you with the small amount of Vitamin A needed for good vision, but they are one of many natural sources of Vitamin A – which is essential for keeping your eyes healthy! Milk, fish, broccoli, sweet potatoes, pumpkin and dark-green leafy vegetables such as spinach, kale and silver beet are all rich sources of Vitamin A.

Making sure your diet is jam-packed with Vitamin A can help lessen the chance of developing night blindness as well as other eye problems including vision loss. While not common in Australia, vision loss due to a lack of Vitamin A can still occur if your diet is particularly poor. Those most at risk are adults and children with restricted diets, pregnant women and those with bowel disease.

As one of the most common eye myths, eating carrots is an easy way to maintain and contribute to better eye health. Eating a healthy, well balanced diet contributes to your overall health and wellbeing as well as your eye health. Other important dietary nutrients for eye health include; Omega-3 (sources include all fish and shell fish, fish oils containing liver and butter), Zinc (sources include oysters, seafood, nuts and legumes), vitamin E (sources include nuts and whole grains), vitamin C (sources include citrus fruit, berries and tomatoes), and selenium (sources include nuts).

We welcome you to our centre for an assessment or please feel free to contact our friendly staff with any inquiries.

Donate Life

The Precious Gift of Sight – Donate Life

The Precious Gift of Sight

Did you know that the first ever successful organ transplant occurred in 1905! This was a cornea transplant performed in Austria and at a time where there were no medications and no anesthetics. Both eyes were operated on, and one of the transplants worked giving this blind man vision for over 40 more years.
Cornea donation is a gift of sight possible by most people within the community, last year in NSW / ACT the Lions NSW Eye Bank had 424 donors that made this sight saving decision. The gift from these people and the support from their families allow the gift of sight to more than 700 patients within our community. In NSW we have highly trained corneal surgeons who are able to perform sight saving surgery with these donations.
At Focus Eye Centre our surgeons also perform such transplants and we would like to thank the donors and their families also for their precious gift.
If you wish more information about eye and organ donation please follow the link to the Donate Life website. Please consider also being a organ/tissue donor.
Dr Con Petsoglou MB BS, MMed(Clin.Epi), FRANZCO
Senior Lecturer / Postgraduate Coordinator
Save Sight Institute, Discipline of Clinical Ophthalmology

Deputy Director, Lions NSW Eye Bank
University of Sydney
Glaucoma Awareness Week

Glaucoma Awareness Week 2018

Glaucoma Awareness Week 2018

Glaucoma Awareness Week campaign aims to find 150,000 Aussies who are unaware they have glaucoma.

Despite being the world’s leading cause of irreversible blindness, more than 10 million Aussies do not automatically think to have a simple eye exam by an optometrist or ophthalmologist which can save their sight. This means they are potentially suffering preventable but irreversible blindness.

More than 300,000 Australians have glaucoma, yet only 50% have been diagnosed, typically because they lack noticeable symptoms and haven’t had a simple eye exam.

Anyone may develop glaucoma, but the incidence increases with age.  About 1 in 10,000 babies are born with glaucoma, by age 40, about 1 in 200 have glaucoma, rising to 1 in 8 at age 80. Overall the incidence in Australia is about 2.3% of the population.

During World Glaucoma Week, 11 – 17 March 2018, Glaucoma Australia is encouraging relatives of those with glaucoma to have a comprehensive eye exam by an optometrist or ophthalmologist from age 40 and every 2 years ongoing.

orthoptics awareness week, Sydney Orthoptists

Orthoptics Awareness Week 2018

This week we celebrate Orthoptics Awareness Week!

Discover the Depth of Orthoptics

Who are Orthoptists and what do they do?

Orthoptists are eye health professionals who care for patients with eye disorders. Through a unique set of skills, orthoptists play a crucial role in the detection, diagnosis and management of eye diseases in both adults and children. The tests performed by the orthoptist play a crucial role in aiding the Ophthalmologist to diagnose and treat several eye conditions.

How does orthoptics differ from other eye health professions?

With speciality university training, orthoptists possess a unique and versatile set of skills in eye health; depending on the setting, orthoptists may be responsible for a variety of eye health practices.

As an example, an orthoptist may be primarily responsible for the pre- and post-operative care of patients with cataracts. This involves undertaking a number of investigations to determine the patient’s potential vision, surgical requirements including the optical lens to be inserted in the eye during surgery and the prescribing of glasses.

To perform these investigations, orthoptists are highly trained in using specialised technology to detect and measure the progression of eye disease – these include instruments such as ultrasonography machines, (A-scans, B-scans and pachymmeters), topogrophers (Ocular Coherence Tomographer (OCT), Orbscans) and retinal cameras.

Orthoptists may also prescribe management programs for those with conditions such as refractive error (need for glasses), double vision, neurological disorders and ocular motility disorders, as well as aiding in the rehabilitation of impaired vision.

In contrast, an optometrist is a primary care practitioner who examines eyes, gives advice on visual problems, and prescribes and fits glasses or contact lenses. If eye disease is detected, an optometrist will generally refer patients to a specialist for further management.

An ophthalmologist is a medical doctor who has undertaken additional specialist training in the diagnosis and management of disorders of the eye and visual system. Ophthalmologists can prescribe medication and perform surgical procedures in the management of eye disease. Often, an orthoptist and ophthalmologist will work collaboratively together in investigating and managing diseases of the eye.

laser eye surgery, latest technology in ophthalmology

Latest technology at FOCUS Eye Centre

In 2018 we continue to offer our patients the latest technology in eye care.

For patients with a cataract, based on your assessment, we may be able to offer you the latest generation of multifocal intraocular implants, which aim to give patients functional distance, intermediate and near vision and may reduce your need for spectacle correction.
For patients interested in laser eye surgery, you may be a candidate for SMILE, LASIK or PRK refractive surgery allowing you to say goodbye to your glasses or contact lenses.
We routinely screen all patients for glaucoma and macular degeneration using the latest imaging technology and offer treatment options where suitable, such as minimally invasive glaucoma surgery (MIGS).
Our dedicated clinical team continues to attend annual conferences and training to stay up to date and well versed in the latest technology in ophthalmology.

We welcome you to our centre for an assessment or please feel free to contact our friendly staff with any inquiries.