Annual Mooney Lecture 2024 – focus on TED

Prof Geoffrey Rose, Consultant Orbital, Lacrimal and Plastic Reconstructive Surgeon, Moorfields Eye Hospital, London, UK, delivered this year’s Annual Mooney Lecture 2024 at the Irish College of Ophthalmologists (ICO) Annual Conference 2024.

The lecture was on the subject of trends in rehabilitation of patients with thyroid eye disease (TED).

 The historical treatment of TED relied on leaving the condition to ‘burn out’. This often took one-to-two years.

The treatment was then directed towards surgical attempts to reverse the structural changes that have occurred – in some cases these were very severe.

Many patients were unhappy with the outcomes of rehabilitation at that time.

Four decades ago, changes in treatment were largely directed to improving surgical techniques to allow a better restoration of function and appearance, with less injury to neighbouring tissues, Prof Rose explained.

From the 1990s, it was widely recognised that the final functional deficit and aesthetic disturbance could be reduced considerably by shortening the inflammatory phase of TED.

Early immunosuppressive regimes were based on various regimes for systemic corticosteroids, either oral or intravenous (and occasionally intraorbital administration). These early regimes were modified by adjunctive use of steroid-sparing agents and, in some cases, use of low-dose orbital radiotherapy.

 More recently, the immune response has been mollified with monoclonal antibodies – such as rituximab — directed against the inflammatory mediators or cells. Over the last 20 years, it has been shown that changes of TED appear to be produced through an immune activation of the TSH-receptor and IGF1-receptors, two membrane-bound receptors that are co-localised on the surface of orbital fibroblasts; this activation leads to the characteristic hyaluronate deposition and adipogenesis.

With the recent proliferation of biological therapeutics, the treatment of TED is now very much directed towards blocking activation of the TSH and IGF1 receptor pathway. Early biological agents directed against IGF-1 receptors have shown an excellent effect on the active phase of TED, and also some activity in the apparently ‘burnt-out’ phase of the condition; usage of these drugs can, however, have some major side-effects, Prof Rose noted.

Meanwhile, Mr Michéal O’Rourke, Consultant Ophthalmic Surgeon, Royal Victoria Eye and Ear Hospital, St James’s Hospital and Children’s Health Ireland (CHI) at Crumlin, Dublin, delivered this year’s European Society of Ophthalmology Lecture 2024, on the topic of paediatric oculoplastics.

This topic was included within the scope of Mr O’Rourke’s Fellowship training at Manchester Royal Eye Hospital, UK, and Melbourne Children’s Hospital, Australia, with specific allocation to clinic and surgical sessions for paediatric oculoplastics. A similar blueprint was utilised in establishing an oculoplastic service at CHI Crumlin with the aim of treating all such patients which streamlines their care. A review and update on various paediatric oculoplastic conditions was presented by Mr O’Rourke at the ICO 2024 Annual Conference.

William Wilde Medal 2024

Dr Patrick Murtagh received the Sir William Wilde Medal for the Best Poster at the ICO Annual Conference 2024.

Dr Murtagh, who is currently undertaking a Fellowship in Ocular Oncology at Liverpool University Hospital in the UK following the completion of his ophthalmic surgical training in Ireland, was awarded the prize for his poster ‘Local Tumour Control and Visual Outcomes in Uveal Melanoma (UM) Patients Treated with Iodine Plaque versus Ruthenium Plaque versus Proton Beam Radiation: A Ten-Year Review’.

UM is the most common intraocular tumour in adults. It has a high rate of metastases and in some studies as many as 50 per cent develop metastases over a 10-year period. Ireland has a high rate of UM when compared with incidence rates in Europe and the rest of the world.

The mean age-adjusted incidence of UM in Ireland is reported to be 9.5 per million of the population.

Also, Prof Brendan Kelly, Consultant Psychiatrist, Tallaght University Hospital, Dublin and Professor of Psychiatry at Trinity College Dublin, was a guest speaker at the conference.

Prof Kelly delivered a presentation on ‘Pandemics in Ireland, and Lessons Learned (if any)’. 

The history of similar events in history was explored through the work of Sir William Wilde, Victorian eye doctor and father of playwright Oscar Wilde.

 Prof Kelly’s talk reflected on the mental health impact of the Covid-19 pandemic in Ireland, what we might learn as a society, and what pandemics teach us about ourselves: “Our proclivity to panic is enormous”.

Spina bifida project winner of Barbara Knox Medal

Dr Shane O’Regan, ICO Higher Medical Trainee, CHI at Temple Street, Dublin, was the winner of this year’s Barbara Knox medal for best paper at the ICO Annual Conference, for his research on ophthalmic manifestations of spina bifida in Irish children.

 There is a significant lack of data on this cohort internationally, thus the findings are important and will help inform the creation of local guidelines for assessing and treating these patients, Dr O’Regan told the Medical Independent.

 Dr O’Regan and colleagues carried out a comprehensive review of the medical records of 239 children with spina bifida at Temple Street, spanning a two-decade period from December 1999 to March 2020.

 The findings underscore a substantial incidence of varied ocular and visual pathway involvement. Overall, while most children had good vision (6/9), strabismus and refractive errors are very common. Those with higher neural tube defects had worse vision and more refractive error. Notably, papilloedema was found in about one in ten children with spona bifida, but optic atrophy (5.9%) and cortical visual impairment (2.4%) were very low, and the rate of strabismus was ten times that of the normal population.

 In conclusion, this extensive retrospective chart audit provides useful insight into the multifaceted ophthalmic manifestations associated with spina bifida, enhancing understanding and highlighting the need for careful ophthalmic monitoring within this demographic to address potential pre-emptive visual sequelae.

Sustainability in healthcare an issue for all clinicians

There are many ways in which the healthcare system can reduce its carbon footprint and excess wastage but clinicians really need to ‘buy in’ to sustainability and lead by example, a dedicated symposium on the topic during the ICO 2024 Annual Conference in Westport heard.

 The session featured a number of national and international speakers looking at how healthcare, and in particular ophthalmology, can become more sustainable.

Cataract surgery is the number one surgical procedure in Ireland carried out by volume, and utilises a high amount of consumables and energy, and generates significant waste, the session heard.

However, more efficient workloads and appointment approaches, increased re-use of single use items (once appropriately sterilised), and getting rid of excess packaging, excessive spare consumables, and long drapes can really improve the situation, Dr Alison Greene, ICO Surgical Trainee, said during her paper presentation earlier that day, looking at the specific carbon footprint of cataract surgery in University Hospital Waterford and efforts to reduce it.

Dr Philip Crowley, HSE National Lead for Climate Change, outlined the details of the HSE Climate Action Strategy 2023-2050 and efforts to reduce emissions and protect population health in the Irish healthcare system. The HSE is retrofitting and improving many of its older buildings to make them more energy efficient, with some facilities now self-sustainable energy wise having been fitted with solar panels, while newer buildings are being designed to be as energy efficient as possible. The HSE is also continuing to work with international partners to pressurise its supply chain to reduce packaging waste and become more sustainable, as well as improving recycling and re-use practices and reminding healthcare staff to be more mindful of unnecessary energy and resource wastage, Dr Crowley said.

He noted that climate change has a significant impact on healthcare systems in relation to disease trends, and even flooding and storm damage to healthcare facilities.

 Also speaking during the session, Mr Arthur Cummings, Consultant Ophthalmic Surgeon, Wellington Eye Clinic, Dublin, discussed the growing burden of ophthalmic needs building globally while the number of ophthalmologists is decreasing.

 “The only way that we are going to be able to deal with this situation is to become more efficient and effective while we address the shortage of ophthalmologists.”

 Mr Cummings focused on three areas that can help ophthalmology achieve greater efficacy and efficiency, namely system design, the use of artificial intelligence (AI), and maximising the role of optometry. He said that AI can be extremely useful for note taking and summarising patient consultations, as well as reducing administrative burden in helping organise patient appointments and data, and also in the area of helping guide clinical decision making.

Ms Radhika Rampat, Consultant Ophthalmic Surgeon, Royal Free London NHS Trust, London, gave a virtual presentation during this session entitled  ‘Sustainability in Ophthalmology – How can I act locally and share globally?’

She discussed the development of the American European Congress of Ophthalmic Surgery – Green Working Group, and outlined a number of tips and examples from other countries for how to make ophthalmic practice more efficient and sustainable.

Over 200 specialists from around the country attended this year’s ICO Annual Conference, which took place at the Knockranny House Hotel, Westport from Wednesday 15 to Friday 17 May.