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BIPOSA comes to Dublin

According to the BIPOSA 2016 Annual Meeting convenor Mr Donal Brosnahan, Consultant Ophthalmologist, Royal Victoria Eye and Ear Hospital (RVEEH), Dublin, the paediatric ophthalmology event attracted 340 delegates and saw 220 research abstracts submitted for consideration. 

The BIPOSA programme ran over three days, from 12-14 October in Dublin Castle, and included symposia, a video symposium, free paper sessions and e-poster displays, with a number of high-profile Irish and international speakers and research presentations.

“The meeting had a record attendance and proved very popular with adult ophthalmologists, not just paediatric ophthalmologists. In Ireland, you can be on the register as an ophthalmic surgeon as well as an ophthalmologist, so many of our ophthalmologists work in the community, which is a model that they don’t have in the UK, so paediatric ophthalmology comprises a very significant part of their workload,” Mr Brosnahan told the Medical Independent (MI).

“Most ophthalmologists don’t need to understand a lot about vision but paediatric ophthalmologists do, because we are working with children, we are seeing patients during a critical period when vision is developing, so any interruption in that process is going to impact on their vision for life. It is therefore important to understand how vision develops and what the effects of any disruption in that development will have on the child, in terms of vision, stereo vision, depth perception and motor perception. Ophthalmologists working with adults; that is not part of the equation at all, as their vision is already fully formed. 

“For this reason, we have always interacted with vision scientists who research early visual development and throw light on how we might evaluate treatments which best facilitate normal visual development,” he explained.

ROP

The meeting featured a major session on retinopathy of prematurity (ROP), which was chaired by Prof Michael O’Keeffe, Consultant Ophthalmologist at Temple Street Children’s University Hospital, Dublin.

ROP occurs in premature babies and can cause retinal detachment, leading to blindness. Some cases of ROP are mild and correct themselves, but others require treatment with laser eye surgery to prevent vision loss or blindness, though intraocular anti-VEGF (vascular endothelial growth factor) injections have now emerged as a successful treatment option.

In Ireland, babies who are born before 30 weeks’ gestation have their eyes screened and if ROP is detected, these babies require treatment as soon as possible, within 36 to 72 hours.

“The session discussed the use of anti-VEGF injections for the most severe forms of retinopathy, what we would call ‘zone one ROP’, which previously had a very poor prognosis — more than half these patients develop retinal detachment and blindness in the eye, so it is a very significant improvement in the treatment of that group. ROP is still treated with laser, but in this particular group avastin is now the primary treatment,” Mr Brosnahan said.

He also noted that anti-VEGF injections can be administered in “the nursery and they don’t have to go to the operating theatre for a long procedure that can take a couple of hours to undertake in a baby, while the injection can be done in a short amount of time, with little disturbance to the infant”.

However, infants with ROP given anti-VEGF injections need longer follow-up than those who receive laser surgery, Mr Brosnahan added. “Long-term outcomes look promising but it is still early days… with more outpatient visits, there are manpower implications.”

An Irish paper presented at the meeting by Dr Claire Hartnett, SpR in Ophthalmology, RVEEH, and Prof O’Keeffe, showed that there were higher levels of myopia in laser-treated eyes versus bevacizumab-treated eyes. The prospective, randomised study (with six-year follow up) compared the results of using bevacizumab in one eye and laser in the fellow eye of 15 preterm neonates (30 eyes).

Anisometropia was significant between the two groups, with higher levels of anisometropia in zone one-treated eyes. The results showed there was a greater magnitude and higher prevalence of astigmatism in laser-treated eyes and that the risk of refractive amblyopia was higher in the laser group.

In summary, refractive results appear to be more favourable in bevacizumab-treated verses laser-treated eyes. The difference between the two treatments may be related to anterior segment development, which is adversely affected by laser treatment, concluded Dr Hartnett.

“I think in future it [anti-VEGF injections] will probably replace laser in most cases of ROP, once we titrate the doses more precisely,” Mr Brosnahan commented.

40-year follow-up

Dr Conor Malone, RVEEH, presented the findings of an Irish study of rhabdomyosarcoma cases in Ireland over the past 40 years. Orbital rhabdomyosarcoma is rare but it is the most common orbital tumour in children. The study, which was co-authored by Mr Brosnahan and Dr Jae Yee Ku, identified 21 cases over 40 years, all treated at Our Lady’s Children’s Hospital, Crumlin. The average follow-up was seven years, with the longest being 24 years. The study shows patients are assessed and treated according to the latest international guidelines, with excellent results, Dr Malone told the meeting. The most common complications, such as cataract and dry eye, are treatable and serious complications are rare, he reported.

Visual outcomes were excellent in the studied patients, with most patients achieving 6/9 or better. International studies report survival rates of 86-94 per cent and the study showed patients treated at Crumlin exceed this.

“Crumlin is a national centre for paediatric oncology so there was a register of all patients there, allowing the 40-year follow-up, which is a large study by any means. We compared the results with international norms and they fell favourably within those. Things have changed treatment-wise over the years. Initially, they didn’t all have chemotherapy but now they do and the older patients had radiotherapy. While almost all the patients survived — there was one death — they do have significant morbidity/problems related to treatment, particularly radiotherapy. They nearly all develop cataracts which need treatment, and they developed dry eyes from the radiotherapy. So while they do have problems, which require management, the visual outcomes at the end of the day are very good,” Mr Brosnahan said.

Genetics

The meeting also heard an update from Dr Emma Duignan, Clinical Fellow, RVEEH, on the Fighting Blindness Target 5000 project, which aims to provide genetic testing for the estimated 5,000 people in Ireland who have a genetic retinal condition. 

Mutations in over 200 genes have been implicated in inherited retinal disorders as a whole to date, with the result that traditional sequencing approaches are usually inadequate for the task of identifying causative mutations. The arrival of next-generation sequencing (NGS) technologies offers for the first time an opportunity to locate these mutations. Dr Duignan discussed her work on characterising all identified Irish patients with Usher’s syndrome using this technology. 

“We now have a population of patients that have been genetically characterised so that if treatments become available, we are able to identify where those patients are and enrol them in trials. It is such an exciting time in the development of genetic treatments for retinopathy and it is really important to characterise the retinopathies that exist in our patient population, as they may differ from other countries,” Mr Brosnahan explained. 

He also praised the “inspirational lecture” by Dr Jane Farrar, Professor of Molecular Genetics of Retinopathies, Trinity College Dublin, on finding the cause and designing the cure for inherited retinal degenerations. “Where they are working now was beyond our imagination really five, 10 years ago. The potential of new treatments, like genetic treatments for retinopathies, is amazing,” Mr Brosnahan said.

Strabismus

Mr Edward Loane, Strabismus/Neuro-Ophthalmology Fellow at Aintree University Hospital NHS Foundation Trust, and formerly RVEEH, presented a study looking at treatment of strabismus with intramuscular bupivacaine. The study found that it is a useful adjunct in the management of smaller-angle strabismus and can reduce or remove the need for prisms. The procedure uses the same equipment as for intramuscular Botox and the effect may be augmented with Botox injection to the antagonist muscle. Mr Loane said patients need to be warned that the effect takes time and the deviation will be worse before it gets better.

“That was an interesting study. It is a new tool in the management of small-angle strabismus, which will be useful in the treatment of this condition where surgery would not be considered appropriate,” Mr Brosnahan commented.

Paediatric uveitis

The meeting heard that childhood uveitis is frequently complicated by sight-threatening complications such as cataracts, macular oedema and glaucoma. Surgeons have always been cautious in implanting intraocular lenses in this cohort because of increased risk of adverse outcomes, Mr Brosnahan explained. Mr Michael O’Rourke, RVEEH, presented a review of children with uveitis having cataract surgery in Crumlin and the RVEEH, which demonstrated that with adequate immunosuppression such as anti-TNF, surgery can be undertaken safely with improved outcomes.

Glaucoma

The meeting’s Claud Worth Lecture was given by Prof Sir Peng Tee Khaw, Moorfields Eye Hospital, UK, who Mr Brosnahan described as a “world-renowned innovator in glaucoma”.

“He spoke about paediatric glaucoma and highlighted how much management has improved over the last 10-20 years. Visual outcomes are now much better for these patients due to improved medical and surgical management.”

For more information on BIPOSA, see www.biposa.org.

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