Insight May 2022

MAY

2022 INSIGHT AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

Dr Robert Harvey, 69, tried to map a succession plan, but ended up resigning in frustration.

WHAT TO DO WITH EXTREME DRY EYE? Dr Margaret Lam explores the use of anti-inflammatory agents to break the cycle.

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REGIONAL HOSPITAL LOSES OPHTHALMOLOGIST

26

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MAY 2022

Coming in May: HOYA MiYOSMART 6-year follow-up study, the 1st long term effectiveness results on myopia control spectacle lenses

SPOTLIGHT ON MACULAR DISEASE Special report on the potential intravitreal injection rebate cut and a new optometry pilot.

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With a network of over 350 partner-owned stores producing average annual sales of $3 million each, Specsavers continues to have a growing impact on the Australian eye care landscape – and also on the lives and livelihoods of our current army of 800+ optometrists, dispensing and audiology professionals who have joined us as partners in their own stores.

Profits are strong and sustainable, investment in technology is supporting ever improving health outcomes and our community partnerships are real and enduring with millions of dollars raised and distributed every year.

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Visit spectrum-anz.com or contact Kimberley Forbes on +61 (0)429 566 846 or kimberley.forbes@specsavers.com.

‘I DON’T’

want to be an owner in a group

that has uncertain store performance that requires personal bank borrowing to get started that doesn’t guarantee a regular salary that is a mix of partner-owned stores competing with company owned stores that under-invests in TV, radio and print marketing that is not committed to investing in OCT for every patient as part of standard eye care where community ‘partnerships’ may not be as real as presented

MAY

2022

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

REGIONAL SPECIALIST SHORTAGE BITES VIC HOSPITAL AS OPHTHALMOLOGIST DEPARTS An ophthalmologist nearing retirement is disappointed at the lack of action to find a replacement after he recently resigned from a regional Victorian public hospital, creating uncertainty for 150 patients on his surgical waitlist and thousands more attending clinics for chronic conditions like glaucoma and agerelated macular degeneration (AMD).

For several years Dr Robert Harvey has worked in a salaried position with Portland District Health (PDH). Aged 69, he requested a contractual change that would have seen him become a visiting medical officer (VMO).

This would have allowed him to practise from rooms while still performing surgery at Portland’s hospital. Importantly, it also would

have provided a pathway for him to seek and secure a successor VMO ophthalmologist for his patients, as he transitions to retirement.

Harvey finished at the hospital on 31 March, resigning due to frustrations with the hospital board who he said ultimately declined his VMO request.

Without a permanent replacement, he is concerned about the erosion of specialist services in Portland with other medical specialties affected in a similar way.

He recently launched a petition with other doctors from Portland concerned about a perceived agenda to reduce services. In the meantime, they say the hospital is devoting funds to more costly locums, also affecting trainee positions that require supervision by permanent staff.

in Portland on a salaried basis.

Attracting eye doctors to regional areas is already difficult in Australia, an issue highlighted by RANZCO at its congress in February.

Dr Robert Harvey has left Portland District Health with no obvious successor.

In response, PDH denied the hospital will be closed, downgraded or amalgamated, but did expect ophthalmology services to be impacted in the short-term with Harvey’s departure.

Without a VMO opportunity, Harvey said few ophthalmologists would be enticed to take up his work

“I wanted to become a VMO so the service would carry on,” Harvey, who has worked in south west Victoria and south east South Australia since 2013, said.

“There hasn’t always been an ophthalmology service in Portland.

There are plenty of people in the area and people are travelling long distances to see me already.

Now that I’m gone, I’m worried it will fall by the wayside and people will find it harder having to travel to Warrnambool (102km) and continued page 8

WINNERS AND LOSERS OF 2022-23 FEDERAL BUDGET The Federal Government has laid out a $132 billion health agenda for the coming year – if it regains power at the next election – and while there were no major wins for eye health, changes to the PBS safety net and small business incentives are expected to trickle down to the ophthalmic sector.

While there was nothing “revolutionary” for eye health and optometry, Optometry Australia (OA) said of interest within the health portfolio is additional investment across primary healthcare, rural healthcare, mental healthcare, the ongoing COVID-19 response, and the Medicare Research Future Fund.

On 29 March, Treasurer Mr Josh Frydenberg delivered the Federal Budget 2022-23 that had a particular focus on easing cost of living pressures and infrastructure projects in regional Australia.

Measures expected to positively impact optometry included:

Outgoing Federal Health Minister Mr Greg Hunt announced $132 billion in 2022–23 for his portfolio, increasing to $140 billion in 2025–26, with a total commitment of $537 billion over the next four years.

• Free interpreting services for allied health, with $1.95m spent over four years allowing allied health professionals access to the Australian Government’s Free Interpreting Services for patient care. OA is pursuing more details to share with members.

• Auslan services in primary health, with $600,000 allocated to a

scoping study to identify the need and opportunity to provide Auslan and spoken language services for patients who are deaf.

• A relatively small investment of $500,000 in allied health digital readiness, to work with the allied health sector to identify barriers to greater adoption of digital health tools. OA has been working with the Digital Health Agency for some time on identifying and addressing these barriers as they relate to optometry, and said it would continue to advocate for support to ensure optometry practice management software is integrated with initiatives such as My Health Record.

• I ncreased investment in scholarships for Aboriginal and continued page 8

IMAGING WITH CONFIDENCE A market-leading retinal imaging device was the final instrument WA optometrist Adrian Rossiter needed to modernise his equipment suite.

He discusses using the device in an optometry setting. page 38

IN THIS ISSUE MAY 2022

EDITORIAL

FEATURES

CATERING FOR OUR REGIONS The need for more regional ophthalmology services is nothing new for our sector, but recent events have brought the issue into stark focus.

It’s unsettling to learn in our lead story (page 3) the main ophthalmologist in Portland, Victoria, has left his post, with no obvious successor. This story has similarities to the profile on early-career ophthalmologist Dr Phoebe Moore (pages 18-19), who has returned to her Tamworth hometown where ophthalmology services have faced a near-critical shortage.

18

TIMELY HOMECOMING Dr Phoebe Moore has brought her overseas training back to Tamworth where it’s needed most.

20

COLLABORATIVE CARE Dr Jack Phu shares key lessons from a unique glaucoma clinic (0.75 CPD for optometrists).

Unfit policies and a lack of interest among doctors to permanently move out Country are compounded by Australia's sheer vastness.

Data shows the proportion of people without a specialist nearby increases from 6% in major cities, to 22% for inner regional areas, 30% in outer regional areas, and 58% for remote and very remote areas. Although outreach services plug some gaps, service delivery and healthcare variation is an issue RANZCO is addressing as part of its Vision 2030 and Beyond initiative.

At the Vision 2030 launch (pages 45-47), Tasmanian ophthalmologist Dr Kristen Bell presented heat maps dramatically confirming eye outpatient clinics are mainly located within larger metropolitan areas. In effect, 30% of the population, and 65% of the Indigenous population, have no or limited publicly funded outpatient services where they live.

31

INJECTION LIMBO Some 47,000 more Australians may have severe vision loss if the intravitreal injection rebate is cut.

45

VISION 2030 RANZCO has revealed its blueprint to even-out eyecare equality across Australia.

EVERY ISSUE 07 UPFRONT

55 MANAGEMENT

09 NEWS THIS MONTH

56 PEOPLE ON THE MOVE

53 OPTICAL DISPENSING

57 CLASSIFIEDS/CALENDAR

54 ORTHOPTICS AUSTRALIA

58 SOAPBOX

She advocated for an Atlas of healthcare delivery by specialty, patient demographics and geographic area, providing Local Hospital Networks with a map of public services to be delivered within their area, and accounted for.

Equally, ophthalmologists need to be incentivised into regional jobs. RANZCO knows ophthalmologists with a regional background are 2.7x more likely to settle regionally. It recently increased the percentage of trainees with a regional background to more than 40% and introduced selection points for this.

Clearly, institutions like RANZCO are pulling their weight, but it requires an appetite for major policy shifts to avoid more Portland-Tamworth situations.

MYLES HUME Editor

INSIGHT May 2022 5

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UPFRONT Just as Insight went to print, the COMMONWEALTH BANK (CBA) entered the healthcare payments and claims market – currently dominated by NAB’s HICAPS system – with the launch of CommBank Smart Health that can integrate with the optometry-focused Optomate practice management system. CBA’s foray into health payments follows the bank’s May 2021 acquisition of Whitecoat, Australia’s largest digital healthcare services directory that also included a digital payments solution capable of processing Medicare, private health insurance, and government scheme n

WEIRD

A New Zealand woman has taken her eye bank employer to the Employment Relations Authority, claiming constructive dismissal, after only learning the job entailed enucleation after she started.

The employer said “retrieval, processing, storage, testing and evaluation of eye tissue” was mentioned in the job ad, but a judge said this could be interpreted as picking up, rather than surgical removal of an eye. n

manage this ocular condition,” IMI chair Prof Serge Resnikoff said. FINALLY, Australian engineers have invented a new surgical glove with low-cost sensors that can record hand movements in fine detail, giving trainees and mentors data to evaluate and improve on intricate procedures. The Western Sydney University research team are working with surgeons and students at Liverpool Hospital to develop the technology, which they anticipate will augment rather than replace traditional surgical training. “Teachers will be able to give precise feedback on minute details post-surgery, and students can analyse their performance," Dr Gough Lui, who led the work, said.

WACKY

A UK optometrist has sounded the alarm over a Tik Tok trend seeing people fill a bag with bleach, hand sanitiser, jelly and shaving cream before holding it up to their eyes in an attempt to make them appear brighter. If the bag splits, the optometrist warned people could experience corneal scarring, extreme pain and blindness.

insightnews.com.au Published by:

11-15 Buckhurst Street South Melbourne VIC 3205 T: 03 9690 8766 www.primecreative.com.au Publisher Christine Clancy christine.clancy@primecreative.com.au

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Editor Myles Hume myles.hume@primecreative.com.au Journalist Rhiannon Bowman rhiannon.bowman@primecreative.com.au

Commissioning Editor, Healthcare Education Jeff Megahan Business Development Manager Alex Mackelden alex.mackelden@primecreative.com.au

Client Success Manager Justine Nardone

WONDERFUL

The Cardiff and Vale University Health Board recently held its first optometry appointments for homeless citizens in Cardiff, Wales, in what is set to become a monthly service. Having teamed up with local dispensers and optometrists and being supported by suppliers, the clinic is held in the city centre and includes new optometry equipment and a refurbished clinical assessment room. n

claims. IN OTHER NEWS, Hoya Vision Care and the International Myopia Institute (IMI) announced a new partnership. Their shared goal is to raise awareness about myopia and the importance of practising myopia management with an evidencebased approach. They also hope to advance research, collaborate on improving management standards and educate key stakeholders on prevention, treatment and management. “The eyecare profession plays a dominant role to educate the general public and make them aware of the impact of this progressive eye disease and the available management approaches. Early prevention and treatment are the keys to

justine.nardone@primecreative.com.au

Design Production Manager Michelle Weston

REGIONAL DIVIDE

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Sixteen per cent of ophthalmologists practise in regional locations, despite 29% of the Australian population being regionally based. Full report page 45.

WHAT’S ON

Complete calendar page 57.

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INSIGHT May 2022 7

NEWS

DISRUPTION AS HOSPITAL SEEKS REPLACEMENT continued from page 3

across the South Australian border to Mount Gambier (108km).”

Harvey is also concerned about his 150-patient Portland public surgical waitlist that would need to be redistributed to other hospitals already under pressure.

“In Warrnambool, the waiting list for public ophthalmology cataract surgery is two years. I’ve got Portland patients who have already been waiting a year, so that's not fair for them to wait longer again for public surgery,” he said.

“I’ve asked the Victorian Health Minister Martin Foley what is going to happen to those patients on the waiting list for surgery, and thousands of patients needing appointments for AMD, glaucoma follow up, diabetic retinopathy and anti-VEGF injections, but I’ve had no response.

“I'm particularly worried about anti-VEGF patients. One woman I see every month gets motion sickness so can only travel 2-3km in the car without getting severely motion sick, so this situation could lead to someone like her going blind.”

Harvey is continuing to work as an ophthalmologist in Mount Gambier and will increase his workload by one day a week to see the patients from Portland.

DOCTORS STAND UP TO BOARD Harvey said the issues have emerged after several resignations from the hospital board, with Minister Foley appointing new members, many whom are not locally based.

In the recent petition, Harvey and other doctors said they were “dismayed by the actions of the current hospital board” whose “stated aim is to save money”.

We know how important high-quality ophthalmology services is for our community and will ensure all community members continue to receive the care they need.”

“Strangely the board is squandering scarce funds by employing numerous expensive medical locums. It seems the board wants to prove the hospital is not financially sound. This will inevitably lead to loss of some services and/or amalgamation with distant hospitals,” they wrote.

On February 10, PDH board chair Professor Peter Matthews responded to the doctor’s claims outlined in the petition, stating PDH faces challenges that have developed over several years and they will take time to remedy.

“We need junior doctors on the wards and in urgent care. These doctors get excellent training here, but training is only recognised when supported by accredited permanent medical staff. No new or replacement permanent medical staff are being appointed.”

They said PDH required $10 million dollars of additional annual government funding that would allow senior medical staff to be permanently appointed.

“THERE IS NO SUBSTANCE TO CLAIMS MADE BY VARIOUS PARTIES THAT PDH WILL BE CLOSED, DOWNGRADED OR AMALGAMATED.” PETER MATTHEWS, PORTLAND DISTRICT HEALTH

“Improvements will not occur without a willingness to embrace necessary change,” he said.

“It is well known that it is very difficult to attract medical specialists and GPs to regional and rural settings across Australia.

This is not a challenge unique to Portland.

To maintain services at an appropriate level it is necessary to engage locums, as do many other health services. We continue to actively recruit subject to requirements set by the Department of Health.”

Matthews said PDH would continue to explore partnership arrangements with neighbouring regional institutions.

HOSPITAL RESPONDS In a statement, PDH told Insight it recently accepted Harvey’s resignation, and thanked him for his service.

“Again this is not new; it is a sensible approach, a benefit to not only the Portland community but potentially to the south west region,” he said.

“Given this resignation and the challenges faced by all regional healthcare providers in recruiting specialist services, we anticipate some minor disruption to some of our ophthalmology services during April as we find a replacement, but we are confident this will be rectified very soon,” a spokesperson said.

“The PDH Board cannot and will not comment on individual employees nor will the board comment on matters regarding responsibilities of the Minister or Department of Health.

There is no substance to claims made by various parties that PDH will be closed, downgraded or amalgamated.” n

“Our staff will be working hard to ensure any delays to service are minimal and that we provide continuity of care for patients.

PBS INVESTMENT TO BENEFIT MORE PATIENTS continued from page 3

Torres Strait Islander people to undertake health care studies, including in allied health and optometry.

Additionally, Hunt announced $45.5 billion over four years to access more affordable medicines through the Pharmaceutical Benefits Scheme (PBS), and more than $2.4 billion this budget to add new medicines to the PBS. In keeping with its cost of living agenda, the government is investing $525.3 million to lower the PBS safety net thresholds from 1 July 2022 by the equivalent of 12 fully priced scripts for concession card holders

8

INSIGHT May 2022

and the equivalent of approximately two fully priced scripts for non-concessional patients. This is expected to benefit over 2.4 million people.

• A 20% deduction for the cost of external training courses delivered to their employees from budget night to 30 June 2024; and

For concessional patients, the safety net threshold will be lowered by 25% from $326.40 to $244.80 – an $81.60 reduction for concessional patients. This means when a concession card holder reaches the safety net threshold, after 36 full priced concessional scripts, they will receive PBS medicines at no charge for the rest of the year.

• A 20% deduction for the cost of expenses and depreciating assets that support digital uptake, up to $100,000 of expenditure per year, until 20 June 2023.

For small business, including small business optometry practices, the government announced those with annual turnover of less than $50m can access:

Greg Hunt, Federal Health Minister.

“Notably for small and medium businesses, the temporary full expensing measure has not been extended beyond 30 June 2023,” OA stated.

“This election period remains a critical time for us to continue our advocacy efforts and reinforce our conversations about eye health in Australia." n

NEWS

FUNDING FOR LUXTURNA GENE THERAPY FOLLOWING MSAC RECOMMENDATION Luxturna has become the first gene therapy to receive government funding in Australia, in a landmark decision that will see the treatment jointly funded by federal and state governments.

Novartis announced on 25 March the treatment would now be funded for patients with an inherited retinal diseased (IRD) caused by pathological biallelic RPE65 mutations, following a Medical Services Advisory Committee (MSAC) recommendation.

This makes Luxturna (voretigene neparvovec) – first approved by the Therapeutic Goods Administration in August 2020 – the first and only gene therapy to be jointly funded by federal and state/territory governments, the company stated.

IRDs are a group of conditions causing blindness which are linked to more than 260 different genes in the body.

A double mutation in gene RPE65 is considered rare and thought to affect around 125 Australians.

Affected patients may be diagnosed with subtypes of either Leber congenital amaurosis or retinitis pigmentosa.

Luxturna is delivered in a single injection behind the retina by a specialised retinal surgeon. It then enters cells and delivers a working copy of the mutated gene, which begins producing the normal proteins essential for sight. The therapy is given only once per eye and does not modify any of the patients’ other genes.

Gene therapies like Luxturna are said to represent a significant advance in medicine, addressing the root cause of genetic conditions by replacing the faulty gene with working versions in one single treatment. By doing so, they can stop a disease in its tracks, reducing the burden for patients and their families.

This is in contrast to more conventional medicines, that traditionally manage ongoing symptoms and may need to be taken continually for life.

The Royal Victorian Eye and Ear Hospital (RVEEH) was announced by the Victorian Government as the designated Victorian provider of Luxturna, for eligible patients under the 2021–25 National Health Reform Agreement (NHRA).

The therapy delivers a working copy of the mutated gene.

Dr Tom Edwards is the clinical lead for implementation of Luxturna and a RVEEH vitreoretinal surgeon. He’s also principal investigator of retinal gene therapy research at the Centre for Eye Research Australia (CERA).

“The funding of Luxturna, the first ocular gene therapy to be available to people with an inherited retinal disease caused by mutations in the RPE65 gene, marks a new era of treatment in Australia,” he said.

Mr Richard Tew, country president of Novartis Australia and New Zealand, said the reimbursement and funding of the first ocular gene therapy in Australia marked a milestone and has the potential to bring real value to patients in Australia living with IRDs, their families and society. n

NEWS

MAJOR PUSH FOR NEW $16 MILLION MIDLAND EYE CLINIC IN WA

Public eye hospitals (starred) are located in the west of the Perth region, with the proposed Midland Eye Clinic (green dot) to cater for the under-serviced eastern corridor.

The Lions Eye Institute (LEI) is joining forces with local MP and Minister for Indigenous Australians Mr Ken Wyatt to push for a new $16 million communitybased eye clinic to better service patients in Perth’s eastern corridor and reduce strain on the public system.

Wyatt, the Member for Hasluck, used a recent visit to the LEI to reiterate his support for the new Midland Eye Clinic project that would provide Medicarefunded services.

It comes after LEI recently lodged proposals with state and federal governments to support the state-ofthe-art, specialist eye health clinic that it believes will plug a significant gap in eye healthcare services in the Eastern and North Eastern metropolitan, Wheatbelt and Goldfields areas.

It would sit alongside an existing private eye clinic in Midland that LEI has operated since 2016.

The second eye clinic proposed for Midland would effectively enable access to public services for more than 8,000 patients per year. This would lead to an additional 18,672 eye health services provided with no service expansion cost to the state.

Currently, the only public eye clinics are located in the west at Royal Perth, Sir Charles Gairdner and Fremantle hospitals, considered lower disease prevalence zones.

The median ophthalmology wait time at the three public clinics is 197 days, compared with wait times for other

10

important treatments like cardiology (105 days), oncology (89 days) and renal services (151 days).

Wyatt, who has launched a petition with more than 880 signatures for the project, said a quarter of WA public eye patients lived in the Midland region but the closest public eye clinics are Perth or Fremantle. The average waiting time for an appointment is more than six months.

“A new Lions Eye Institute Midland Eye Clinic will deliver regular eye check-ups and also treat chronic conditions like glaucoma, diabetic retinopathy and macular degeneration – three conditions causing 75% of all blindness,” Wyatt said.

The proposed development would cost $16 million to cover the building acquisition, fit-out, project management, equipment and start up.

The clinic would feature an innovative comanagement model thanks to a partnership between the LEI and The University of Western Australia’s new optometry school. It will provide placements for optometric and ophthalmology (doctors in training) students to assist in training the next generation of eyecare professionals.

This will see optometrists triage patients with early signs of eye disease, referring them to an on-site ophthalmologist where relevant. LEI believes this will result in optimal efficiency, accessibility and affordability, with services paid for through Medicare. Publicly listed surgery will occur at St John of God Midland Public Hospital. n

n

DRY (COVID) EYE

One in five people who have had COVID-19 suffer from at least one symptom related to dry eye disease such as blurred vision or itching, according to a study from the Chinese University of Hong Kong.

Researchers from the department of ophthalmology and visual sciences also found the risk of dry eye, which can significantly impair daily, social and physical activities, was related to the severity of the infection, according to a report in the South China Morning Post. The research team evaluated 228 recovered COVID-19 patients one to three months after their diagnosis in 2020 and compared them with 109 healthy participants who had not been infected. The study also showed the tear break-up time was 1.6 seconds shorter in recovered patients who had received any form of supplementary oxygen during hospitalisation compared with an average of 10 seconds in healthy individuals.

n

GLAUCOMA GUIDELINES

The UK’s guidelines for glaucoma treatment have had a significant update, with the National Institute for Health and Care Excellence (NICE) advising the primary intervention should be selective laser trabeculoplasty (SLT). Previously eye drops were the long-time standard of care, with SLT being a second-line approach when drop instillation proved problematic for some patients, Optometry Times reported.

The new guidelines arose from the findings of the multicentre Laser in Glaucoma and Ocular Hypertension (LiGHT) study, led by ophthalmology consultant and chief investigator Professor Gus Gazzard from Moorfields Eye Hospital, and professor of Glaucoma Studies at the University College London Institute of Ophthalmology, London.

n

CLIMATE CRISIS

RANZCO president Professor Nitin Verma is one of 10 medical college signatories, representing more than 100,000 doctors, petitioning the country’s political leaders for a climate-ready and climate-friendly healthcare system. In the lead up to the federal election, the college’s assert GPs and psychiatrists are witnessing the mental health impacts of climate change and extreme weather events on people of all ages. “Specialist physicians across the country are bracing for an onslaught of illness caused by the impacts of climate change. The recent floods in NSW and Queensland, unprecedented in magnitude in living memory, demonstrate why we must act now to reduce the devastating impacts of severe weather events,” their letter stated.

INSIGHT May 2022

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NEWS

FLOODED OPTOMETRY PRACTICES COUNT RECOVERY COST Flood-affected optometry practices are counting the cost of the clean-up and lost business after the natural disaster inflicted large scale damage to businesses and homes in parts of Queensland and NSW in early March.

“OFFERS OF EQUIPMENT, MANPOWER AND FINANCIAL CONTRIBUTIONS SHOW THE TRUE SPIRIT OF INDEPENDENT OPTOMETRY”

According to ProVision – an independent network with around 450 practices – a handful of its members reported flooding of their practices. The extent of damage ranged from closure due to evacuation orders, to low level flooding, and for some being fully submerged.

Areas affected included Lismore, Casino, Kingscliff, Collaroy, Kempsey, Singleton and parts of western Sydney.

Apart from those severely affected, several optometrists had been impacted by secondary flood issues including accessibility for both staff and patients.

Loss of business and has been an unfortunate result with a significant number reporting closure of between one and five days.

One of the worst affected practices was Lamas & Brown Optometrists, which operates two practices in Lismore and Casino – both affected by flooding.

On its Facebook page, the practice said its Casino store had become operational within a matter of days, however at the time of writing, it had set up a new temporary premises in Wollongbar while

PROVISION

In some good news, the practice stated its spectacle jobs were above flood level and OK, while its most expensive diagnostic equipment was also saved.

On social media, another practice, Be Seen Eyewear, also reported flooding in its Lismore store, as well as Mullumbimby Optometrist which stated it would not be able to operate for at least three weeks.

ProVision said while a few practices will take months to rebuild and reopen, secondary impacted practices have been returning to full operations.

“Even after re-opening, there may be a slow return to normal business where whole areas are impacted, including people’s homes,” the organisation stated.

Lamas & Brown Optometrists, with practices in Lismore and Casino. Image: Facebook.

it seeks to rebuild the Lismore practice over the coming months.

“ProVision is assisting affected practices with fee relief and payment plans, as well as working with our supplier partners on extended trading terms and top-up discounts to ease cash flow pressures over the coming months. We are also providing leasing advice in relation to property repairs, HR support, and marketing communications assistance.”

“We ventured into Lismore [on 2 March] and like everyone we were confronted by a disaster beyond belief,” the practice wrote on social media.

“But we started the rebuild. Two practices – two floods. Our wonderful Casino crew and their partners have cleaned out the shop and have everything back in running order. Lismore is going to take a lot longer. We had about 500mm of water through our top level. Yesterday we managed to remove the suspended ceiling, then the underlying gyprock ceiling. We then cleaned all the mud and grime off downstairs.”

ProVision said it had also been inundated with offers of assistance by fellow members showing concern for their colleagues.

“Offers of equipment, manpower and financial contributions show the true spirit of independent optometry.” n

GEORGE & MATILDA APPOINTS NEW GENERAL MANAGER OF PARTNERSHIPS AS NETWORK EXPANDS Ms Cassie Gersbach, a founding member of George and Matilda (G&M) who has been with the company for six years, has been appointed general manager of partnerships, as the company's practice network climbs to 86.

The G&M network services more than 100 communities across Australia and has recently welcomed practices in Atherton, Northlakes, Grafton and Aspley.

With 11 years’ experience in the optometry and eyewear sector, including in operations, sales, human resources, and now partnerships, Gersbach said she is well placed to share her experiences and open the door for more independents to connect and explore G&M as their next move.

“I do believe we have suitable solutions that can benefit practice owners both

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INSIGHT May 2022

personally and professionally in a meaningful way. G&M have ambition to grow and offer more to the independent market,” she said.

“Due to our proven success, we are well placed to grow our community by offering many competitive models that suit potential partners, including succession planning, assisting with transition through expert support, and ideally setting up and paying respects to their legacy.”

Gersbach also highlights other key benefits for an independent optometrist or partner joining G&M. “Practices have more support around them and can lean into experts to continue to grow business revenue and improve profitability, and more time to continue to provide excellent clinical care and balance

to home life, while we take care of the rest,” she said.

Gersbach said she had witnessed a lot of growth and change at G&M throughout the past six years, including navigating COVID. Cassie Gersbach, George & Matilda.

“Our experienced and passionate team make the difference as we are personally invested in our partnerships.

We offer in-practice support for a bestin-class onboarding transition. We simply take the time to care for our team and patients," she said.

“More personally, amidst the challenges COVID presented, building and coordinating a new operations team who are aligned, committed, and have a high level of trust to deliver our best results yet, has been very rewarding. I care about my team a lot.” n

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NEWS

MAJOR PRIVATE EYE HOSPITAL OPENING NEW SYDNEY SITE

MEDICARE UTILISATION REPORT SHOWS OPTOMETRY HARDEST HIT BY LOCKDOWNS

Epping Surgery Centre (ESC) is moving to a new site to open a state-of-theart private eye hospital, featuring a $5 million fit-out that it says will set a new professional benchmark for the Australian ophthalmic sector.

A new Federal Government report shows the volume of optometry services utilised under Medicare decreased sharply during Optometrists were lockdowns – down limited to essential by 20.1% compared or time critical care. to the same time last year – for two notable reasons.

The facility is part of the PresMed Australia (PMA) group of day hospitals and originally opened in 2004. Currently located in Oxford St, it houses 12 ophthalmologists focusing on cataract, glaucoma, cornea, medical retina and plastic eye surgery, treating more than 30,000 patients in 18 years.

The significant drop has been highlighted in the Australian Institute of Health and Welfare (AIHW) latest quarterly report on the impacts of COVID-19 on Medicare Benefits Scheme (MBS) and Pharmaceutical Benefits Scheme (PBS).

Having outgrown its current location, ESC will open a new custom-built, stateof-the-art facility at a greenfield site, on the corner of Boronia Ave, Epping.

The new hospital will have two operating theatres, four first-stage anaesthetic and recovery trolleys and six second stage day surgery recliner chairs. Building works commenced in April 2021 with the hospital opening scheduled for April 2022.

The report compares data for the first quarter of 2021–22 (the quarter ending September 2021) with the preceding quarter (the quarter ending June 2021) and with the same quarter from the previous year (the quarter ending September 2020).

“ESC secured a greenfield site to develop a new private eye hospital to provide a platform for the long-term growth of our services,” Mr Marc Resnik, managing director of PMA, said.

One of the reasons cited for the sharp decrease in optometry services was that during the quarter ending June 2020, a large number of optometry practices were closed. According to the report, services were down 38.4% on the March quarter 2020, but this decrease was picked up in the September quarter 2020.

“This is an exciting venture which will

The categories experiencing the largest falls compared with the quarter ending June 2021 were optometry (down by 22.3% to 1.9 million services), other allied health (down by 5.4% to 4 million services) and diagnostic imaging (down by 4.9% to 7.3 million services).

“These falls can be attributed to COVID-19 lockdowns in New South Wales, Victoria, and the Australian Capital Territory, and patients deferring non-urgent allied health attendances and diagnostic imaging,” the AIHW report states. n

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cement Epping as one of the leading destination for eye surgery in Sydney, as well as setting a new professional benchmark for the Australian ophthalmic community.”

PMA CEO Mr Roger Cronin said eye surgery is characterised by rapid developments in technologies which continuously improve patient safety and clinical outcomes.

“The new eye hospital will represent an unsurpassed level of care in Sydney and will provide local ophthalmologists with the latest technology to undertake the full spectrum of eye surgery procedures for both adults and children,” he said.

Epping Surgery Centre is one of five facilities in the PresMed Group, which includes Chatswood Private Hospital, Central Coast Day Hospital, Madison Day Surgery, MetWest Eye Care & MetWest Surgical Centre. n

LUCENTIS NOW TGA-APPROVED FOR RETINOPATHY OF PREMATURITY

“The fall in optometry services in the September quarter 2021 compared to the September quarter 2020 was due to the high base in the September quarter 2020,” the report said.

Furthermore, during lockdowns optometry practices could remain open but were limited to essential or time critical care to patients (as opposed to routine checkups) in many cases.

The new Epping Surgery Centre site.

The Therapeutic Goods Administration (TGA) has granted Lucentis (ranibizumab) an indication for retinopathy of prematurity (ROP), making it the first anti-VEGF therapy approval for the rare disease affecting premature infants in Australia.

It’s the seventh indication for the Novartis therapy.

Novartis Australia recently announced the approval for ROP zone I (stage 1+, 2+, 3 or 3+), zone II (stage 3+) or AP ROP (aggressive posterior ROP). There are five different stages defining the severity of disease, with stage 5 indicating a total retinal detachment.

According to Novartis, by targeting and reducing the level of VEGF, a key factor in the progression of ROP, Lucentis may help avoid some of the common complications associated with eye tissue damage like severe near-sightedness. In targeting VEGF, Lucentis acts differently to laser therapy, which is currently the first

line treatment in Australia. ROP affects the vision and is caused by abnormal development of retinal blood vessels in premature infants. The blood vessels deliver oxygen to the retina. Imbalances or blockages in the oxygen circulation process may result in vision loss or blindness.

ROP most commonly occurs in preterm infants less than 30 weeks’ gestation, with close to 50% of babies born ≤24 weeks’ gestation having severe ROP. In infants registered to the Australian and New Zealand Neonatal Network, the ROP incidence depends most on gestation at birth, with close to 50% born ≤24 weeks’ gestation having some stage 3-4.

The Lucentis approval is based on the Phase 3 RAINBOW study comparing the efficacy and safety of Lucentis with laser surgery in preterm infants with ROP. n

INSIGHT May 2022

VEI2975

INTERNATIONAL

DIRECT CONNECTION BETWEEN IMPROVED EYECARE AND ADVANCES IN EDUCATION AND EQUALITY Improving access to eye health services is essential to achieving the targets of at least seven United Nations Sustainable Development Goals (SDGs), according to a new study.

Published in The Lancet Planetary Health, the research, led by the International Centre for Eye Health (ICEH) at the London School of Hygiene and Tropical Medicine, found that improved eye health services are associated with moving closer to SDG targets related to overall health, poverty, economic productivity, education and equality.

The study, carried out as part of the collaborative Lancet Global Health Commission on Global Eye Health, looked at 226 studies that reported the relationship between an eye health service and outcomes or pathways related to the SDGs. These services included cataract surgery, free cataract screening, provision of spectacles, trichiasis surgery, rehabilitation services, and rural

community eye health volunteers.

Overall, 27 studies reported that eye health services had a positive effect on advancing one or more SDG targets, with indirect effects proposed for all further goals. Cataract surgery and spectacles had the largest number of studies reporting beneficial effects on an SDG.

Professor Matthew Burton, director of the ICEH, said eye health is often overlooked, but it is an important factor for improving global health and quality of life.

“Our study, which is one of only two studies looking at the connections between improvements in a specific area of health and the SDGs, demonstrates that eye health is a powerful enabling tool for sustainable development, both directly and indirectly,” he said.

The study examined findings of 226 papers.

The potential human impact of not including eye health as an SDG target could be vast, affecting not only individuals but communities and countries as a whole.

Dr Aubrey Webson, the permanent representative to the United Nations for Antigua and Barbuda and chair of the UN Friends of Vision group, said eye health should be recognised as integral to sustainable development goals.

“Currently, eye health does not feature within any of the many targets and indicators of SDG monitoring. This study is part of a growing body of evidence that eye health policies should be embedded across education, the workplace and social services. Interventions, such as improved access to glasses and cataract surgery, need to be prioritised and receive the financial support that a challenge of this scale deserves.”

“No one should have to live with avoidable blindness or addressable visual impairment in the 21st century when we have proven lowcost solutions to address these conditions.

The SDGs represent the highest ambition of the global community, and it is time eye health is recognised as integral part of that.” n

DRY EYE

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COMPANY

KERING EYEWEAR TO ACQUIRE MAUI JIM

MYOPIA SPECS JOINT VENTURE ‘COMES TO LIFE’ The first SightGlass Vision myopia spectacles are starting to reach the market as EssilorLuxottica and SightGlass Vision CooperCompanies spectacle lenses. announce their joint venture has commenced operation.

Kering Eyewear – a global eyewear company whose portfolio comprises Gucci, Cartier, Saint Laurent and other luxury brands – has signed an agreement to acquire Maui Jim. Founded in 1987, Maui Jim is said to be the world’s largest independently owned high-end eyewear brand with a leading position in North America. Its eyewear is also found in optometry practices throughout Australia.

Their collaboration accelerates the commercialisation of novel spectacle lens technologies to expand the myopia management category.

Headquartered in Illinois, US, the brand includes high-quality sun and optical frames sold in more than 100 countries, with one of its key products being its proprietary PolarizedPlus2 lens technology that protects from glare and UV while enhancing colour naturally perceived by the eye.

SightGlass Vision’s trademark Diffusion Optics Technology incorporates thousands of micro-dots into the lens that softly scatter light to reduce contrast on the retina, which is intended to reduce myopia progression in children.

Since its inception in 2014, Kering Eyewear has built a business model that enabled the company to reach more than €700 million euro (AU$1 billion) in external revenues in FY2021. In Australia, the Kering portfolio is distributed by privatelyowned Sydney firm Sunshades Eyewear.

Mr Norbert Gorny, co-chief operating officer at EssilorLuxottica, said the company was ‘thrilled’ to see the progress of their innovative product.

“As a global leader with a 30-year track record in myopia research, we have been developing the myopia management category for more than a decade. As such, we are thrilled to see our joint venture with CooperCompanies come to life as SightGlass Vision begins to operate and the first products start to reach the market,” Gorny said.

According to a statement, the Maui Jim purchase represents a major milestone in Kering Eyewear’s expansion. Just months after the acquisition of Lindberg, Kering Eyewear is set to own a second proprietary brand, reinforcing its place in

“Together with eyecare professionals, we will be able to grow awareness about existing solutions and improve access to technologies that can help children today and in their future lives."

“SightGlass Vision’s commitment to clinically based performance fits well with CooperVision, which has conducted the world’s longest-running myopia management clinical study and is committed to establishing myopia management as a standard of care for affected children,” McBride said. n

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INSIGHT May 2022

the high-end eyewear segment.

Kering Eyewear expects the acquisition to increase its revenue above the billioneuro mark (AU$1.5 b) on a full-year basis and bolster profit margins.

“Maui Jim has a unique positioning in the market, with very high-end and technically innovative sunglasses that are beloved by its clientele, and we are delighted that the brand is joining Kering Eyewear’s exceptional portfolio,” Mr Roberto Vedovotto, president and CEO of Kering Eyewear, said.

“We see strong potential globally for Maui Jim, which will benefit from our expertise and worldwide network to extend its geographical footprint and build on its core values to attract new consumers.”

The transaction is subject to the clearance by the relevant competition authorities and is expected to be completed in the second half of 2022.

n

SMS HEALTHCARE EXPANDS LASER EYE SURGERY CLINIC PORTFOLIO Private health provider SMS Healthcare has expanded its ophthalmology portfolio with the addition of Lasersight Australia's five-clinic refractive eye surgery network.

Mr Dan McBride, chief operating officer and general counsel at CooperCompanies, shared Gorny’s excitement in growing the overall myopia management category.

“Adding spectacle lenses with SightGlass Vision technology to our portfolio of myopia management products translates into better eyesight and brighter lives for countless children.

The deal should be completed later in 2022.

Lasersight operates five clinics.

The co-investment will see with three Queensland Lasersight clinics and two clinics operating under the Lasersight banner in Victoria and Tasmania join SMS, whose eye surgery portfolio has now grown to 14 clinics.

It’s the latest in a series of coinvestments, with SMS also acquiring Medownick Laser Clinic, Victoria, Eye and Laser Centre, Gold Coast, and KindSIGHT Eye Specialists, Brisbane and Redcliffe, in late 2021.

This follows private equity group Alceon’s backing of SMS’ expansion

strategy in September last year.

“This strategic co-investment supports SMS Healthcare's primary goal of giving patients across the eastern Australian seaboard access to top specialists, cutting-edge technology, and best-inclass treatment options in accessible locations near to home, assuring the best patient results," SMS stated.

Across its wider portfolio, SMS Healthcare now holds co-investments alongside the medical professional founders of 21 assets, including day and short-stay hospitals, allied health, and specialist medical practices spanning ophthalmology and laser eye surgery infrastructure across Queensland, New South Wales, and Victoria. n

RESEARCH

MIGS GO HEAD-TO-HEAD IN AUSTRALIAN STUDY Australian ophthalmologists have published the first independent head-tohead comparison of two leading minimally invasive glaucoma surgery (MIGS) devices, finding no significant difference in intraocular pressure (IOP) outcomes but a potential greater reduction in medication use in one group.

The paper was published in the peerreviewed RANZCO journal Clinical & Experimental Ophthalmology earlier this year and compared real-world 24-month outcomes of phacoemulsification (cataract surgery) combined with either the Glaukos iStent inject or Hydrus Microstent.

The analysis was performed on data from the Fight Glaucoma Blindness (FGB) international registry, established by the Save Sight Institute in Sydney. The registry’s chief investigator Dr Mitchell Lawlor co-authored the paper.

The study featured anonymised data from 344 eyes with mild-to-moderate open-angle glaucoma, normal-tension glaucoma or ocular hypertension that underwent phacoemulsification combined

with either iStent inject (224 patients) or Hydrus Microstent (120 patients).

Importantly, the data was adjusted for baseline characteristics using linear regression and propensity score matching. The primary endpoint was a comparison of mean IOP at 24 months.

At 24 months, there was no significant difference in mean IOP reduction between the two groups, consistent across all analyses. The matched cohort showed iStent inject achieved a 3.1 mmHg reduction and Hydrus a 2.3 mmHg reduction (p = 0.530).

A mean medication reduction of 1.0 was reported for iStent inject versus 0.5 for Hydrus (p = 0.081). A total of 5.4% of eyes in the iStent inject group and 7.5% of eyes in the Hydrus group required subsequent procedures to improve IOP control within 24 months.

“Twenty-four-month outcomes showed sustained IOP reduction with a good safety profile for both groups,” the authors concluded.

“There was no significant difference in IOP outcomes between the groups. There may be a small additional reduction in glaucoma medication usage following cataract surgery with iStent inject compared to Hydrus.”

The Glaukos iStent inject.

Lawlor said the study was the first publication of data from the FGB registry, launched during the 2017 RANZCO Congress in Perth.

“Randomised trials provide information on a highly selected group of patients having surgery with a highly selected group of surgeons. In contrast, this study provides real world comparative data of a large and varied population of patients as part of routine clinical care. It therefore tells us what sort of outcomes surgeons can expect for patients as part of their clinical care.”

Lawlor said the study provided reassurance that surgeons should feel comfortable selecting either trans-trabecular bypass device in combination with cataract surgery, and that they will achieve clinically meaningful reductions in medication use and IOP out to at least two years. n

PROFILE

e m o h

A ONE WAY TICKET

orth. logist father Dr David Moore, in Tamw Dr Phoebe Moore and her ophthalmo

O

phthalmologist and mother-of-two Dr Phoebe Moore has been practising in her hometown of Tamworth for the past year, at North West Eyes, a clinic her father Dr David Moore established in 2003. A highly awarded and talented surgeon, her homecoming follows a tumultuous twelve months prior.

Moore graduated first in her undergraduate medical degree at the University of Newcastle in 2011. In addition to graduating with distinction, she was awarded the RANZCOG Women’s Health Award for the highest overall ability and capacity in obstetrics and gynaecology and the Andrew Lojszczyk Prize in Surgery, for the highest overall performance in surgery. She also graduated with the Australian Medical Association (AMA) prize for the student with the highest overall ability and capacity.

She completed her internship through the Hunter New England Health Network while also completing her Master of Medicine in ophthalmic science.

She then graduated first in her master’s degree, being awarded both the Anthony Molteno award for optics as well as the Clarence and Mabel Clark Award for the most proficient graduate.

Moore says she always held an interest in medicine, partly owing to growing up with an ophthalmologist father.

“I was interested in studying medicine, or law as my next option. But reflecting back on it, law wouldn’t have suited me. I like science and the practical application of it. I like working with people and pushing myself to be the best I can be. I enjoy expanding my knowledge and skills, and ophthalmology offers opportunity for continual growth and development,” she says.

Moore commenced ophthalmology training in Melbourne through The Royal Victorian Eye and Ear Hospital in 2015. She graduated first across Australia and New Zealand, adding another award to the mantlepiece – the KG Howsam medal for excellence in 2018. All the while, she became a mother of two while completing her training.

Moore, with her husband and two sons, departed for the UK in January 2020 to undertake a Fellowship at Bristol Eye Hospital, subspecialising in retinal diseases and uveitis, in particular management of immunosuppression for patients with inflammatory diseases of the eye.

LIFE IN BRISTOL “We were committed to spending a year in Bristol for my fellowship, and were considering staying a further six to 12 months after that, all going well,” Moore recalls.

“Beyond that, we were tossing up between Tamworth and Newcastle, where my husband is from, as a place to come back to.”

A few months into their planned year in Bristol, the outbreak of COVID disrupted their day-to-day, but not their longer-term plans. Then, a sudden family emergency back in Australia meant Moore and her family had to reassess.

“Dad had a heart attack in May, at the height of lockdown in the UK, and he didn’t work for the following five months. That made the decision to come

18

A Tamworth native has brought specialist training in retinal diseases and uveitis acquired at a world-class UK eye hospital back home where it’s needed most. back to Tamworth obvious,” Moore says.

But they decided not to return immediately, for multiple reasons, Moore says.

“I made a commitment to RANZCO to complete a 12-month fellowship – without it, I wouldn’t get my qualification. I had also signed a contract with the NHS in the UK,” she says.

Despite the many personal challenges, including navigating a pandemic in a foreign country with a young family – her youngest son was 7-months-old at the time – and an unwell parent in Australia, on a professional level, she was learning more than anticipated, with the pandemic heightening the need to triage patient diagnosis and treatment.

Midway through her fellowship and with no signs of the pandemic abating, in September 2020, after Australia introduced a cap on passengers arriving into the country, Moore and her family began looking at flights from London to Sydney.

After witnessing other Australians being “bumped off” flights, they borrowed money for business class tickets with Singapore Airlines to maximise their chances of getting home.

“But in January 2021, the cap was slashed in half again, and our February flight was cancelled, with no alternatives until late March,” Moore says.

Adding to their dilemma, they had given notice on their lease in Bristol, and Moore’s medical registration and visa were due to expire. With few options, she met with Bristol Eye Hospital administration to explore the possibility of staying on, and began applying for an emergency extension of their visas.

Moore’s plight garnered mainstream media attention, with 7News, Sunrise and The Guardian all seeking an interview. Her predicament coincided with news at the time that Australia’s High Commissioner to the UK, Mr George Brandis, had abandoned his post at the peak of the COVID crisis.

“I became a spokesperson of sorts for Australians stuck abroad. The online commentary and the tone of discussion on ex-pats living abroad, who were now stranded, was quite negative. I felt ostracised at the time and wanted to raise awareness of the circumstances beyond our control,” she says.

“In the wake of the media coverage, a representative from Singapore Airlines got in touch, and said they’d managed to find space on a flight for us.”

RETURNING HOME Part of the concern Moore raised in the press coverage was the impact her delayed return to Australia would have on the eye health of the Tamworth community.

At the time, Tamworth ophthalmologists – servicing an area comprising 240,000 people who travel from as far as southern Queensland and western New South Wales – faced a workforce shortage that could have been much worse if internationally-trained Dr Kayvan Arashvand wasn’t granted a special extension of his Medicare Provider Number to continue practising in Tamworth.

Without this, the region would have been left with 1.5 fulltime equivalent ophthalmologists.

INSIGHT May 2022

ECP_Ins

Tamworth’s ophthalmology situation has since become a flashpoint in a push for policy change around how the government determines areas of workforce shortage.

In addition to consulting at the Tamworth rooms, ophthalmologists at Moore’s father’s practice, North West Eyes, operate at Tamara Private Hospital and Tamworth Rural Referral Hospital. Outlying clinics are provided in Narrabri and Moree, as well as surgery in Moree.

Knowing she could be part of the solution, Moore was relieved to finally return to Tamworth in 2021. She began her career in earnest and was thankful to have completed her formal training, but faced a significant step-up in responsibility.

“I have more work than I can keep up with. Most new consultants starting out take a while to build up a patient list, but I’ve been busy from the get-go.

We cover an area of 250,000 to 300,000 patients, from Moree, to the coast, to Muswellbrook. Dad works two days a week, and we have two other permanent doctors. There have previously been some fly-in fly-out doctors working – all of these have stopped coming to Tamworth due to a variety of personal commitments,” she says.

“It’s a fine balance in knowing there is always more work to do but you are no good to your community if you work into early burn-out.”

Moore says her training in Bristol has been “incredibly beneficial” in treating her Australian patients.

“Cataract is one of the most common conditions I treat, and the cases I see are, generally speaking, more challenging than those in city populations because here, the wait is longer, and cataracts are denser. It pushes you as a surgeon. I don’t have a vitreoretinal surgeon around the corner I can consult with,” she says.

Moore is also the only ophthalmologist in northern NSW practising her sub-

specialty in retinal disease and uveitis.

“Patients requiring my specialty could go to Sydney or come to see me, but they don’t want to go to Sydney, especially in a pandemic. Treating these patients is stretching my own ability, not just in my specialty, but into other sub-specialties too,” she says.

“Although isolated in the sense we don’t have an entire eye hospital [in Tamworth], the care we provide with the resources available in Tamworth is exceptional. Patients are not disadvantaged, their eyecare is not compromised,” Moore says.

It’s a point Moore wants to make clear.

“In my experience, when liaising with my city counterparts, there is an assumption that rural medicine and rural ophthalmology is sub-standard. It’s rhetoric, a subconscious bias, that I’ve picked up on,” she says.

“In truth, rural ophthalmology is on par with any care given anywhere in the world. At North West Eyes, we do everything out of private practice, apart from operating, and our equipment is as good as anywhere.”

Working in a regional clinic with colleagues who offer a different set of expertise, depending on their speciality, means she encounters various conditions she might not otherwise.

“Tamworth ophthalmologists are a small, collegial community. I’m grateful for my colleagues and their shared experience at North West Eyes, as well as Dr Peter Hinchcliffe from Tamworth Eye Centre,” she says.

“Although the ego in me would like to make a name as an academic in a big city hospital, the reality is long hours, and years spent trying to make a name for yourself. In contrast, working in rural and regional ophthalmology, I have a five-minute commute to the clinic four days a week, and can spend more time with my family including my sons, now aged two and five.” n

Join Eyecare Plus and benefit from the support and knowledge of experienced members.

Looking to buy, sell or join contact Philip Rose 0416 807 546 or philip.rose@eyecareplus.com.au

Multi Award Winning Practices

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CPD

LEARNING OBJECTIVES: At the completion of this CPD activity, optometrists will have developed their knowledge of glaucoma management.

Including: • Understand the structural and functional indices that play a role in the monitoring of glaucoma • Inform their own glaucoma-management plan based on assessment techniques and workflow used at the CFEH’s Glaucoma Management Clinic • Recognise some uncommon differential diagnoses for patients presenting with glaucoma-like clinical features • Review an example of a collaborative approach to the diagnosis and management of a patient presenting with potentially glaucomatous clinical features

LESSONS FROM A GLAUCOMA MANAGEMENT CLINIC When the Centre for Eye Health established its Glaucoma Management Clinic eight years ago, it wanted to provide a new care model that would be more efficient for clinicians and easier to navigate for patients. DR JACK PHU and HENRIETTA WANG share key learnings from the clinic.

G

laucoma is a chronic, progressive disease that requires lifelong management to prevent irreversible blindness.1 With an ageing population, the burden of the disease is expected to increase, presenting a challenge to the limited resources available in the healthcare system. In particular, ophthalmologists and the public health system are expected to be overburdened by an increasing volume of patients with or suspected of having glaucoma. 2 To alleviate this burden, an alternative pathway is required that can manage the allocation of precious healthcare resources to where they are most needed. In March 2022, the Centre for Eye Health (CFEH) at the University of New South Wales marked the eighth year of operation of its Glaucoma Management Clinic (GMC). Staffed by optometrists and technicians from the CFEH and consulting ophthalmologists from the Prince of Wales Hospital, the GMC was designed to reduce the burden of glaucoma on the public hospital healthcare system by providing an alternative, no-cost pathway for patients suitable for collaborative care.3 The collaborative care model follows the best practice and collaborative care guidelines established at the time, including guidelines from the Optometry Board of Australia, the Royal Australian and New Zealand College of Ophthalmologists (RANZCO), and the National Health and Medical Research Council (NHMRC).

Patients are suitable for collaborative care if they met specific thresholds, such as early-tomoderate stages of glaucoma, stability while on medical therapy and uncomplicated by other significant ocular comorbidities.4 Patients who did not meet the criteria for collaborative care were referred onward to the ophthalmology department of their local health district.

After eight years of working alongside ophthalmologists from the local health district in this collaborative setting, we would like to

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INSIGHT May 2022

share some of our experiences and key learning points with the readers of Insight. Our hope is that more collaborative arrangements in the community can emerge to tackle the significant public health issue of glaucoma diagnosis and management.

PATHWAYS TO COLLABORATIVE CARE A patient can enter the GMC through three main pathways.3 Pathway 1: Accessible care (direct community referral) The first pathway is a direct referral from a community clinician, typically an optometrist.

Such a patient would have a history of diagnosed glaucoma that meets the criteria for collaborative care, or are highly suspicious for developing glaucoma. Such patients might already be on treatment. Typically, the patients have financial constraints and are unable to afford ongoing care in a private setting.

Pathway 2: Referral refinement (internal referral from the CFEH General Clinic)5 The second pathway is an internal referral of an existing patient seen in the General Clinic of the CFEH. The General Clinic is where most referrals to CFEH are sent. These would typically include patients with risk factors for glaucoma who require further comprehensive assessment. Patients who are initially seen in the General Clinic might eventually develop signs of glaucoma, and are given the option to be seen in the GMC for treatment initiation and follow up.

Pathway 3: Direct referral from the Prince of Wales Hospital As one of the goals of the GMC is to reduce the burden of glaucoma in the public healthcare system, we will often take over care of patients sent to our clinic directly from the Prince of Wales Hospital. These are often patients who are glaucoma suspect or have glaucoma that has

ABOUT THE AUTHORS: Dr Jack Phu BOptom (Hons), BSc, MPH, PhD, FAAO, Diplomate (Glaucoma) Lecturer, School of Optometry and Vision Science, UNSW

Henrietta Wang BOptom (Hons), BSc, FAAO Senior Staff Optometrist/Research Optometrist, Centre for Eye Health, UNSW

demonstrated long-term stability. Such patients are excellent candidates for our collaborative care setting and free-up hospital appointment times for more in-need patients.

PRACTICE POINT 1: Identify the most suitable level of glaucoma care required for each patient, and identify the pathway that enables them to best access that level of care.

How might these pathways be applied in community care or private practice? – A commonality among these pathways is the process of having experts review patients and their individual glaucoma care needs. The fundamental question is which level of eyecare – primary, intermediate, tertiary – does the patient require and what is the best way for the patient to access that level of care?

The CFEH model is able to leverage expertise from highly-experienced, recognised experts in glaucoma who are able to provide second

Patient referred for glaucoma management

Risk profile assessment

Clinical assessment (workflow)

•V ision • Perimetry: Humphrey Field Analyzer 24-2 SITA-Faster (frontloaded) 2+ tests per eye

• Refractive error and clinical history obtained from referral letter (including previous perimetry and/or imaging results)

Contact procedures: applanation tonometry, pachymetry, gonioscopy

Patient basic information gathered electronically • Demographic: age, gender, race/ethnicity • Prior ocular clinical history (including previous ocular diagnoses of glaucoma) • Contributory medical history, medication list and allergies (including systemic vascular/ metabolic disease, previous ischaemic/vascular events, neurological disease) • Contributory family history (first degree relative most important)

Ocular imaging • OCT retinal nerve fibre layer and optic nerve head scan, and ganglion cell-inner plexiform layer scan • Colour fundus photography: posterior pole and stereoscopic optic nerve head

Tentative diagnosis made

Further ocular assessment indicated

• Intraocular pressure profiling (water drinking test ans/or iCare HOME self-tonometry) • Repeat perimetry (including 10-2) to confirm defect (or central defect) • Repeat imaging (including OCT angiography) • Repeat assessment at a late date to obtain longitudinal data

Further systemic investigations indicated

• Neuroimaging (MRI) of brain and orbits, guided by pattern of visual field loss • Cardiovascular investigations, including carotid Doppler ultrasonography, and full blood counts and lipid profile • Blood tests for inflammatory and/or nutritional markers

Further investigations not indicated

Final diagnosis and management plan

Figure 1: Workflow of patients referred to the CFEH for glaucoma management.

opinions on cases.6 These act as another opportunity to increase case detection rates (true positives) and reduce false-positive referrals.5 Many of these refinement steps can be done asynchronously, (for example: remote review of electronic medical records including visual field and imaging results). A similar approach can be done in private practice. Given the availability of technology such as visual field testing and optical coherence tomography, it is simple enough to ask a colleague or collaborator (optometrist or ophthalmologist) for an opinion.

of ocular imaging (colour fundus photography and optical coherence tomography), intraocular pressure profiling and the importance of high volumes of perimetric testing have been emphasised.9 Figure 1 provides a list of

assessment techniques and workflow for a glaucoma assessment performed at CFEH, including instances where further investigations are required.

Our clinical thought processes at the CFEH focus on two main questions for patients seen in the GMC.9 First, are the patient’s ocular findings consistent with glaucoma, or are they explained by an alternative diagnosis?

Second, if the patient has glaucoma, what is the trajectory of the disease and how should we arrest it?

Glaucoma is a diagnosis of exclusion – It is often tempting to diagnose glaucoma in patients who have significant retinal nerve fibre layer thinning (RNFL) and visual field loss.

Although glaucoma is the most commonly diagnosed optic neuropathy, it is also a diagnosis of exclusion. Recent studies have suggested that up to half of patients diagnosed with glaucoma do not have the disease (in other words: a false positive diagnosis).10 Before we commit a patient to a lifetime of treatment and follow up, we must be certain that the diagnosis is correct. Aside from other common optic nerve diseases such as optic nerve head drusen or optic neuritis, considerations for alternative diagnoses and the workflow are listed in Table 1.

The GMC shows how an additional layer of clinical care can differentially diagnose glaucoma. Processes should be in place, such as additional supplementary testing (including increased volumes of visual field testing and intraocular pressure profiling) that aim to reduce false positive glaucoma diagnoses. As part of the differential diagnosis process, further tests include blood panels (for systemic inflammation), carotid doppler ultrasound (for carotid stenosis), and neuroimaging (for lesions of the visual pathway beyond the retina).

Some less common but important differential diagnoses for patients who may present with glaucoma-like clinical features Condition

Signs to look out for

Further investigations that may be required

In the sections below, we will be detailing our experiences on establishing effective communication channels and pathways that facilitate the most appropriate collaborative care plans.

Ischaemic RNFL loss and/or optic neuropathy

• W ell-delineated, non-progressive RNFL wedge defects • Absence of optic nerve head cupping (i.e. shallow and small cups with intact neuroretinal rim)

• • • •

What does a glaucoma-specific clinical examination look like? – Optometry Australia has recently released a document outlining current, evidence-based recommendations for clinical examination techniques for glaucoma.7 Many of the techniques remain similar to the older NHMRC guidelines for glaucoma,8 with several more recent paradigms being recognised for their importance. The indispensable nature

Retrograde degeneration

• R elatively symmetrical disc pallor and vertical midline respecting structural and functional defects • May have accompanying neurological signs or symptoms

• N euroimaging with guidance from patterns of structural and functional loss

Inflammatory RNFL or optic nerve defects

• V ascular sheathing around the vessels exiting the optic disc bsence of optic nerve head • A cupping (i.e. shallow and small cups with intact neuroretinal rim)

• Full blood count • Inflammatory blood markers • Review of systems

Full blood count Blood sugar level Lipid profile Carotid doppler ultrasound

Table 1: Some less common but important differential diagnoses for patients who may present with glaucoma-like clinical features.

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pointwise or global analysis of perimetry results.

For example, pointwise examination of the location of visual field loss (central or peripheral) reveal areas pertinent to a patient’s visual function. Assessing mean deviation worsening (global analysis) provides a quantitative overview of disease progression rate over time. Potentially useful indicators include the mean deviation levels at worsening stages of glaucoma (worse than -6 dB for moderate glaucoma, worse than -12 dB for advanced glaucoma, and worse than -22 dB for severe glaucoma).11

N

PRACTICE POINT 3: Ongoing development of clinical knowledge is essential for evidence-based assessment and management, and this should be supplemented by legible and interpretable clinical data presentation.

Continuing education is essential – In the eight years since the start of the GMC, a notable change that we’ve observed in our clinic is the increase in the confidence and initiative of staff optometrists. Developing the required confidence involves time and work.

At the CFEH, we are fortunate to have the capacity to develop expertise and leadership in the field of glaucoma and optic nerve disease through our research and education programs.

This has translated into improving the capacity of clinical staff through the dissemination of the latest in evidence-based medicine in glaucoma.9 Two major innovations implemented in our clinic have been frontloading visual field tests for earlier detection of glaucomatous change,12,13 and the deployment of intraocular pressure profiling including iCare HOME self-tonometry.14

Figure 2: A 63-year-old female referred for glaucoma assessment. (A-B) Colour fundus photographs shows an intact disc appearance in the right eye with superotemporal disc pallor in the left eye. Retinal nerve fibre layer and ganglion cell-inner plexiform layer optical coherence tomography heat (C-D) and deviation map (E-F) matches the disc appearance with superotemporal RNFL and GC-IPL thinning in the left eye. (G-H) 24-2 visual field testing shows an intact right field and an inferonasal defect in the left eye.

PRACTICE POINT 2: Clinical assessment of glaucoma needs to be comprehensive to accurately differentially diagnose glaucoma from other retinal, optic nerve or visual pathway pathologies and manage expected disease trajectory.

What is the trajectory of glaucoma? – The goal of glaucoma management is to prevent irreversible visual impairment within a patient’s lifetime. As part of that process, clinicians need to carefully assess the risk of progression, project the likely visual outcome over time and titrate treatment appropriately.

Both structural and functional indices play a role in the monitoring of glaucoma. Static automated perimetry, the current clinical standard for monitoring visual function across the visual field, remains critical for assessing the risk of functional impairment. Perimetry

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results are correlated with activities of daily living and quality of life, are patient-relevant indicators for treatment success.

Disease trajectory is assessed by either

It is challenging to remain informed of the latest in evidence-based practice in any field. There are many resources available to optometrists, including continuing education programs, podcasts, research papers and quality-assured CPD articles like the one you are currently reading.

Quality in collaboration – In addition to the underlying knowledge of the patient’s case and the clinical evaluation process, it’s also essential to prepare clinical data in a form that is legible, interpretable and unambiguous

Summary of entrance test findings at the initial visit OD

OS

Refraction and visual acuity (VA)

+0.75/-1.00x66 (6/6-2)

+1.50/-1.00x105 (6/6-)

Intraocular pressures (applanation)

11mmHg

10mmHg

Central corneal thicknesses

510 microns

515 microns

Slit lamp examination and gonioscopy findings

Open angles with no signs of secondary conditions

Table 2: Summary of entrance test findings at the initial visit.

INSIGHT May 2022

MARCH

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to other members of the healthcare team.

A practice management system that allows collation of all relevant clinical data provides a convenient platform for visualisation. The FORUM software from Carl Zeiss Meditec is an example of a platform that can integrate visual field, optical coherence tomography data and colour fundus photographs.

CASE STUDY Knowledge and application of evidence-based medicine provides structure to case analysis and a systematic approach to diagnosis and management. Here we describe a case that we recently assessed and managed in the GMC. First visit A 63-year-old female was referred to the CFEH GMC by her optometrist who noted ‘large cupping’ in both eyes. She denied any visual or ocular symptoms. Her best-corrected visual acuities were 6/6 -2 in the right eye and 6/6 - in the left eye. While her personal ocular history was unremarkable, she had a distant family history of glaucoma (grandfather).

Her self-reported medical history was also unremarkable. Her entrance test findings are summarised in Table 2.

Dilated fundus examination showed average-sized discs with wide but shallow cups in both eyes. The neuroretinal appeared intact in the right eye and slightly thin superotemporally in the left eye with corresponding loss of RNFL reflectivity (Figure 2A-B).

The temporal aspect of the neuroretinal rim appeared pale in the left eye. There were no disc haemorrhages present. Optical coherence tomography (OCT) results were concordant with funduscopic findings and showed superotemporal RNFL and ganglion cell-inner plexiform layer (GC-IPL) thinning in the left eye (Figure 2C-D). Visual field testing (24-2 test grid) showed a clear right field and an inferonasal defect in the left eye (Figure 2E-F).

While there were some features typical for glaucoma present (cupping, RNFL and GCIPL thinning with a corresponding field defect),

Figure 3: Left eye retinal nerve fibre layer (RNFL) thickness heat map (A) and (B) OCT-Angiography of the radial capillary plexus (slab set from the inner limiting membrane to the posterior border of the RNFL) shows reduced capillary perfusion matching the area of RNFL thinning.

the depth of neuroretinal rim thinning was disproportionate to the extent of RNFL/GC-IPL loss. The presence of pallor was also atypical for glaucoma. As the clinical picture was suspicious but not conclusive for glaucoma, the patient was booked in for glaucoma supplementary testing at CFEH. Second visit The patient returned four months later. Her ocular and medical histories were unchanged.

Repeat visual field testing was performed and confirmed the inferonasal defect in the left eye with no evidence of progression from the last visit. A water-drinking test was also undertaken to assess the patient’s intraocular pressure response to osmotic stress. Her water drinking test results are shown in Table 3.

No significant elevation in intraocular pressure was noted. OCT-Angiography of the optic nerve was also performed and showed reduced capillary perfusion in the superotemporal peripapillary regions, corresponding to the areas of RNFL thinning (Figure 3).

Considering the functional stability and the less than 4 mmHg spike in intraocular pressure associated with the water-drinking test, non-glaucomatous conditions needed to be excluded. Thus, the patient was referred for neuroimaging of the head and orbit.

Three months later, the patient returned to review her neuroimaging results with our consulting ophthalmologist. Magnetic resonance imaging with contrast showed background moderate chronic microvascular ischaemic change. These findings were suggestive of an ischaemic optic neuropathy rather than glaucoma. The patient was advised to see her general practitioner for evaluation of her cardiovascular disease risk factors. She was also scheduled for a six-month review at the CFEH. This case demonstrates the value of a collaborative approach to diagnosis and management of patients with clinical features highly suspicious for glaucoma.

CONCLUSIONS Glaucoma is a common cause of irreversible vision loss in the community, and represents a significant burden to the healthcare system.

Clinicians need to be judicious in managing patients with glaucoma, keeping in mind outcomes that are relevant to the patient, including their quality of life and impact on activities of daily living. There are strategies in place that are effective in reallocating precious resources to those in need. Optometrists play a vital role in the journey of care of patients with glaucoma. n NOTE: All references can be found in the online version of this article.

Water drinking test results from visit #2 OD

OS

Intraocular pressures (baseline)

12mmHg

12mmHg

15 minutes after water ingestion

14mmHg

15mmHg

30 minutes after water ingestion

13mmHg

13mmHg

45 minutes after water ingestion

12mmHg

12mmHg

Table 3: Water drinking test results from visit #2 with no significant (>3 mmHg) elevation over time.

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Third visit

NOTE: Optometry Australia members can scan the QR code or visit the online version of this article at insightnews.com.au/cpd/ to enter their details to have their CPD hours automatically updated to their Learning Plan. Event ID: 90004162, Session ID: 10555.

INSIGHT May 2022

NOXI254

DISRUPT INFLAMMATION IN DRY EYE DISEASE 1–4

Lasting symptom relief from moderate to severe dry eye disease in as little as 2 weeks1–3*

*In some patients with continued daily use. One drop in each eye, twice daily (approximately 12 hours apart)1

FOR MORE INFORMATION ON XIIDRA VISIT MEDHUB

Currently Xiidra® (lifitegrast ophthalmic solution) 5% is only available via prescription from an ophthalmologist or therapeutically endorsed optometrist through a Special Access Scheme process.

PBS Information: This product is not listed on the PBS. This medicinal product is subject to additional monitoring in Australia. This will allow quick identification of new safety information.

Healthcare professionals are asked to report any suspected adverse events at www.tga.gov.au/reporting-problems.

See approved Product Information before prescribing. For the most up to date Product Information go to www.novartis.com.au/products/healthcare-professionals Indication: Treatment of moderate to severe dry eye disease in adults for whom prior use of artificial tears has not been sufficient. Contraindications: Patients with hypersensitivity to lifitegrast or any of its excipients.

Dosage and administration: Single-dose ampoule for ophthalmic use only. Discard after use. Adults and elderly: Instil one drop in affected eye(s) using a single-use container per administration, twice a day. Paediatric population: There is no relevant use of XIIDRA in children and adolescents aged below 18 years old in the treatment of dry eye disease. Contact lenses should be removed prior to the administration of XIIDRA and may be reinserted 15 minutes following administration. Precautions: •Prior to initiating therapy, a comprehensive eye examination is recommended to determine the aetiology of the symptoms and treat any reversible underlying conditions. •Allergic-type hypersensitivity reactions, including anaphylaxis, have been reported, rarely. Immediately discontinue administration and initiate appropriate treatment if hypersensitivity reactions occur. •The safety and efficacy of XIIDRA have not been established in paediatric patients. •Use in Pregnancy: Category B1. There are no or limited amount of data from the use of lifitegrast in pregnant women. The use of XIIDRA may be considered during pregnancy, if necessary. •Lactation: It is not known whether lifitegrast, or any of its metabolites, are excreted in human milk. Interactions: Due to the low systemic absorption, it is unlikely that lifitegrast contributes to systemic drug interactions Adverse effects: •Very common (≥10%): Eye irritation, dysguesia, eye pain, instillation site reactions, •Common (1 to 10%): Eye pruritus, lacrimation increased, vision blurred, headache. •Unknown: conjunctivitis allergic, swollen tongue, anaphylactic reaction, hypersensitivity, type IV hypersensitivity reaction, asthma, dyspnoea, pharyngeal, oedema, respiratory distress, angioedema, dermatitis allergic. Based on TGA approved Product Information dated 4 September 2020 (xii040920m).

References: 1. Xiidra Australian approved Product Information, September 2020. 2. Tauber J et al. Ophthalmology. 2015;122(12):2423–31. 3. Holland EJ et al. Ophthalmology. 2017;124(1):53–60. 4. Perez VL et al. Ocul Surf. 2016;14(2):207–15.

Novartis Pharmaceuticals Australia Pty Limited ABN 18 004 244 160. 54 Waterloo Road, Macquarie Park NSW 2113. Ph (02) 9805 3555. ®Registered Trademark.

AU-20085. April 2022. NOXI25421W. Ward6.

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LEARNING OBJECTIVES: At the completion of this CPD activity, optometrists will have developed their knowledge of treatment options for severe dry eye disease.

Including: • Understand the use of anti-inflammatory agents in the treatment of extreme dry eye • Understand the benefits and contraindications for treatment of dry eye with topical ciclosporin and lifitegrast • Understand the benefits, indications and contraindications of amniotic membrane therapy for dry eye

UNDERSTANDING NEW TREATMENT PROTOCOLS FOR SEVERE DRY EYE DR MARGARET LAM addresses the complicit role of inflammation in the most extreme dry eye cases and explores the use of anti-inflammatory agents to break the cycle, reduce symptoms and restore eye health for patients.

PATHOPHYSIOLOGY OF DRY EYE DISEASE Dry eye (keratoconjunctivitis sicca) is a multifactorial ocular surface disease, accompanied by ocular symptoms, and characterised by clinical signs including a loss of tear film homeostasis. These ocular signs include tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities. Collectively, these changes all play aetiological roles in the pathophysiology of dry eye disease.

In 2017 the definition of dry eye was established by the Tear Film and Ocular Surface Society’s International Dry Eye Workshop II (DEWS II). Our understanding of dry eye focuses on tear film hyperosmolarity as a core mechanism, precipitating a compounding inflammatory cascade that damages the ocular surface.1,2

Today we understand that dry eye disease, beyond a condition that is caused simply by insufficient tear production, is a complex ocular surface disorder in which the tear film is unstable and no longer provides sufficient nourishment or protection to the ocular surface – which thus becomes inflamed and damaged.3 Inflammation has a complicit role in the pathophysiology of dry eye disease, promoting symptoms of irritation and ocular surface damage. Anti-inflammatory agents are thus appropriate treatments in the management of dry eye disease. The purpose of these treatments is to inhibit inflammation, re-establish the appropriate production of a healthy tear film and to reduce signs and symptoms of the disease.4 This article looks at the role of three new treatments for dry eye patients: topical pharmaceutical agents ciclosporin and lifitegrast, and amniotic membrane therapy with bandage contact lenses.

CICLOSPORIN Prescribing anti-inflammatory agents, such as ciclosporin, that target specific inflammatory pathways to break the inflammatory cycle, is a therapeutic strategy worth considering for severe dry eye disease.5 Ciclosporin inhibits calcineurin, which creates a multi-step immune response that prevents the transcription and release of pro-inflammatory cytokines and dampens the message from pro-inflammatory cellular messenger proteins.6 Ciclosporin also inhibits cellular apoptosis of the conjunctival epithelial cells, potentially increasing tear film production, hence its benefits in the management of patients that exhibit dry eye disease.7 DOSAGE GUIDE TO CICLOSPORIN

Figure 1: Severe grade 5 corneal staining and dry eye disease secondary to graft vs host disease. The patient showed extreme dry eye signs and symptoms to the extent that simply opening her eyes caused unbearable levels of pain.

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INSIGHT May 2022

There are currently two commercially-available formulations for topical ciclosporin for patients with severe keratitis with dry eye disease that can be prescribed by optometrists in Australia.

ABOUT THE AUTHOR: Margaret Lam BOptom UNSW OA CCLSA OSO IAO GAICD Optometrist, Head of Professional Services, George & Matilda Adjunct Senior Lecturer, School of Optometry & Vision Science, Faculty of Medicine and Health, UNSW National President, Cornea & Contact Lens Society of Australia National Deputy President, Optometry Australia State Director, Optometry NSW/ACT

• Cequa ciclosporin (0.09mg/mL 0.09%), prescribed one drop instilled twice a day, (ideally twelve hours apart). Cequa is not listed on Pharmaceutical Benefits Scheme (PBS).

• Ikervis ciclosporin (0.1mg/mL 0.1%) prescribed as one drop instilled once a day. Ikervis is listed on the PBS if the patient meets criteria for approval.

NANOMICELLAR TECHNOLOGY VS NANOEMULSION DELIVERY By itself, ciclosporin is poorly absorbed on the ocular surface. The two commercially-available ciclocporin brands differ from one another by how they deliver the drug so that it can be absorbed.8 Cequa’s ciclosporin incorporates ‘nanomicellar technology’ to increase its penetration in ocular tissues. The nanomicelles are composed of polymers that create a hydrophilic outer layer compatible with the tear film which allows it to transport through the tear film onto the ocular surface.

The ciclosporin molecules gain entrance into corneal and conjunctival cells, and once inside the tear film’s aqueous layer, the nanomicelles break up to release ciclosporin into the ocular tissues.9 Ikervis’ ciclosporin uses a positively charged oil-in-water nanoemulsion delivery system.

The corneal epithelial cells are negatively charged, and the positive charge of Ikervis’ oil-in-water emulsion prolongs its time on the ocular surface and allows corneal and conjunctival penetration.10 The cationic emulsion itself in Ikervis has been shown to contribute to tear film stability and provide beneficial moisturising and lubricating effects.11,12 In combination with ciclosporin, the emulsion suppresses the secretion and expression of pro-inflammatory cytokines.14

Schirmer Tear Test and other clinical signs of dry eye disease.

CONTRAINDICATIONS TO CICLOSPORIN Ciclosporin should not be used in patients who are allergic to ciclosporin, or any other ingredients in the prescribed ciclosporin medium. Ciclosporin is also contraindicated in patients with active or suspected ocular or periocular infection, or patients with ocular or periocular malignancies or premalignant conditions.

Due to its actions as an immunosuppressive agent, ciclosporin should be prescribed with caution to patients who have a potential for eye injury and those with active infections.

For patients who wear contact lenses, the use of ciclosporin should be closely monitored.

Although safety and efficacy has not been

In addition to contributing to tear film stability, the nanodroplets contain cetalkonium chloride (CKC) which act as its cationic surfactant, further increasing its time on the ocular surface.14

established in patients below the age of 18,16 topical ciclosporin has shown no difference in safety and effectiveness in the elderly.

LIFITEGRAST (XIIDRA) Lifitegrast 5% (commercial name: ‘Xiidra’) is another effective pharmacological therapeutic agent for patients with severe dry eye. This has been a new addition to optometrists to be able to prescribe Lifitegrast since Optometry Board Approval on December 10, 2021.

LIFITEGRAST MECHANISM OF ACTION In dry eye, the hyperosmolarity of the tear film causes the ocular surface to over-express a molecule known as intercellular adhesion molecule (ICAM-1).

ICAM-1 molecules have binding sites for

Severe keratitis with DED

WHEN AND WHY TO PRESCRIBE CICLOSPORIN Ciclosporin is indicated for patients whose symptoms do not improve despite the use of ocular lubricants. In our practice, once a patient shows no improvement despite artificial tear film supplements, our current prescribing algorithm considers pharmacological agents such as topical corticosteroids, to inhibit the expression of inflammatory mediators; restore the secretion of a healthy tear film; and finally, to reduce signs and symptoms of the disease.13 Very early in their normal treatment protocol, many eyecare practitioners prescribe a short pulse of a two-to-four week course of topical corticosteroids to attempt to reduce the inflammatory reaction and obtain symptomatic improvement.

Normally, it would be appropriate to taper topical corticosteroid therapy after a short period of corticosteroid use when there is improvement of ocular symptoms. Even though it is milder, long-term corticosteroid use has been shown to have a causative link with glaucoma, cataracts, and other steroid-related adverse effects.

Should dry eye symptoms persist beyond the initial course of corticosteroids, it would be appropriate to consider prescribing topical ciclosporin therapy. Ciclosporin could also be prescribed with the straight-forward intention of alleviating symptoms of dry eye disease while avoiding the potential adverse effects of topical corticosteroid therapy.

For many reasons, the prescription of ciclosporin could be more widely-adopted than it currently is: for the potential improvement in symptomatic relief for patients, reduction in corneal fluorescein staining; and clinically based symptoms recorded in dry eye surveys such as patient scores Ocular Surface Disease Index (OSDI); Tear Break Up Time (TBUT);

Non-medical management Ensure all non-medical options are adhered to: • Education on conditions, management, treatment and prognosis • Modification of local environment • Proper eyelid hygiene and hot compresses for blepharitis • Dietary modification: omega/ fatty acid supplementation • Identification and modification/ elimination of offending systemic and topical medications

Artificial Tears (AT) • Preservative free AT. Switch patient if taking AT with preservatives (including BAK) • Ensure regular use of AT: minimum three times per day and before all activities that are going to cause symptoms (screen time, air conditioned environments). Not only using on a need basis.

• Explain the symptom ‘sting’ may occur with instillation, lasting 10-20 seconds, and will improve overtime.

Short term corticosteroids (CS): • Some patients may initiate a 6-8 week course of CS. Not as a long term treatment.

• Monitor after 1 month to ensure no AEs from CS

Severe symptoms persist or recur

Ikervis • Ongoing, long term treatment • Monitored after initiation at 3 months then every 6 months after that

Symptoms improve or remain mild

Compounded unregistered CsA/ Registered Cequa / Restasis via SAS • Self-payed • Ongoing, long term treatment • Monitored after initiation at 3 months then every 6 months after that

Best supportive care • Remain on preservative free AT

Best supportive care • Remain on preservative free AT Table 1: This table outlines a proposed treatment algorithm for when to consider ciclosporin among the existing prescribing options for dry eye.15

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AMNIOTIC MEMBRANE AND ITS MECHANISM OF ACTION Amniotic membrane is an avascular foetal membrane, the overlying layer is the chorion and the amnion tissue that makes up the amniotic membrane is harvested from the amnion, on the innermost layer deeper than the chorion. The amniotic membrane is obtained during elective caesarean sections. Donors are screened for transmissible diseases, and the amniotic membrane is gamma-irradiated to ensure safety and sterility. 21

Figure 2: Patient with grade 0.5 corneal staining after 10day treatment with Amniotek-C dry amniotic membrane therapy applied with a bandage contact lens. The patient reports almost full cessation of dry eye associated pain after the amniotic membrane therapy.

T-cells, also known as T-lymphocytes. On the cellular surface, T-lymphocytes have proteins known as LFA-1 integrin. When LFA-1 integrin and ICAM-1 interact, T-cells activate and migrate to conjunctival and lacrimal glands, releasing cytokines, which are proteins that increase the inflammatory response and increase dry eye signs and symptoms.

Amniotic membrane therapy works in multiple ways in dry eye disease. Firstly, amniotic membranes applied with an overlying bandage contact lens act as a physical barrier to protect the corneal epithelium as it heals and reduces the discomfort from eyelids over a damaged ocular surface.

Secondly, the basement membrane of the amniotic membrane promotes epithelial healing through cellular migration, adhesion and differentiation, and prevents cellular apoptosis.

Thirdly, amniotic membrane also encourages a reduction of inflammation through downregulation of inflammatory cytokines, and the amniotic membrane that contains foetal hyaluronic acid may inhibit fibroblast growth to reduce corneal scarring.

Essentially, at the cellular level, Lifitegrast blocks T-cell adhesion to ICAM-1 and disrupts the dry eye inflammatory cascade.17,18,19

Finally, amniotic membranes may potentially also contain inherent antimicrobial properties to prevent the risk of infection. 22

LIFITEGRAST PRESCRIBING GUIDE

INDICATIONS FOR AMT

Lifitegrast 5% ophthalmic solution comes in individual vials and is prescribed one drop instilled twice a day, ideally 12 hours apart.

ADVERSE EFFECTS OF LIFITEGRAST Lifitegrast adverse effects include ocular irritation, discomfort, blurriness on instillation, conjunctival hyperaemia, discharge, itchy eyes, sinusitis and dysgeusia (distortion of taste sensation). Wheezing, difficulty breathing or swelling on the tongue is possible with Lifitegrast but rare. 20 LIFITEGRAST CONTRAINDICATIONS Xiidra is contraindicated in patients with known hypersensitivity to lifitegrast or to any of the other ingredients in the formulation. It has not been tested for children under 17 years of age.

AMNIOTIC MEMBRANE THERAPY (AMT) Amniotic membrane therapy applied with a bandage contact lens is still fairly new to Australia, but has been well established over the last few decades, particularly in the USA, as a very effective dry eye treatment option that should be considered for moderate-toadvanced dry eye, and particularly for patients that show recalcitrant dry eye disease despite other treatments.

28

Amniotic membrane therapy can be used in any condition that requires promotion of ocular surface healing, as well as conditions that can create corneal scarring and are not responding to existing treatments. These include various types of keratitis, corneal ulcers, neurotrophic keratopathy, and chemical burns. 23 CONSIDERATIONS WITH AMT Amniotic membrane therapy is within the scope of optometrists and ophthalmologists to prescribe in Australia. The only amniotic membrane therapy accessible to prescribing eyecare practitioners in Australia applied as a sutureless therapy is by Amniotek-C and distributed by Designs For Vision with access strictly under approval through application to the Therapeutic Goods Administration (TGA)’s Special Access Scheme.

As with any bandage contact lens therapy, an appropriate broad spectrum prophylactic topical antibiotic eye drop, such as a fluoroquinolone based antibiotic four times daily, is necessary for the duration of the treatment.

Currently, there is some discussion between experts around if amniotic therapy is more effective with corneal debridement vs no corneal debridement.

Currently, corneal debridement with amniotic membrane therapy is not within the scope of optometric practice so any optometric practitioners should consider the application of the amniotic membrane without debriding the cornea. Depending on the condition being treated, corneal debridement may not be required to obtain excellent results from amniotic membrane therapy.

After seven to 10 days of treatment, the amniotic membrane dissolves and the bandage contact lens is removed in office.

POTENTIAL ADVERSE EFFECTS OF AMT Temporary blurring of vision is caused while the amniotic membrane is in place covering the cornea. Mild irritation or a foreign body sensation is possible during the amniotic membrane therapy.

SUMMARY Prescribing topical ciclosporin or lifitegrast should be considered as an appropriate long term therapy to potentially break the complicit inflammatory cascade in dry eye disease. These therapeutic agents have no association with any significant systemic immunosuppressive adverse effects, nor do they have the more serious adverse ocular effects that are associated with long term topical corticosteroid use.

If symptoms of dry eye persist for a patient, or if there are patients that exhibit recurrence of dry eye symptoms, there is increasing support to consider topical ciclosporin or lifitegrast as a safer long term therapy than topical corticosteroids.

For those patients that are seeking relief from their dry eye symptoms and are keen to reduce their pharmaceutical therapy with moderate to severe dry eye signs, amniotic membrane therapy is quickly proving to be a very effective non-invasive treatment option.

As optometrists, we should consider expanding our armamentarium and prescribe these interventions for patients that are experiencing persistent and ongoing symptoms of dry eye disease. n All references can be found in the online version of this article.

NOTE: Optometry Australia members can scan the QR code or visit the online version of this article at insightnews.com.au/cpd/ to enter their details to have their CPD hours automatically updated to their Learning Plan. Event ID: 90004122, Session ID: 10481.

INSIGHT May 2022

SEQ618

WHEN YOU NEED MORE THAN ARTIFICIAL TEARS*

NOW PBS LISTED NEW Ikervis®, once daily ciclosporin, helps break the cycle of inflammation1–3 *For the treatment of severe keratitis in adult patients with dry eye disease which has not improved despite treatment with tear substitutes1 PBS Information: Authority Required. Refer to PBS Schedule for full information.

Before prescribing, please review the Product Information available from Seqirus Medical Information (1800 642 865) or www.seqirus.com.au/products  This medicinal product is subject to additional monitoring in Australia. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse events at www.tga.gov.au/reporting-problems.

MINIMUM PRODUCT INFORMATION: IKERVIS® (ciclosporin 0.1% ophthalmic emulsion) Indication: Treatment of severe keratitis in adult patients with dry eye disease which has not improved despite treatment with tear substitutes. Contraindications: Hypersensitivity to the active substance or any of the excipients; Ocular or peri-ocular malignancies or premalignant conditions; Active or suspected ocular or peri-ocular infection. Precautions: Any reversible underlying conditions, not associated with dry eye disease, should be treated prior to initiating IKERVIS®; History of ocular herpes; Contact lenses should be removed before instillation of eye drops and re-inserted at wake-up time and careful monitoring of severe keratitis is recommended; Glaucoma – limited experience with IKERVIS®.

Exercise caution especially with concomitant beta-blockers; Co-administration with eye drops containing corticosteroids may potentiate effects of IKERVIS® on the immune system; May affect host defences against local infection and malignancies. Use in Pregnancy (Category C): No data available; Not recommended in pregnancy unless the potential benefit to mother outweighs the potential risk to fetus. Use in Lactation: Insufficient information on breastfed infants; it is unlikely that sufficient amounts are present in breast milk. A decision must be made to discontinue either IKERVIS® or breastfeeding during treatment. Use in Children: No data available. Interactions with other medicines: No data available. Adverse Effects: Common: erythema of eyelid; lacrimation increased; ocular hyperaemia; vision blurred; eyelid oedema; conjunctival hyperaemia; eye pruritus. Very common: eye pain, eye irritation. Dosage and administration: The recommended dose is one drop of IKERVIS® once daily to be applied to the affected eye(s) at bedtime.

References: 1. Ikervis Product Information. 2. Jones L et al. Ocul Surf 2017; 15:575-628. 3. Baudouin C et al. Br J Ophthalmol 2016; 100:300-306.

Seqirus (Australia) Pty Ltd. ABN 66 120 398 067. 63 Poplar Road, Parkville Australia 3052. Seqirus Medical Information: 1800 642 865. Seqirus is a trademark of Seqirus UK Limited or its affiliates. IKERVIS is a registered trademark of Santen S.A.S. and distributed by Seqirus (Australia) Pty Ltd under license from Santen Pharmaceutical Asia Pte Ltd. Date of Preparation: October 2021. ANZ-Iker-21-0058

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MACULAR DISEASE

WHAT PRICE DO YOU PUT

on sight?

As macular disease enters the spotlight with Macula Month this May, Insight delves into the strongly debated case over the MBS Taskforce’s proposal to cut the Medicare fee for administering intravitreal injections.

S

hortly before Christmas 2020, the Medicare Benefits Schedule (MBS) Review Taskforce published its final ophthalmology report, maintaining a recommendation to reduce the Medicare rebate for intravitreal injections (IVIs), despite widespread opposition from ophthalmologists and patient advocates.

In doing so, the Taskforce wants to align the IVI cost with peri/ retrobulbar injections, item 18240.

Within months, the Macular Disease Foundation Australia (MDFA) issued a dire warning that tens of thousands of Australians would no longer be able to afford anti-VEGF treatments for disease like neovascular age-related macular degeneration (nAMD) if the Federal Government adopts the Taskforce recommendation to slash the MBS fee by 69%, from $310 with a rebate of around $250, to a $96 fee with a rebate of around $75.

If adopted, MDFA grimly predicts the increase in out-of-pocket costs will translate into an additional 47,000 Australians experiencing severe vision loss and blindness within the next five years.

Perhaps unsurprisingly, 16 months since the final report and with a federal election looming, there is still no firm decision from the government. Insight speaks with leading experts about what fate may await.

'THE NUMBERS DON’T ADD UP' Associate Professor Alex Hunyor is a Sydney retinal specialist with expertise in vitreoretinal surgery and macular disease. Practising

privately at Retina Associates in Sydney, he also holds positions on the Macular Research Group at the Save Sight Institute, University of Sydney and at Sydney Eye Hospital.

Speaking in a different but related capacity, as an Australian Society of Ophthalmologists (ASO) board member, Hunyor says if MBS cuts are made, patients will ultimately suffer through a lack of affordability in the private system and, therefore, would need to try and access an overwhelmed public system.

“Australia is different to other jurisdictions in terms of intravitreal injection treatment. Here, 90% of injections are delivered in the private healthcare system, 10% in the public system. By comparison, in New Zealand, it’s the other way around,” he says.

Given the majority of injections are delivered in the private system, the proposed 69% Medicare rebate cut would have a significant impact on patients' capacity to afford ongoing treatment.

“Even the existing MBS fee of $312.95 is below what the Independent Hospital Pricing Authority (IHPA) has set, based on the National Efficient Price. For intravitreal injections, the funding is $392 per episode for 2021/22,” Hunyor says.

“The numbers don’t add up. If the Medicare fee is cut, the service is not viable. And if services can’t continue, more people will lose their vision.

“Australia would go from a position as one of, if not the best, in the word in terms of its intravitreal injection treatment system, with MBS and

INSIGHT May 2022 31

MACULAR DISEASE

PBS subsidising, to an appalling discriminatory system, where access to treatment is based on an individual’s finances.”

Hunyor fears the nation’s public health system is already at capacity in terms of macular disease treatment, and it doesn’t have the capability to deal with an influx in patients who would be driven to public hospitals, no longer able to afford private treatment.

“Many practices do bulk-bill some patients on financial grounds, but it is likely that many would have to stop doing that – which means an even more overwhelming number of patients trying to get into the public system,” Hunyor says.

“Even though a substantial number of intravitreal injections are given in a public hospital environment, the majority are federally funded through the MBS, not state-funded through hospitals. If you dropped the MBS rebate drastically for another procedure, such as hip replacement, it would drive patients into the public system, and waiting lists would go up. But with macular disease, there simply can’t be a waiting list because people go blind."

When he started providing intravitreal anti-VEGF treatment in 2006, all injections were performed through private clinics.

The public system took a long time to catch up.

“Speaking from the Australian Society of Ophthalmologists’ perspective, we want to deliver good quality service that is accessible and affordable. If the numbers don’t add up, patients suffer.”

He says economic modelling commissioned by the MDFA and conducted by PwC was telling.

“They did estimates of the cost savings from slashing the rebate, and the additional costs associated with the avoidable blindness this would cause. The numbers are pretty stark from a pragmatic economic perspective. The net effect is that the government would lose, not save, money if this goes ahead,” Hunyor explains.

“You only have to look at the difference intravitreal injections have made to people’s lives. It really is life changing. Some of my patients are coming up to 15 years of continuous intravitreal injection treatment.

They’re still driving and reading – without treatment, they would have gone blind 10 years ago. That’s testament to how phenomenally successful this treatment is. Patients are coming back time and again because they’re motivated by the fact their sight is saved with these injections. It would be a tragedy not to be able to tell those stories.”

CITY CLINIC DRAWS PATIENTS FROM AFAR Dr Devinder Chauhan established an eye injection clinic at Vision Eye Institute (VEI) Boronia in 2016, to offer affordable and convenient IVIs to combat high rates of patients abandoning treatment.

Australia has one of the best reputations in terms of antiVEGF treatment outcomes.

"WITHOUT TREATMENT, THEY WOULD HAVE GONE BLIND 10 YEARS AGO. THAT’S TESTAMENT TO HOW PHENOMENALLY SUCCESSFUL THIS TREATMENT IS" A/PROF ALEX HUNYOR RETINAL SPECIALIST

While it is a private clinic, the service is structured so all patients can receive treatment at minimal cost.

Although it is a VEI clinic, Chauhan says it is “totally independent” with no control or oversight from the institute, describing himself and his colleagues as having ‘medical sovereignty’.

“I’m from England, I’m a product of the NHS – an only child, with a public health background – and I arrived in Australia in May 2006, when intravitreal injections first became available,” he says.

“A decade later, I started the clinic because people were having to pay significant out-of-pocket costs,” he says, not wanting patients to miss out on ongoing treatment because they couldn’t afford it.

“A study by Professor Mark Gillies found that around one in four patients receiving eye injections stop their treatment after 12 months.

This is often due to cost and inconvenience, which is why the low-cost eye injection clinic was set up.”

A self-described “Guardian-reading champagne socialist”, Chauhan’s views on the public versus private healthcare system make him somewhat of an “outsider” in his profession.

At Boronia, Chauhan offers IVIs and accompanying scans at no out-ofpocket expense. Patients only pay the PBS prescription cost – $6.80 for pensioners – if they have a referral from their GP, optometrist or another medical specialist.

T

“I can see up to 100 people in a day who require anti-VEGF treatment by intravitreal injection. My clinic partner Dr Alex Tan and I perform about 8% of Victoria’s intravitreal injections – and that percentage has grown,” he says.

“Last year, we had our ‘slowest’ increase at 30% in terms of injection numbers – but that’s huge growth.”

Chauhan’s clinic attracts patients from the entire state of Victoria – Ballarat, Sunshine, Bendigo, Bairnsdale, Sale, Orbost, to name a few places – meaning they often pass their nearest retinal specialist, preferring to travel to Boronia for treatment.

At one stage, he even had a “retina bus” transporting patients.

“It’s because of cost – but not only cost. Patients receive a vision assessment, scans, one-on-one discussion, and injections, in a 30-to40-minute appointment. We have free parking, and an on-site café. It’s convenient and quick and pensioners are only $6.80 out-of-pocket,” Chauhan says.

Chauhan is aware some Australian private clinics charge $1,000 for IVIs, leaving patients up to $700 out-of-pocket, exceeding the average out-of-pocket cost.

An MDFA consumer survey of 370 IVI consumers found that the average annual out-of-pocket cost is $1,900 per eye. For many patients, this is much higher and varies from practice-to-practice.

w

L In

A O e

J o

The MDFA survey also found the cost for patients with bilateral treatment is doubled, meaning that if the MBS item is cut, the out-of-

32

INSIGHT May 2022

T

pocket cost will double for one and both eyes.

patients to ensure they kept their IVI appointments.

“If a patient needs intravitreal injections in both eyes every four weeks (the highest frequency dose), it can cost them double. That’s ridiculous and simply not possible for many pensioners in particular,” Chauhan says.

47,000 REASONS

“To make it worse, many patients who are initially treated in the public system are being shifted into the private system, where the cost can be prohibitive, meaning that patients stop their injections and may go blind.”

MDFA CEO Ms Dee Hopkins has been at the helm for four-and-a-half years, regularly meeting with ministers and members of parliament to convey the seriousness of affordable treatment for macular degeneration.

Chauhan says the proposed cuts in the Medicare rebate are an existential threat to the Boronia injection clinic.

The MDFA commissioned PwC to conduct economic modelling in response to the MBS Taskforce 'Ophthalmology Draft Report 2019'. The findings were first revealed by MDFA patron Ms Ita Buttrose at a National Press Club address a year ago and passed on to outgoing Federal Health Minister Greg Hunt.

“Our only options would be either to charge patients a significant out-of-pocket fee or simply close and shift patients back into the public system, which cannot cope and won’t accept them. Neither option is feasible, and both will literally result in blindness for hundreds of patients.”

At the Boronia clinic, patients are referred by optometrists, GPs, public hospitals including Monash Medical Centre and the Royal Victorian Eye and Ear Hospital, or through old-fashioned word-of-mouth.

In keeping with his socialist views, all patients at Boronia are treated equally, whether they arrive by taxi or a Bentley, as Chauhan has witnessed from his consulting room.

“Most intravitreal injections take place on Tuesdays at Boronia, when we operate as a pure intravitreal injection clinic. It’s a well-oiled machine with two receptionists, and a third at the door as per COVID protocol, plus four orthoptists and one doctor, and three OCT machines to ensure efficient workflow. Our main limiting factor is floor space.”

Testament to the clinic’s reputation, it did not experience a drop in attendance during COVID, with Chauhan actively contacting

Now operational for six years, it shows no signs of slowing.

PwC’s economic modelling predicts the proposed 69% rebate cut will result in out-of-pocket costs increasing from $1,900 to $3,900 a year on average – double that for patients needing injections in both eyes – with clear negative implications for treatment adherence.

“Minister Hunt could see the logic, the adverse effect the proposed MBS rebate cut would have on patients. He could see the adverse effect if people are having problems accessing treatment, and consequently stopping treatment. He said ‘come back to me’,” Hopkins says.

She did as requested, presenting three costed solutions the MDFA developed to increase access to IVI treatment, each predicated on the MBS rebate staying as is: • I ncreasing the number of healthcare workers who can give injections, such as ophthalmic registrars, under the supervision of qualified ophthalmologists.

• Empowering patients to be better informed about fees so they can self-

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MACULAR DISEASE

"OUR ONLY OPTIONS WOULD BE TO CHARGE PATIENTS A SIGNIFICANT OUT-OF-POCKET FEE OR CLOSE AND SHIFT PATIENTS BACK INTO THE PUBLIC SYSTEM" DR DEVINDER CHAUHAN CLINIC PARTNER advocate if they can’t afford treatment.

• N ew low cost-regional clinics, so patients can access treatment without needing to travel to metropolitan clinics that are already at capacity.

“That’s happening,” Hopkins says of the first solution, “and RANZCO have made more registrars available.”

Progress is also being made on educating patients about fee structure and how to negotiate financial stress through a funding recommendation for MDFA to lead this work.

The Medical Costs Finder website, a Federal Government initiative, helps Australians understand the cost of common medical procedures provided by specialists in Australia.

“I met with the Department of Health who put a team together to include information about the cost of intravitreal injections. It’s empowering patients, paving the way for more consistent financial transparency. We want to prevent bill-shock and we want patients – many of whom are either pensioners or self-funded retirees – to understand that intravitreal injection treatment is for the rest of their life,” Hopkins says.

But there has been little progress on MDFA’s third strategy, to establish low cost-regional clinics.

“I have briefed state health ministers around Australia but there is little appetite for it. Originally when anti-VEGF treatment became available here, procedures were performed in public hospitals. Now the majority take place in private treatment, and few public hospitals,” Hopkins says.

“For example, The Royal Victorian Eye and Ear Hospital administers each patient three loading doses, then the patient has to find care elsewhere, in the private system. How do we, as advocates, incentivise the states? The Health Minister in NSW recommended I speak with the Agency of Clinical Innovation to address the whole of NSW.” Hopkins says the MDFA hasn't recently been actively pursuing politicians on the subject as Canberra is in election mode.

In the meantime, the Federal Government has appointed an Implementation Liaison Group (ILG) to review each of the 19 recommendations in the MBS Taskforce Review.

“Minister Hunt has appointed several representatives in eyecare, including optometrists, ophthalmologists and specialists, and invited me to be on it, representing patients, to ensure there are no negative consequences for patients. It makes sense to review the recommendations. As Minister Hunt put it, it’s ‘making sure the MBS is fit for purpose’,” Hopkins says.

At the time of writing, the ILG has held three meetings, and Hopkins can’t see a decision on the MBS rebate for IVIs being made this side of the election. MDFA supports several of the other recommendations as they will improve patient care.

But that doesn’t mean the MDFA is sitting on its hands. In that, it’s quite the opposite.

“We’re creating a resource to brief the next Parliament. Access to this treatment is a long-term issue and we want to make sure the next

34

INSIGHT May 2022

MDFA patron Ita Buttrose discussing the implications of cutting the intravitreal injection rebate at the National Press Club in Canberra in May last year.

Parliament understand the importance of saving sight," she says.

“May is the annual Macula Month that will coincide with the federal election. This year, MDFA’s campaign is called 47,000 reasons, because 47,000 more Australians will experience severe vision loss or blindness if the Medicare rebate is cut."

As part of its campaign, the MDFA is creating social media content targeting certain constituents to bring a human element into its political message.

“We’re speaking to patients who couldn’t access or afford treatment, to highlight the policy problem. We are also seeking stories about the benefits of saving sight and the impact on people’s quality of life,” Hopkins says.

“As Minister Hunt says, ‘Surely we want more people accessing treatment, not less’. We need collaboration between State and Commonwealth governments. Because, in addition to the impact a rebate cut would have, there is another problem: we know there are around 150,000 people who have nAMD, but only 51,000 are receiving treatment.

Why aren’t the rest accessing treatment and why do more than 25% drop out of treatment after the first 12-20 months?,” she asks.

To that end, the MDFA has established a pilot program with Specsavers, which readers can learn more about on page 36.

“It’s called My Eyes Program and it only started a few months ago, with 16 Specsavers stores taking part. The goal of the program is to get patients to their first ophthalmologist appointment, and we’re hoping to secure funding to implement the program more widely,” she says. n

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MACULAR DISEASE

Ayah Hadi, Specsavers Botany, New Zealand.

TURNING OUR EYES TO AGE-RELATED MACULAR DEGENERATION As part of Macula Month, DR JOSEPH PAUL, head of professional services at Specsavers, reveals data and insights on macular degeneration and discusses the organisation’s long-term plans to improve vision and health outcomes for patients with the condition.

A

ge-related macular degeneration (AMD) is one of the more potentially devastating eye conditions seen in everyday optometry – a blinding disease that affects an estimated 1.4 million1 Australians, causing irreparable damage to vision in the precious older years of one’s life.

Of the 1.4 million people, it is further estimated that more than 156,0002 are living with neovascular age-related macular degeneration (nAMD), requiring ongoing treatment to prevent progressive vision loss. Despite the risk of non-adherence to treatment leading to the development of severe vision loss or blindness3, it is estimated 20%-25%4 of patients cease the intravitreal injection treatment required to save their sight within the first year.

As eyecare practitioners, we have a responsibility to appropriately support our patients through their treatment journey, ensuring they are armed with the information and knowledge required to make the right decisions about their eye health. We all have a role to play, both individually as eyecare practitioners, and as part of a larger whole, collaborating

with the wider industry on strategies that improve outcomes for all patients.

With that in mind, Specsavers has begun sharing its key findings on AMD and formed a strategic scoping partnership with Macular Disease Foundation Australia (MDFA). In the first phase of the partnership, both organisations are collaborating with an ambition to gain a true understanding of incidence and prevalence of nAMD across Dr Joseph Paul, Specsavers Australia, with a vision to enhance support head of professional services. for patients diagnosed with the condition.

Longer-term goals are focussed on developing a sustainable approach to achieve the best possible outcomes for nAMD patients, including minimising treatment dropout and removing barriers to access.

AMD CLINICAL BENCHMARKING PROJECT PILOT Macular Disease Foundation Australia and Specsavers have announced a strategic scoping partnership, aiming to overcome preventable vision loss for patients with nAMD by improving appointment attendance and treatment adherence rates.

The project has begun in a pilot phase with 16 Specsavers practices from around the country currently involved.

MDFA and Specsavers agree their shared vision for the project is that the successful measures determined will be shared with the entire industry to further impact the nation’s eye health.

While the project may take several years to test and slowly grow, key trends and data will be shared as it emerges from the pilot phase. Insight will follow the project and report on key milestones and data as it is shared.

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INSIGHT May 2022

Figure 1: Since 2017, the percentage of AMD referrals being made for patients with new onset nAMD has increased significantly among Specsavers optometrists.

Though it is early in the process, it’s possible to identify some key factors influencing care for AMD patients in recent years: • Technology changes within optometry • Patient review periods • The impact of COVID-19 TECHNOLOGY CHANGES WITHIN OPTOMETRY With increased access to optical coherence tomography (OCT) in clinical practice, and the RANZCO-led Referral Pathway for AMD Management evolving to reflect this, optometric management of patients with AMD has transformed over the past five years.

These transformations can be clearly identified in the makeup of referrals to specialists. In 2017, 70% of patients referred to specialists were referred with early or intermediate AMD. Since then, the percentage of patients being referred in early stages has steadily decreased (Figure 1), making up only 54% of patients referred in 2021. In contrast, the percentage of AMD referrals being made for patients with new onset nAMD has increased significantly. This is not to suggest a sudden increase in incidence of nAMD – rather, it reflects the benefits for clinical decision-making gained through the routine use of OCT for every patient.

Figure 2: Following referral, the vast majority patients (68%) were recommended a follow up optometrist appointment within 7-12 months of their AMD referral.

The vastly superior clinical information afforded by OCT allows a greater level of comfort and clarity for optometrists when staging and managing early and intermediate AMD, and in detecting, classifying and appropriately referring nAMD as early as possible.

APPROPRIATE REVIEW PERIODS One of the major benefits of OCT is the ability to accurately monitor changes over time. This is of most benefit when patients are being reviewed regularly, and early changes can be detected quickly. To better understand how optometrists are reviewing and managing patients with early AMD, Specsavers examined the review periods set by optometrists for patients with the condition.

It found that in the years leading up to an initial AMD referral, patients were regularly reviewed by their optometrist, with an average review period of 13 months. Following referral, the vast majority patients (68%) were recommended a follow up optometrist appointment within seven to 12 months of their AMD referral (Figure 2).

Once a tentative diagnosis of AMD was made and the patient was referred for specialist care, both the review periods set by optometrists and patient behaviour changed, with an average review period of nine months for these patients. Regular review in this way, combined with consistent OCT scans, gives optometrists the best chance of detecting progression or new onset neovascular changes and referring in a timely manner.

THE IMPACT OF COVID-19 Internationally reported rates of loss to follow up for many eye conditions, including glaucoma and diabetic retinopathy, approach one in every three patients. Even in the best circumstances, this results in less than optimal outcomes for many patients.

The past two years have been far from the best circumstances, with the ever-changing restrictions, mandates and rules due to COVID-19 making them difficult and arduous for patients and optometrists alike – leading to thousands of missed appointments and a backlog of patients requiring care.5 It is very likely that restrictions on eyecare services resulted in otherwise avoidable vision loss for many patients.

Despite these challenges, the volume of patients being referred for AMD has increased since 2019, even in New South Wales and Victoria – Australia’s most locked down states. While this is a positive outcome, the volume of referrals did drop in 2019. With fewer patients attending optometric services, fewer patients were referred for specialist care.

Figure 3: While more patients were referred for specialist care in 2021, many of these may have been patients who did not attend care in 2020.

While more patients were referred for specialist care in 2021, many of these may have been patients who did not attend for care in 2020, and potentially have had their referral for specialist care delayed by COVID-19 restrictions (Figure 3).

Limited access to eyecare services had a negative impact on patients with AMD and Specsavers will continue to monitor the trends as it navigates the years ahead. It is incumbent upon us all as eyecare practitioners to ensure we are doing everything possible to minimise avoidable blindness, and to fully support all our patients through their diagnosis and treatment journeys. n REFERENCES 1. Deloitte Access Economics and Macular Degeneration Foundation (2011). Eyes on the future - A clear outlook on age-related macular degeneration. Accessed at https://mdfa-s3fs-prod. s3-ap-southeast-2.amazonaws.com/s3fs-public/Deloitte_Eyes_on_the_Future_Report_web.pdf 2. Deloitte Access Economics and Macular Degeneration Foundation (2011). Eyes on the future - A clear outlook on age-related macular degeneration. Accessed at https://mdfa-s3fs-prod. s3-ap-southeast-2.amazonaws.com/s3fs-public/Deloitte_Eyes_on_the_Future_Report_web. pdf. (2022 prevalence estimates are derived from a straight-line extrapolation between 2020 and 2025 estimates in this report.)

3. Wong T et al. (2007). The natural history and prognosis of neovascular age-related macular degeneration: a systematic review of the literature and meta-analysis. Ophthalmology. 2008 Jan;115(1):116-26. doi: 10.1016/j.ophtha.2007.03.008. Accessed at https://pubmed.ncbi.nlm. nih.gov/17675159/.

4. Obeid A et al (2018). Loss to follow-up among patients with neovascular age-related macular degeneration who received intravitreal anti-vascular endothelial growth factor injections. JAMA Ophthalmol. 2018;136(11):1251-1259.

5. COVID-19 and Australia’s eye health. Accessed at https://healthhub-anz.com/understanding the-impact-of-covid-19-on-australian-eye-health/

INSIGHT May 2022 37

IMAGING

RETINAL IMAGING

with confidence

A right infero temporal horseshoe retinal tear. This was an incidental finding as the patient had no symptoms.

Image: Adrian Rossiter.

A market-leading retinal imaging device was the final instrument Western Australian optometrist ADRIAN ROSSITER needed to modernise his equipment suite. He discusses using the device in an optometry setting.

A

s a full scope optometry practice based in Fremantle, Western Australia, there are few areas of eyecare For Eyes Optometrist won’t venture. Myopia control, axial length measurement, vision therapy, dry eye and intense pulsed light therapy, diabetic retinal screenings, anterior eye imaging, OCT and orthokeratology make up just some of its services.

Principal optometrist Mr Adrian Rossiter, a therapeutically-endorsed Fellow of the Australasian College of Behavioural Optometrists with 40 years’ experience, acquired the independent practice six years ago.

He describes himself as an eyecare enthusiast, hence his motivation to modernise his practice with the latest equipment.

The nature of For Eyes Optometrist means the bulk of its patient-base comprises paediatric patients – some only a few months old – middleaged patients, and a significant older demographic often affected by three of the major sight-threatening diseases: age-related macular degeneration, glaucoma and diabetic retinopathy.

When it came to retinal examinations, For Eyes Optometrist previously relied on traditional digital photography and, if indicated, a dilated fundus examination and binocular indirect ophthalmoscopy (BIO).

“We had a Canon 45-degree retinal imaging device which was great, however it wasn’t ideal for smaller pupils or a wide image capture,” Rossiter explains.

“Before acquiring our new Optos system, we were also required to use a reasonable amount of skill to capture a good quality image; either by dilation, changing exposures, getting someone to fixate off-centre etc, so it wasn’t necessarily a straight-forward process. We were using this to primarily monitor the macula and changes to the optic nerve head in conjunction with OCT scans. For the peripheral retina we had to perform a dilated fundus examination.”

Rossiter was acutely aware of the need to upgrade his retinal imaging capability, particularly for capturing images of the peripheral retina, in what would be the final instrument to modernise his equipment suite.

It was a decision he mulled over, running two week-trials with various imaging devices before settling on the Optos Daytona.

The device has been available in Australia for several years, but has undergone continuous hardware and software upgrades. According to Optos, the instrument produces a 200° single-capture optomap retinal image in less than 0.5 seconds. Its ultra-widefield (UWF) imaging technology has been designed for healthy eye screening and has been

38

INSIGHT May 2022

shown to improve practice flow and patient engagement.

Wanting to embed the Daytona as a screening tool, Rossiter says these features made it an ideal choice for his practice. He’s been able to use it for pupils as small as 2 mm and young children. And the 200° single capture often means he’s able to perform scans without the need to dilate pupils. If a wider field of view is required the instrument can also easily create an image montage, again without the need to dilate.

After installing the device a year ago, he has noticed improved communication with ophthalmologists, largely due to the clarity, scope of the images and easy-to-use software. He’s also found the scan to be a useful education tool, especially for the high number of diabetic patients under his care.

“The beauty of this Optos device is that it is very easy to capture a competent image – that is pretty much a given – and as an optometrist it adds familiarity with what is typically out there in the periphery, so you become adept at differentiating what is pathology versus normal aging changes,” Rossiter explains.

“The huge benefit is that some of the primary conditions optometrists would fear missing, such as a retinal tear, you have much greater confidence that you’re not going to miss it routinely because you know you’re seeing 80% of the back of eye in one capture.”

FITTING INTO THE WORKFLOW When hunting for a new retinal imaging device, Rossiter was adamant that he wanted a system that would be used as a screening tool on every patient. In addition to its imaging capabilities, he was drawn to the Daytona due to its reasonable footprint (width: 425 mm, depth: 475 mm, height: 800 mm), speed of image acquisition, and the need to take just one image without pupil dilation.

When patients enter For Eyes Optometrist, they are taken to a prescreening room where autorefraction, keratometry, intraocular pressure and pachymetry tests are performed. Next, they go into the pre-testing room where scans are taken with the Daytona.

“I still have the original Canon 45-degree camera because I was convinced I would need it to continue following optic nerve imaging, but I’ve been very happy with the image quality provided by the Daytona in this respect, so the Canon has become redundant,” Rossiter explains, noting that it is also easy to compare a time series of images with the Daytona so that subtle retinal changes can be detected.

The Daytona was a big investment the practice didn’t take lightly. But because Rossiter was keen to use it in a screening capacity, he was able to justify the ROI by charging a small incremental fee ($10) across the board, with costs communicated to patients before they visit. Screening a few selected patients didn’t make sense from a clinical or financial perspective.

“And from the experience I have had I am very comfortable we made that decision as well,” he adds.

As an optometrist, Rossiter has been surprised by how much more he can see in the periphery and the clinical confidence this provides. The Daytona’s imaging modalities include colour view, sensory view (red-free), choroid view, and autofluorescence.

“Having the added benefit of autofluorescence is amazing. You not only instantaneously see where something is – whether it’s the choroid layer – but you see things that you would not have a hope of seeing with a red/green image. For example, angoid streaks, changes to Bruch’s membrane, are easily detectable with autofluorescence,” he explains.

“You can also scan the anterior vascular layer right down to the deeper retinal layers, so for simple things we see often, like choroidal nevus, you can quickly determine where it is and whether it has characteristics that are more sinister.”

In patients with cataracts, he’s able to show the obstructive effects of their cataract, impacting the fidelity of the image. He can also clearly spot cuneiform cataracts that sometimes wouldn’t appear without dilation.

“But they show up very clearly in the peripheral retina and it’s something that you might otherwise not have detected,” he says.

Although he could delegate Daytona image acquisition to support staff, Rossiter chooses to capture the image himself, creating important opportunities to educate patients about their conditions and form stronger relationships.

If he spots obvious pathology, he can immediately start thinking about how this will change the nature of the upcoming exam. For diabetic retinopathy patients, the optomap allows Rossiter to demonstrate the impact of leaky blood vessels, seeing patients become more engaged in their treatment. In one recent example, he saw a woman who had been living with diabetes for 14 years. She hadn’t had an eye examination in four years because she was coming to grips with a cancer diagnosis, but thought her prescription needed updating due to deteriorating eyesight.

“I took the first image of the right eye with the Daytona and was taken aback by the number of diabetic retinal haemorrhages. Although not severe, they were spread across her entire posterior pole, and I could also see changes to the macula, so we hadn't even got to the consulting room and I’m looking at the picture saying this isn’t a glasses problem, it’s a diabetes problem,” he says.

“An OCT scan then confirmed diabetic macula oedema which was reducing the quality of her vision, so I didn’t even get to the traditional eye test because the whole process was short-circuited by the fact I had the relevant information in front of me.”

Optometrist Adrian Rossiter, For Eyes Optometrist.

In another interesting case, Rossiter saw a man who had been bounced between optometrists, unhappy with his clarity of vision. Once he was screened on the Optos Daytona, Rossiter saw he had been treated for a retinal detachment in both eyes, sparking a conversation about his ocular troubles.

“It gave the patient confidence in the practitioner that he immediately understood his eye condition,” he explains.

“Without having ultra-widefield imaging, I wouldn’t have seen those previous retinal changes, or had a sense of the health of his macula and indication of visual acuity this person ultimately is going to have in a pair of specs. It then became an easy conversation to discuss his needs, and then coming up with a solution.

“That was one instance where the machine wasn’t detecting anything new, but it gave the patient a sense of being somewhere where the technology and the eyecare professional is current and up-to-date.”

Finally, when his patients are referred to an ophthalmologist, Rossiter feels the optomap adds quality information, bringing clarity around his referral decision.

“The device and software make it so easy to export images and send off as a PDF to an ophthalmologist. I wouldn’t say the installation of the Daytona has increased my number of referrals, but certainly it has improved practice efficiency and communications with ophthalmologists because we can specifically say this is what I am concerned about, and back it up with the images we have sent via the Oculo system.” n

An autofluorescence image of a middle aged male with central serous retinopathy.

Image: Adrian Rossiter.

INSIGHT May 2022 39

COMPANY PROFILE L-R: The Nidek Tonoref III, Reichert Phoropters and Nidek COS-6100 Compact Refraction System.

Below: Nidek RT-6100 Intelligent Refractor.

ENDURING PRODUCTS,

enduring service

BOC Ophthalmic Instruments managing director TONY COSENTINO explains why he operates his distribution business on the knowledge that customers will ultimately remember him for the service, not the sale.

I

t was 2014 when independent Melbourne optometrist Mr Lawrie Jacobson was asked to join Bailey Nelson to run a proof-of-concept that would ultimately see the optical retail chain formally introduce optometry into its business model.

Following the initial success of the pilot at its Chapel Street store, the company immediately turned its attention to how it could offer a unique optometry experience aligning with its market positioning as a verticallyintegrated, fashion-forward outlet for younger patients.

A major part of the solution was the Nidek COS-6100 Compact Refraction System, a unique configuration seeing optometrists perform refractions and other tasks in a face-to-face manner, as opposed to alongside the patient, offering a more personable experience.

BOC Ophthalmic Instruments has been the long-time distributor of Nidek equipment in Australia and swiftly began supplying the workstations to Bailey Nelson as it continued rolling out optometry services across its store network, which recently surpassed 50.

“The COS-6100 workstations are robust, reliable, recognisable and the optometrists love it. That opened us up to Nidek and the services of BOC and after that we ended up buying the full testing lane from them for our stores,” Jacobson says.

But new equipment installations are only part of the service, with BOC overseeing aftersales service for Nidek equipment maintenance and repairs.

“When dealing with BOC you quickly realise you’re dealing with someone who is emotionally and financially invested in the supply of the equipment.

Tony Cosentino, his son Ricardo and their family run the business and that shines thorough,” Jacobson says.

“Nothing is ever an issue and there is always follow up and follow through, and you have certainty that when the equipment is installed, it is going to be in a way that the optometrist can start their work from day one with everything running smoothly.”

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MORE THAN JUST A SALE Enduring products and prioritisation of aftersales service are the key ingredients to BOC’s longevity, says Cosentino, who personally marked 51 years in the ophthalmic industry this year and celebrated BOC’s 102nd birthday.

“I have always maintained the sale is just the beginning of the relationship,” he explains.

“It is the aftersale that people will ultimately remember you for, and is also one of the reasons why I have always maintained that we should only deal with high-quality, enduring equipment. I have customers that I did installations for 30 years ago still using the same equipment and we’re able to service it, so for me that indicates enduring value.”

An example of this is the classic phoropter. This year the instrument’s original manufacturer Reichert (previously American Optical (AO) and distributed locally by BOC) is celebrating the product’s 100-year anniversary. While new features have been added and other manufactures have since copied it, Cosentino says it has remained largely unchanged.

While many suppliers separate their salesforce and aftersales service department, BOC’s technical consultants in Victoria, Western Australia and Queensland perform both functions, in addition to a seven-strong team of technicians at BOC’s Sydney headquarters.

They all receive ongoing training for classic instruments, as well as the latest state-of-the-art equipment, which involves a considerable amount of factory training. This has been even

harder with COVID, with much of the training conducted online with overseas manufacturers.

Last year, closed borders due to the pandemic created other challenges for BOC. New equipment for interstate customers is typically sent via freight, with the technical consultant flying in for the installation.

However, Queensland’s strict border protocols meant BOC had to load a van with equipment, obtain a special permit and venture into northern Queensland.

Cosentino’s son Ricardo drove from Sydney to Cairns (2,600km or 27 hours) to deliver equipment and complete an installation, before trekking to Longreach (900km or 10 hours), then Emerald (400km or four hours), Gladstone (360km or four hours), Brisbane (830km or 9.5 hours), and then back to Sydney (900km or nine hours).

Over two months, he performed this trip six times, racking up 16,000km.

Although this was largely for new equipment installations, Cosentino says it’s vital to have a nimble team that can keep BOC’s customers operational.

“Our sales people are technically trained and are also able to perform installations, so they need to be multi-trained,” Cosentino explains.

“Over in the US and Europe, they tend to have the salesforce separate from the service support, and that sometimes leads to complications because service people don’t always realise the importance of keeping a customer going when things break down. You can’t have a situation where you advise a customer with a broken-down instrument that you’ll see them in two weeks, it’s not going to work.”

To address this, BOC keeps a large inventory of loan equipment which it can quickly send to practices while repairs are made. Cosentino has also made this equipment available for practices who may have been affected by the recent flooding in eastern Australia.

“That solves the downtime issue for the practice and makes it easier for us because we can then repair it in our own time as opposed to rushing out and trying to help everyone at once,” Cosentino says.

“Logistically Australia is a big country to navigate and it’s a challenge that all suppliers in our industry face.”

DOING BUSINESS WITH A STRAIGHT BAT It was the summer of 1979/80 when Mr Ray Fortescue first met Cosentino. At the time, Fortescue was a fearless 22-year-old optometrist setting up his first greenfield practice in Ramsgate Beach, southern Sydney. Cosentino was a fresh-faced technician for AO tasked with personally installing the practice’s full suite of top-end equipment.

It’s been a lasting supplier relationship that sustains today – even after Cosentino moved on when AO was sold, to eventually take over BOC, while Fortescue’s career progressed, seeing him become executive chairman of EyeQ Optometrists, with more than 20 practices nationally today.

Fortescue says some of the original equipment from 1980 still works perfectly. As both companies evolved over the years, BOC continues to be included in all EyeQ’s purchase considerations, for all classes of clinical equipment.

been a question from BOC, but always an option,” Fortescue explains.

A&R Grace Optometrists, a dual-practice business in Tanunda and Gawler, South Australia, is also a long-term customer of BOC. It’s also an example of the geographical difficulties BOC contends with, especially in the event of a breakdown.

Principal optometrist Mr Ashley Grace first met Cosentino nearly 40 years ago and purchases 90% of its equipment from BOC today, including Nidek cameras, autorefractors and vertometres, Optovue OCTs and other products.

The Nidek Tonoref III “is one of the best instruments” he’s ever bought.

“I have always found BOC good to deal with as they are reliable, their equipment is amazing and they play it with a straight bat in all their dealings,” Grace says.

“On one occasion I had a patient accidently push over the table holding the non-contact tonometer (NCT),” he says.

“The patient was very upset and the NCT was damaged, and I ended up having to console the patient. Within two days I had a loan unit arrive from BOC so that I could continue doing NCT while my unit was being repaired.”

MODERN-DAY CHALLENGES A stalwart of the industry for more than five decades, Cosentino has been privy to some of the major trends shaping eyecare in Australia. The push for all optometrists to own a slit lamp, and the revolutionary impact of non-contact tonometry and OCT are just a few technological milestones he’s witnessed.

As a supplier, he’s noticed how the classic equipment – like the phoropter – forge on, unabated, while newer technology evolves at a rapid pace and can be quickly superseded.

“It means you sometimes get into a position where you can’t always provide the desired aftersales service because the manufacturer no longer has the components to help. In other cases, it’s often computerdriven software updates which can happen every 12 months, which has made servicing more difficult. Equipment is more software-driven than mechanically-driven nowadays.”

On the other hand, Cosentino says it means many faults can be rectified by remotely logging into the system, or even over the phone. In one recent case, Optovue – a manufacturer based in Fremont, California – logged into a Brisbane practice to perform a major upgrade that took three days.

“We were able to come up with the best solution for the customer that made sense economically, because a new replacement would have been $30,000 compared to the cost of performing the upgrade,” he says.

“Ultimately, it’s about putting the customer’s interests first – and that’s how I’ve always run BOC.” n Ricardo Cosentino on one of his recent outback trips to Longreach, Queensland.

“Quality products and excellent technical workmanship has resulted in BOC supporting us for over 42 years. As recently as February, a Nidek Tonoref III was installed at one practice requiring a couple of visits due to unforeseen hurdles,” Fortescue says.

“The BOC team were responsive, flexible and ultimately successful in overcoming the challenge. No complaints – they just solved the problem.

There is a feeling of partnership with BOC which gives comfort in this increasingly depersonalised and complex industry.”

Critical equipment breakdowns are inevitable, but often Cosentino and his team of technicians have intervened with a true emergency fix.

“BOC has defused potentially disastrous situations for us. You need support to be available when you need it. At times we have required loan equipment to keep the practice open – and we have found this has never

INSIGHT May 2022 41

BUSINESS

Eyecare Plus Wallsend, Newcastle, New South Wales.

a sound investment INDEPENDENT OWNERSHIP

More younger optometrists are seeking fulfilment in their careers through practice ownership.

PHILIP ROSE explains how Eyecare Plus can help aspiring business owners with the transition.

O

ver the past couple of years industry figures have noted that practice owners have been reconsidering their personal and business priorities.

As a result, they have adjusted and reset their succession plans and expectations, creating a shift in the independent ownership market.

While many non-optometry businesses had to close their doors, optometry practices in general were able to stay open, albeit with slight adjustments to their levels of service provision.

In particular, Eyecare Plus – with more than 140 optometrists as members of the group – has seen a spike in younger optometrists moving into ownership earlier.

“People value their vision over any of their other senses,” he says, in a claim supported by Optometry Australia’s '2020 Vision' report revealing 76% of all Australians consider their eyesight to be their most important sense, while 59% are concerned about the quality of their eyesight, and know they need to do something about it.

The organisation says this has a lot to do with ownership opportunities becoming available, with COVID-19 accelerating many older optometrists’ retirement and exit plans.

“We’ve been finding that 30- to 40-year-old optometrists are approaching us to purchase practices,” says Mr Philip Rose, Eyecare Plus national business development manager.

“They have learnt from working in practices, often various business models, to know what they want in their own. At the same time, the younger the buyer, the more daunting self-employment can be for them. They want to take the leap into ownership but tend to gravitate back to the employment safety net because it’s what they know. Unfortunately, this will ultimately limit their potential earning capacity and lifestyle choices.

“Younger optometrists underestimate the opportunities that an independent lifestyle can bring.”

Eyecare Plus helps optometrists run their own independent practice in their own exclusive geographic territory.

It’s a formula the organisation says has worked successfully since its launch in 2000.

PRACTICE OWNERSHIP SUGGESTIONS The past has shown that optometry is a resilient profession and practice ownership has proved a sound investment.

During the 2008 financial crisis, while most businesses suffered enormously, optometry practices in Australia generally stayed afloat with stable income.

A lot of the time, retail sales were up every month, with many achieving record levels of turnover and profitability during what was said to be the toughest economic conditions in 20 years.

According to Eyecare Plus, this trend has also been evident during COVID.

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INSIGHT May 2022

Rose says it has a lot to do with eye health being an essential service.

BUYING OPTIONS Rose explains there are two options potential buyers have in entering the market: either they buy an existing practice or purchase a new (greenfield) practice.

He says the difficulty with buying into a greenfield practice location is that a practice owner is taking all the risk themselves. This can not only be daunting but enormously risky.

This is the reason why many potential owners contact Eyecare Plus, Rose adds, stating that the national office is prepared to assist practice owners who are looking to open their own practice.

“We can work with a new owner to find the right practice for them. We can set them up into a partnership because we know which optometrists are planning to exit and in how many years. We also have all the KPIs and knowledge of the market they are entering into,” Rose explains.

“Eyecare Plus can provide owners – both current and new – with personal advice and assistance. Current members and practice owners are happy to talk with and mentor anyone who does not have experience with the business side of optometry.

“Also, due to our protected territories, one point of difference with Eyecare Plus is that members can exchange ideas and talk freely at meetings because they know that their direct competitor will not be in the same room. This creates a fantastic collegiate culture within the group.”

BUSINESS PLANS In addition to practice benchmarking and understanding the local competitors and changing patient demographics, Rose says Eyecare Plus recommends that practices create a business plan.

A new or revised business plan can improve a practice’s ability to recognise and meet its goals, as well as steer future success and personal reward.

"ONE POINT OF DIFFERENCE WITH EYECARE PLUS IS THAT MEMBERS CAN EXCHANGE IDEAS AND TALK FREELY AT MEETINGS BECAUSE THEY KNOW THAT THEIR DIRECT COMPETITOR WILL NOT BE IN THE SAME ROOM."

Eyecare Plus recommends business plans exist as a "living" document.

“Your business plan must have ‘meaning’ to you and be the guideline by which you manage and develop your business,” Rose says.

“We have recently started doing face-to-face appointments again, but also continue to offer these via Zoom meetings.”

Rose explains there are three elements to the Eyecare Plus business plan: 1. Situation analysis (where you are) Eyecare Plus looks at a broad range of KPIs and compares them to industry benchmark figures, together with an incremental growth demonstration tool to show the impact of small changes.

2. Goals and objectives (where you want to be) Depending on identified strengths and weaknesses, the organisation works with members to achieve their personal and business goals.

3. Strategies and tactics (how to get there) Eyecare Plus considers which actions need to be followed to achieve the business’ goals and objectives for an improvement to the practice’s performance.

RURAL OPTOMETRY BOOM Rose says that young optometrists are not only driven by the potential business opportunity and independence that ownership brings, but they also want to build long term relationships with their patients and use their full scope of optometric skills.

“This is where owning a regional or rural optometry practice comes into its own. A rural practice is such a good fit for a new owner,” he says.

“In a country practice you will see all sorts of eye conditions. Optometrists who move from the city to take over a partnership in a rural practice are always surprised about the diversity of eye conditions that walk through the door. In a rural practice, you’re not just dispensing glasses all day.”

Rose notes that more flexible working conditions, such as working from home during the pandemic, has had a long-term affect on property purchase decision making, particularly for younger people who have found the major cities unaffordable.

“There has been a huge surge in home ownership in regional towns and that hasn’t slowed down during the pandemic,” he explains.

“These regional towns are seeing big population booms for the first time in decades, and they need services. This is why a potential new optometry practice in a rural setting will thrive. Populations are moving out of the city and buying homes. Because of their investments into these rural areas, it is unlikely they will pull up stumps and return to the capital cities.”

PHILIP ROSE EYECARE PLUS

Rose says the Marketing Plus team can create and execute a marketing and communications plan for any of its partner practices.

“Marketing Plus continues to help support and grow the Eyecare Plus brand at a local and national level. They work closely with individual members to market their practice within their local community,” he says.

“Nationally, Marketing Plus continues to evolve and adapt marketing strategies through online offerings, digital advertising and the Eyecare Plus website.”

HUMAN RESOURCES Finally, at Eyecare Plus, Rose says new owners have access to a human resources consultant.

“This also includes our library of Human Resources Procedures, which covers areas such as recruitment and selection, performance management, pay reward and recognition, policies and procedures, workplace health and safety and wellbeing,” he says.

Once a practice is established, the Eyecare Plus national office staff will accredit the practice to give on-site feedback to help improve practice operations and ensure the provision of quality patient care.

Regular practice business performance reviews and monthly benchmarking will guide new owners on areas to improve in their practice.

“Whether taking over an established practice or opening a new practice Eyecare Plus can help you make the transition seamlessly from working as an employee, to becoming a successful independent practice owner,” Rose concludes. n Wayne Derrick, Eyecare Plus Maroochydore.

MARKETING ASSISTANCE Once practices come into the Eyecare Plus fold, the organisation’s services extend into providing practice owners with marketing assistance under its Marketing Plus division.

For the benefit of its members, Eyecare Plus National Office has funded digital advertising during the past two years across two main channels – social media (Facebook and Instagram) and Google Ads. According to Rose, the Eyecare Plus website attracts more than 143,000 unique visitors each year and has been purpose-engineered for optimal user experience through easy navigation that provides relevant and topical information.

Marketing Plus also works to continuously adapt messaging and creative presentations to bring people back to the site regularly. In turn, this helps grow brand awareness and, as a result, increased online bookings for practices operating under the Eyecare Plus banner.

INSIGHT May 2022 43

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RANZCO UPDATE

h t l a e h e y e Australia’s A PIVOTAL OPPORTUNITY TO TRANSFORM

One of the most important presentations at this year’s 52nd RANZCO Congress was the launch of the college’s Vision 2030 and Beyond plan to overcome Australia’s long-standing and complex eye health equity issues.

R

ANZCO’s inaugural virtual congress has been hailed “a huge success”, with hundreds of delegates tuning in to view four days of lectures and events.

The digital event – which ran in place of a face-to-face event originally planned for Brisbane due to the Omicron outbreak – kicked off on Saturday 26 February, with more than 200 people attending Alcon’s hosted morning symposium, and more than 300 for the Opening Plenary.

In addition, well over 400 signed in for the Dame Ida Mann Memorial Lecture with Dr Alex Hewitt, with numbers remaining strong throughout, given it was a digital conference.

In the Opening Plenary, RANZCO president Clinical Professor Nitin Verma said he hoped this would be the first and final full virtual congress, with the last face-to-face event held in 2019. RANZCO’s 53rd congress is scheduled for later this year 28 October to 1 November 2022 in Brisbane.

In his presentation, Verma acknowledged 25 fellows who had recently passed away and, in particular, the sudden death of renowned Sydney cataract, corneal and refractive surgeon Dr Con Moshegov. He also acknowledged the many ophthalmologists listed in the Australia Day and Queen’s Birthday honours, with the most notable of these being the 2020 Australian of the Year Dr James Muecke.

The congress also provided the platform for RANZCO’s comprehensive launch of its Vision 2030 and Beyond plan focused on eyecare equity and sustainability.

Verma chaired the session, which then included lengthy presentations by speakers Dr Kristen Bell (service delivery), Dr Justin Mora (workforce & training), Associate Professor Prof Ashish Agar (Closing the Gap). Other key areas of the plan include global eye health, preventative healthcare, sustainability. In this report, Insight covers service delivery and workforce & training.

Verma said a lesson from pandemic is that delayed access to outpatient services results in poor outcomes – with issues around inequality and access being a major driver in often totally unnecessary and preventable vision loss.

“In 2021, RANZCO met with the Minister for Health and outlined inequity and access to eyecare and that, as a nation, we are not adequately

prepared to face the future,” Verma said.

“We were asked to develop a plan, not only to close the eye health gap for Aboriginal and Torres Strait Islander peoples, but to ensure equitable access to all Australians to stop avoidable blindness and visual impairment. This is the aim of the Vision 2030 and Beyond plan, a plan based on collaboration and consultation, to be delivered by the eye health sector and allow us as a nation to futureproof not only the eye health of our country, but also the region of Australia’s influence and responsibility.”

OPHTHALMOLOGY SERVICE DELIVERY IN AUSTRALIA

DR KRISTEN BELL is calling for an Atlas of healthcare delivery to help address healthcare variance, depending on where people live.

In her presentation on service delivery issues, Dr Bell – the Vision 2030 and Beyond clinical lead – said ophthalmology differs from other specialties, with 80% being outpatient care-based and 20% surgical.

Chronic sight threatening conditions such as diabetic retinopathy, glaucoma, and age-related macular degeneration make up the bulk of ophthalmic service delivery, with acute care often bypassing surgery and emergency to the outpatient setting.

She said multiple data sources show gaps in public ophthalmology services, noting that most adult and paediatric services are overwhelmed, and over 50% of existing service don’t offer comprehensive care. There’s also a maldistribution of outpatient services between and within Local Hospital Networks (LHNs) and longer waits for public inpatient services in inner and outer regional Australia.

She also pointed out that reportable data – such as elective wait times – failed to include outpatient and procedural wait times, leading to long wait times and making the bulk of ophthalmology services effectively invisible,

INSIGHT May 2022 45

RANZCO UPDATE

She said governments recognise there are problems, noting the current system is fragmented making it difficult for wellcoordinated care. Part of the problem is the complex split between Commonwealth and State governments and the not-forprofit and private sectors, regarding who is responsible for planning, funding and delivering services.

“A reform roadmap has been developed that challenges us to consider innovative models of care and flexible funding arrangements,” she said.

Solution 3 - deliver equitably at the LHN level Bell called for governments to commit to providing services, as defined by the Atlas and being held accountable for it. Planning and implementation should Estimated resident population heat map, with public hospitals marked in blue, and those with eye outpatient clinics take place at LNH level, while adequately are starred – located centrally within larger metropolitan areas across Australia. resourcing existing services, high value patient-centred models of care such as outer urban and inner regional with no data to drive growth of outpatient services. The “wait for the wait” clinics, collaborative care models, multidisciplinary clinics, liaison workers – time between referral and wait list – is unseen, with an internal RANZCO and patient transport. survey finding more half of public eye clinics do not offer comprehensive service and there’s no delivery standard to ensure services are complete.

AN IMPENDING OPHTHALMOLOGY WORKFORCE SHORTAGE Bell added that many outer urban areas and regional LHNs do not fund ophthalmology outpatient services at all.

She presented maps of Australia showing very few public care areas outside of urban areas. Northern Territory and Western Australia fund outreach from Darwin, Alice Springs and Broome, respectively, while Tasmania has recently started funding an additional service in the northwest of the state, giving these three jurisdictions the best regional coverage. But across Australia, 30% of entire population and 65% of Indigenous patients have no or limited access to a publicly funded local outpatient service.

Part of the problem, Bell said, is that local LHNs don’t have delivery maps for specific services, resulting in high healthcare variance, with service delivery largely based on how things have been done in the past. Also contributing to the problem is the fact new hospital developments, such as Fiona Stanley (WA), Gosford (NSW), and Sunshine Coast Hospital (QLD) don’t include eye outpatient services, meanwhile there have been threats and closures to public departments such as Royal Adelaide Hospital, and St Vincent’s Hospital in Sydney.

Bell outlined three solutions that would improve service delivery of ophthalmology in Australia.

Solution 1 – healthcare variation Develop an Atlas of healthcare delivery standard by specialty, patient demographics and geographic area to enable the delivery of safe, high-quality care in the right place at the right time – with appropriate demographic and geographic calibration.

She said this would provide LHNs a detailed map of public outpatient and inpatient services that must be delivered in within that area, addressing healthcare variation and providing equitable access to service at the local level.

Solution 2 – increase outpatient visibility Formal acknowledgement of outpatient services as high value healthcare activities which prevent people from developing more serious comorbidity and reduce mortality, and reduce the rate of more expensive treatments.

Bell also said it was necessary to include outpatient and procedural waitlist data in the Australian Institute of Health and Welfare dataset.

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DR JUSTIN MORA says ophthalmologists with a regional background are 2.7 times more likely to settle in regional Australia.

In his presentation, Dr Justin Mora, the RANZCO censor-in-chief and Qualification and Education Committee chair, said the ophthalmology workforce is under threat due to a lack of investment.

He highlighted 'Australia’s Future Health Workforce Report into Ophthalmology', released in 2018, which projects doctor workforces out to 2030. It recommended trainee intake numbers needed to increase by three each year from 2019 to address the impending workforce shortage. It also demonstrated a lack of funded training positions in the public sector, impending critical shortage of paediatric ophthalmologists and an over-reliance on international medical graduates (IMGs), and a “profound” maldistribution of full time equivalent (FTE) public-private ophthalmologists.

In relation to this final point, Mora said just 16% of total ophthalmology FTE work in the public system. A 2017 RANZCO survey found 45% work in public sector in some capacity.

“There is an assumption this is due to ophthalmologists not wanting to work in the public sector, but we relish the opportunity to increased collegiality, teaching and contributing to their communities. We can see 45% work in public in some capacity, and at Westmead, half of supervising consultant staff have worked in an honorary capacity for no pay for years,” Mora added.

So why is public ophthalmology FTE not growing? Mora said the problem is a lack of public jobs due to a chronic lack of investment in public services. As the workforce has increased, the public FTE has remained relatively fixed because there are no governance measures to ensure

Ophthalmology trainee intake numbers needed to increase by three each year from 2019 to address the impending workforce shortage.

growth in existing services to increase capacity.

9.3% have a regional background,” Mora said.

He said public services are usually available in teaching hospitals in cities and have limited capacity to expand their footprint. Consequently, there are long waiting lists for in and outpatient services, with a disproportionate impact on low income, Aboriginal and Torres Strait Islander communities and outer urban and regional patients.

With this in mind, RANZCO has introduced selection points for trainees with a regional background, and now more than 40% of trainees selected in the past two years had a regional background. This was recently strengthened by allocating eight regional points out of a total of 100 in the RANZCO selection process.

ACTIONS TO DATE

Mora said workforce planning constraints are brought about by a short-term Commonwealth funding delivery and planning model for specialist training via the STP. He said measures that allow forward planning of workforce for a minimum of eight to 10 years are needed to provide more certainty for employers.

Mora said RANZCO has been lobbying for the creation of additional training posts in every jurisdiction at the LHN level with little success.

This is due to a lack of growth in funding for public hospitals for trainees and consultant FTE, equipment and supporting staff, insufficient space in existing departments and operating lists, and LHNs refusing to take Commonwealth Specialist Training Program (STP) funding as this does not fully cover the cost of employing a trainee registrar.

“We have 20 fewer trainees currently than we need, according to workforce report, to avoid a shortage of ophthalmologists by 2030,” Mora said.

“Colleges are caught in the middle between Commonwealth workforce expectations, which RANZCO wishes to prosecute, and jurisdictional funding availability. RANZCO on one hand is required to increased positions by the Commonwealth, while there is no governance mechanism that allows this to happen at the LHN where funding for most specialist training FTE is provided.”

Mora said solutions to the impending overall workforce shortage and maldistribution need to recognise overall workforce distribution and sustainability are inextricably linked with equitable public hospital service delivery.

SOLUTIONS OVERVIEW 1. I ncrease the number of trainees with a regional background – completed.

2. Strengthen comprehensive ophthalmology training – completed.

3. I ncrease the number of regional training posts with the aim of one full year of training at a regional post.

4. Establish the Regionally Enhanced Training Network – completed.

Mora said, if adopted, point three would build regional training posts in crucial areas from the ground up and force teaching hospitals to adopt a workforce-poor regional area. RANZCO is also looking at establishing a bi-national virtual teaching program to start from 2023 allowing trainees to attend teaching no matter where they are based.

As part of the solution, Mora said there needed to be KPIs for workforce and training at the LHN level, which needed to be embedded in the National Health Reform Agreement.

From the government, Mora said KPIs for training, including in regional Australia, would drive growth of regional FTE, and prevent hospitals from declining STP funding such as currently happening at Modbury Hospital in Adelaide.

Across Australia, Mora said ophthalmology inpatient surgical services are delivered using an outsourced-to-private funding model. He said there is a need to incentivise public service provision by specialist ophthalmologists.

A Commonwealth commitment to fund additional STP-Integrated Rural Training Pipeline (IRTP) posts from 2026 would allow for 20, rather than 10, regionally enhanced registrars by 2027.

“Sixteen per cent of ophthalmologists practise in regional locations, despite 29% of the Australian population being regionally based.

Specialists not settling regionally is an ongoing problem. Of ophthalmologists who trained and graduated between 2013-16, 90% now reside in urban areas; we know ophthalmologists with a regional background are 2.7 times more likely to settle in regional Australia, but just

“RANZCO also requires a commitment from states to establish the positions of regionally enhanced trainees in major city hospitals for that component of their training from 2025,” Mora concluded.

RANZCO's launch of the Vision 2030 and Beyond plan can be accessed at: ranzco.edu/home/community-engagement/ n

INSIGHT May 2022 47

Autumn Showcase FIRST PUBLIC SHOWING OF CYLITE HP-OCT Cylite’s first public showing of its Australian-made HP-OCT with Focus software will be at O-Show in May. The system utilises patented Hyperparallel OCT technology to simultaneously scan 1,008 individual beamlets across the eye to produce a scanning speed of greater than 300,000 scans per second. This enables it to minimise the effect of eye motion artefacts and build highly accurate three-dimensional volumetric scans of the anterior and posterior segments.

The award-winning HP-OCT is scheduled to be launched in the latter half of 2022 and O-Show is the first time the Australian optometry eyecare community will be able to see it in a public forum. It will be shown on booth #84 along with its new software platform, called Focus, which is designed to both drive the HP-OCT as well as manage the patient database.

“We are really looking forward to showing off our new technology and giving the Australian eyecare community its first glimpse of what’s to come,” stated the company.

Image: An anterior segment volumetric scan from Cylite’s HP-OCT.

EYES RIGHT OPTICAL INTRODUCES THE LATEST FROM WOOW Eyes Right Optical is urging optical practices to take style to new heights with the art of ROOF TOP from WOOW. On the back of the success of WOOW models ‘ROOF TOP 1’ and ‘ROOF TOP 2’, the frames wholesaler is launching the new WOOW model ‘ROOF TOP 3’.

“These skilfully crafted glasses are as stylish as a Parisian rooftop terrace,” Eyes Right Optical stated.

“The strength of metal meets the generosity of acetate on these chic, superlative frames. A petite piece of metal adds a precious, graphic detail that creates a stunning illusion on the frame front.

A warm sunset gradient of colours seen in colour way 2005 evokes the wearable softness of a sunset. Life at its best... and a view from the top.” sales@eyesright.com.au

info@cyliteoptics.com

HOYA DEVELOPS AN ANTI-BACTERIAL SPECTACLE LENS COATING Hoya Vision Care Australia & New Zealand has introduced a new HiVision Anti-Bacterial lens coating which the company says is proven to reduce bacterial growth on the surface of a lens by 99.9%.

The innovative lens coating can help reduce the chance of eye infections while meeting the increased global demand by consumers for safer, more hygienic products brought about by the COVID-19 pandemic, the company stated.

The Hi-Vision Anti-Bacterial coating – applied to both the front and the back of the lens surface – contains silver ions known as AG+ which penetrate bacteria and change the intracellular enzyme within the bacteria, stopping its function.

According to Hoya, the coating uses Kohkin, an anti-bacterial process that can inhibit bacterial growth for a long period of time, unlike sterilisation or disinfection which only temporarily kill and eliminate bacteria.

Hoya’s Hi-Vision Anti-Bacterial lens coating is certified for both its quality and effectiveness by ISO and The Society of International Sustaining Growth for Antimicrobial Articles (SIAA), with the company being the first eyeglass lens manufacturer to be registered with SIAA.

MENICON BLOOM MYOPIA SOLUTION NOW LOCALLY AVAILABLE Menicon has announced the launch of Menicon Bloom, a holistic treatment plan for myopia control in seven additional markets, including Australia, from March 2022. The launch has been bolstered with a marketing campaign titled ‘see their imagination bloom’.

Menicon Bloom is a complete treatment plan for childhood myopia that features two contact lenses that are CE-approved specifically for myopia control: Menicon Bloom Night, ortho-k contact lenses, and Menicon Bloom Day, soft daily disposable contact lenses.

“Combined with specially formulated Menicon Bloom lens care solutions, our state-of-the-art fitting software and innovative Menicon Bloom App, we offer a holistic treatment plan to help slow down the progression of childhood myopia,” Menicon stated.

“Our marketing campaign … aims to raise awareness of childhood myopia and the possible treatment options. With a rich and vibrant visual world of imagination we aim to make it reassuringly easy for parents and eyecare professionals around the world to incorporate our Menicon Bloom lenses into children’s day, or night routines.” mail@menicon.com.au

Hapl_marketing@hoya. com

48

INSIGHT May 2022

Insight h

Autumn Showcase HIGHLIGHTS FROM THE LATEST LE SPECS BIO COLLECTION

TAKING RETINAL IMAGING TO NEW HEIGHTS The iCare EIDON – distributed by Designs For Vision (DFV) – is the first TrueColor retinal imaging system to combine the best features of Confocal Scanning-Slit technology with those of standard colour fundus imaging. With new ultra-wide field (UWF) optics, EIDON is said to deliver superior edge-to-edge detail up to 200 degrees through pupils as small as 2.5mm, minimising the need for dilation.

The EIDON family’s additional benefits include 3D automation, multi-modal imaging options (colour, IR, FAF, FA) and industry-leading image quality, even through media opacities.

DFV says the UWF lens is an option across all models in the iCare EIDON family, including EIDON AF and EIDON FA. It may also be possible to upgrade older EIDON units with the UWF attachment.

Ph: 1800 225 307

INTRODUCING

Since 1979, Le Specs has been designing unique eyewear specifically for Australian environments, and our Australian way of life.

As a market leader in sustainability, the new Le Specs optical and prescription sunglass collections are luxuriously crafted from sustainable bio acetate that combine the beauty and qualities of acetate with a plant-based and biodegradable composition.

Highlight styles from the latest Le Specs bio collection include the new ‘Bio-nics’ optical silhouette, designed with European sophistication and Australian refinement, offering a rounded vintage aesthetic for men and women.

Prescription sunglass style ‘Bio-metric’ is an update of iconic Le Specs style ‘Bandwagon’ worn by Meghan Markle and impeccably crafted from luxurious bioacetate.

To celebrate the new Le Specs sustainable collections range, simply purchase 10 Le Specs optical frames and receive five pairs free!* *For terms and conditions or to place an order, contact Sunshades Eyewear. customerservice@sunshadeseyewear. com.au

SOLIX

FULLRANGE™ OCT

Next Generation Imaging from CORNEA to CHOROID SOLIX is new technology built upon a proven foundation of ultra-high-speed Spectral Domain OCT. This FullRange platform delivers a field of view that is wide and deep yet does not sacrifice image clarity and resolution. SOLIX delivers multiple tools for a new generation of disease management that empowers practitioners to identify and manage pathologies from the front of the eye to the back.

People you know.....Products you trust

Insight half page for SOLIX_235x144_FEB21.indd 1

Telephone: (02) 96437888

Email: sales@bocinstruments.com.au

Toll Free: 1800804331

Website: www.bocinstruments.com.au

25/2/21 1:36 pm

Autumn Showcase EXPERIENCE PRECISION IN A NEW DIMENSION THE WORLD'S THINNEST LENS – MADE IN JAPAN Tokai Optical Company Limited was founded in Japan as an ophthalmic lens manufacturer in 1939. It’s committed to developing, manufacturing, and selling products full of originality from a customer's perspective and aims to offer unprecedented products.

With this passion, an index of 1.76 is Tokai’s original product created in 2006. Although it's been more than 15 years, the company says it is still the only lens manufacturer with the technology to cast and produce the 1.76 index lens.

With Tokai's in-house R&D team developing an index of 1.76, it can work with the material from many perspectives, such as sunglasses tint, Transitions GEN8, LUTINA (HEV 400-420nm cut) and is available in all lens categories.

“Offering your customers this thinnest material in the world, combined with the most highly scratch-resistant coatings on the market, will undoubtedly increase customer satisfaction and your business opportunity,” Tokai stated. toa.orders@tokaiopt.co.jp

The ZEISS VISUFIT 1000 creates a 180-degree view of the patient’s face and the frames using nine cameras and 45 million points. The centration data determination is based on 3D coordinates. The back-vertex distance can be determined for both sides, right and left. Furthermore, a 3D digital reconstruction of the face can be created and enables the back-vertex distance to be captured, even with frames featuring very thick temples. An additional bonus is that the sunglass lenses are also able to be made transparent if the lenses cannot be removed.

According to ZEISS, the VISUFIT 1000 will also support forthcoming virtual functions, making this more than just a system for the determination of centration data. The data captured with this system is so detailed that it is possible for this information to allow patients to try on glasses virtually as well as for customised frame designs.

Visit the ZEISS stand at O-Show for a demonstration. yvette.barnes@zeiss.com

PBS Information: Xalatan (latanoprost 0.005% eye drops, 2.5 mL) is listed on the PBS as antiglaucoma preparations and miotics.

Before prescribing please review Product Information available via www.aspenpharma.com.au/products or call 1300 659 646.

A first choice for glaucoma management1

✔

If clinically necessary for the treatment of your patient, prescribe by brand and disallow brand substitution2

Minimum Product Information: XALATAN® (Latanoprost 50 μg/mL) Eye Drops. Indication: Reduction of intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension.

Contraindications: Hypersensitivity to ingredients. Precautions: Change in eye colour due to increased iris pigmentation, heterochromia; eyelid skin darkening; eyelash and vellus hair changes; aphakia; pseudophakia; macular oedema; other types of glaucoma; contact lenses; severe or brittle asthma; herpetic keratitis; driving or using machines; elderly; children; lactation. Pregnancy: Category (B3) Interactions: other prostaglandins, thiomersal. See PI for details. Adverse Effects: Iris hyperpigmentation; eye irritation (burning, grittiness, itching, stinging and foreign body sensation); eyelash and vellus hair changes (increased length, thickness, pigmentation and number of eyelashes); mild to moderate ocular hyperaemia; punctate keratitis; punctate epithelial erosions; blepharitis; eye pain; excessive tearing; conjunctivitis; blurred vision; eyelid oedema, localised skin reaction on eyelids; myalgia, arthralgia; dizziness; headache; skin rash; eczema; bronchitis; upper respiratory tract infection; abnormal liver function. Uncommon: Iritis, uveitis; keratitis; macular oedema; photophobia; chest pain; asthma; dyspnoea.

Rare: periorbital and lid changes resulting in deepening of the eyelid sulcus; corneal calcification. See PI for details and other AEs. Dosage and Administration: One eye drop in the affected eye(s) once daily. Other eye drops should be administered at least 5 minutes apart. (Based on PI dated 2 March 2021) References: 1. NHMRC Guidelines for the screening, prognosis, diagnosis, management and prevention of glaucoma 2010 2. Australian Commission on Safety and Quality in Healthcare Active Ingredient Prescribing Guide - list of medicines for brand consideration December 2020 Aspen Australia includes Aspen Pharmacare Australia Pty Ltd (ABN 51 096 236 985) and Aspen Pharma Pty Ltd (ABN 88 004 118 594). All sales and marketing requests to: Aspen Pharmacare Pty Ltd, 34-36 Chandos Street, St Leonards NSW 2065. Tel: +61 2 8436 8300 Email: aspen@aspenpharmacare.com.au Web: www.aspenpharma. com.au Trademarks are owned by or licensed to the Aspen group of companies. © 2021 Aspen group of companies or its licensor.

All rights reserved. Prepared: June 2021 AF05768 ASP2528

Autumn Showcase VIVITY 'A FIRST-OF-ITS-KIND' IOL Presbyopia correcting intraocular lenses (IOLs) – whether trifocals or extended depth of focus (EDOF) lenses – traditionally induce the risk of an increased incidence of dysphotopsia such as glare and halo compared to monofocal IOLs.1 Alcon’s AcrySof IQ Vivity IOL is a first-of-its-kind, non-diffractive presbyopia-correcting lens that the company says provides good distance, good intermediate and functional near vision, while providing a visual disturbance profile comparable to a monofocal IOL.2-4 This means that patients who previously may not have been suitable for a presbyopia-correcting IOL can now experience the convenience of an extended range of vision.2-4 For more information please contact a local Alcon Surgical Account Manager.

References: 1. Kohnen T, Suryakumar R, Extended Depth-of-Focus Technology in Intraocular Lenses. Journal of Cataract and Refractive Surgery. 2019 10447 1-28.

2. Alcon AcrySof Vivity® DFU 3. Alcon Data on File, TDOC-0055575. 09 Apr 2019 4. Alcon Data on File. TDOC-0055576. 23 Jul 2019 simon.allen@alcon.com

OPTOS PUTS SPOTLIGHT ON SILVERSTONE The Optos Silverstone imaging device is described as an industryfirst combining ultra-widefield (UWF) retinal imaging with integrated, image-guided, swept-source OCT. According to the company, Silverstone produces a 200° single capture optomap image with guided OCT, allowing advanced OCT imaging anywhere across the retina, from posterior pole to far periphery. This is said to provide unparalleled UWF guided multimodal imaging in support of detection, investigation and monitoring of retinal disease.

“Silverstone provides greater imaging functionality, and it combines colour, autofluorescence (AF), fluorescein (FA) and indocyanine green (ICG) angiography with SS-OCT imaging capabilities,” the company says. “A comprehensive exam that includes an ultra-widefield optomap image has been shown in clinical studies to enhance pathology detection and disease management, as well as to improve clinic flow. Now by integrating SS-OCT, Silverstone further facilitates detailed examination of the retina from vitreous through the choroidal-scleral interface and helps guide treatment decisions.”

Silverstone also features a 1050 nm OCT light source, providing deeper tissue penetration for clear, detailed choroidal imaging, while 3-in-1 Colour Depth Imaging offers important clinical data from the retinal surface through the choroid. auinfo@optos.com

CATIONORM – A PRESERVATIVEFREE DRY EYE TREATMENT Cationorm (cationic nanoemulsion) is a preservative-free, hydrating and lubricating emulsion which protects the eye surface, reducing the discomfort and irritation of dry eye caused by prolonged use of contact lenses, or environmental conditions.1 The therapy’s triple action repairs the lipid layer to reduce evaporation, lubricate and stabilise the tear film; restores the balance of moisture in the muco-aqueous layer of the tear film; and is positively attracted to the ocular surface, to provide long-lasting protection.2-5 Cationorm is suitable for use with contact lenses, and is conveniently delivered via a preservative free, multi-dose bottle, or single-dose ampoules.6 Cationorm can be administered as one drop, up to four times daily in the affected eye(s).6 References available upon request. orders@ goodopticalservices.com.au

TRANSITIONS XTRACTIVE: CLEAR TO EXTRA DARK Transitions XTRActive range of lenses are clear indoors and extra dark outdoors. They also activate in the car and filter blue light.

The first technology is Transitions XTRActive Polarized. According to the company, it is the one and only dynamic polarised photochromic lens. It is clear and unpolarised indoors. Outdoors as the lens darkens, it also polarises up to 90% polarisation efficiency. Transitions XTRActive Polarized is extra dark outdoors and activates up to category 2 darkness in the car. It is available in Grey.

The second technology in the range is Transitions XTRActive new generation.

“It is extra dark outdoors and is the only photochromic lens to darken to category 3 in 35°C. Transitions XTRActive new generation is also the only clear to dark photochromic lens to achieve category 2 in the car. Transitions XTRActive new generation is 35% faster to fade back indoors compared with previous generation.”

Transitions XTRActive new generation is available in Brown, Graphite Green and Grey. info@transitions.com.au

INSIGHT May 2022 51

Autumn Showcase VEI’S FUTURE VISION FOUNDATION

BOC INSTRUMENTS WELCOMES NEW S.B.M. ACTIVA DRY EYE MASK Italian firm S.B.M. is a global leader for dry eye diagnostic technology and manufactures a range of products.

New to its product range is the Activa, described as an innovative non-invasive eye-mask that provides complete heating and automatic squeezing technology in a single device. It is designed to treat meibomian gland dysfunction associated with tear film evaporation.

According to S.B.M’s local distributor, BOC Ophthalmic Instruments, the Activa relieves evaporative dry eye symptoms by melting the meibum and unclogging glands to restore natural meibum flow and increase meibomiam gland functionality.

“This unique device mechanically warms and massages the lids, is fast and painless, requires no gel and after each use the mask can be easily sanitised,” BOC stated.

In 2021, as part of its 20-year celebrations, Vision Eye Institute (VEI) launched the Future Vision Foundation. One of Australia’s largest providers of ophthalmic services, it has a deep heritage in ophthalmic research to acquire new knowledge and improve patient care. The not-for-profit Future Vision Foundation extends this commitment further by encouraging and supporting the research efforts of the organisation’s staff and associated clinicians.

According to VEI, the foundation's support complements the external research funding many of its doctors receive and includes funding as well as clinical resources to assist with conducting the study, collecting samples and analysing data. It seeks to encourage both staff and external collaborators who have a demonstrated interest in ophthalmic research but may lack formal experience, thus fostering the next generation of eyecare researchers.

The Future Vision Foundation is part of the OneVision ESG program, which encompasses Vision Eye Institute’s various environmental, social and governance initiatives. Visit the website: futurevisionfoundation.com.au. christopher.hodge@vei.com.au

sales@bocinstruments.com.au

TAKE ANOTHER LOOK AT

PREDNEFRIN FORTE Available now across Australia Indicated for non-infectious ocular inflammation1 and back in stock

Reference: 1. Prednefrin Forte Product Information.

PBS Information: PREDNEFRIN FORTE® is listed on the PBS for severe eye inflammation, corneal grafts and uveitis.

BEFORE PRESCRIBING, PLEASE REVIEW APPROVED PRODUCT INFORMATION AVAILABLE ON REQUEST FROM ALLERGAN BY PHONING 1800 252 224 OR FROM www.allergan.com.au/products Allergan Australia Pty Ltd. Level 20, 177 Pacific Highway, North Sydney NSW 2060. ABN 85 000 612 831. ©2022 Allergan. All rights reserved. AU-PRED-220008 V1. Date of preparation: February 2022. ALL2190.

ALL2190-7 _ Prednefrin ads Stage 2_v0.3.indd 1

03/03/2022 11:39

DISPENSING

DISPENSING AND WORK HEALTH AND SAFETY OPTICAL DISPENSERS CAN BE INFLUENTIAL IN MAINTAINING WORKPLACE SAFETY AND PROTECTING THE VISION OF WORKERS ACROSS VARIOUS PROFESSIONS, ACOD DIRECTOR CHEDY KALACH EXPLAINS.

W

hen you hear the term 'health and safety at work', I assume you automatically think about your own workplace, staff or safety spectacles.

As a dispensing optician there is more we can do in the realm of workplace safety for customers.

CHEDY KALACH

“THE DISPENSING OPTICIAN IS IN THE IDEAL POSITION TO ASSIST CUSTOMERS IN CORRECT ERGONOMICS, LIGHTING AND THE APPROPRIATE EYEWEAR”

Eye injuries comprise 5-10% of reported lost time in the workplace. Many are preventable, caused by inappropriate use of equipment or lack of eye protection.

Victims tend to be young and relatively inexperienced workers or experienced workers falling into poor habits. This increases costs to employers and healthcare systems and the injured employee can also suffer loss of future earning potential, due to the long-term effects of reduced vision.

Dispensing opticians are uniquely positioned to provide consulting and preventable services to maintain a safe workplace. In conjunction with optometrists, they can identify workplace hazards, analyse visual demands of workers and plan appropriate programs to provide safety eyewear, and monitor ocular health.

Firstly, the dispensing optician can perform a workplace survey and safety inspection, particularly focusing on oculo-visual hazard analysis. The safety inspection should focus on tasks, workplace areas that have the potential for ocular hazards, allowed limits of worker exposure, safe manual handling procedures and emergency measures.

Even though mechanical/physical hazards comprise 70-80% of work-related injuries, and range in severity, other hazards could be chemical, optical radiation or ergonomic hazards, to name a few.

Physical hazards/foreign bodies are more common. They can vary from small superficial lacerations, ferrous foreign bodies causing possible siderosis (if left in), to deep permanent damage. Chemical hazards comprise approximately another 10% of eye injuries. These include vapours and fumes from volatile solvents or slash injuries from highly concentrated solutions.

Optical radiation is more common during the summer, as solar exposure of just 20 minutes during 10am – 4pm may result in sunburn or mild photokeratitis. Chronic high level UVB retinal exposure in childhood may be a contributing factor of dry macular degeneration later in life.

Another hazard is inappropriate illumination

Injuries can vary from small superficial lacerations, ferrous foreign bodies causing possible siderosis, to deep permanent damage.

in office spaces, or people working from home. As well as computer monitors and computer vision syndrome, the dispensing optician is in the ideal position to assist customers in correct ergonomics, lighting and the appropriate eyewear. You can ask the customer to download a luxmeter app on their smart phone to assess their workplace/home office illumination.

Home offices traditionally aren’t configured like office workplaces, lacking the same level of scrutiny to ensure worker safety. Nearly half of all eye injuries occur at home: will this statistic increase as more of the workforce work from home? Something else to consider for your customers when recommending eyewear.

For tasks with low contrast or small font, it is recommended to have 1000-2000 lux, while general lighting for an occasional visual task is 100-200 lux. Homes are usually 150 lux and dining rooms tend to be darker at about 25-50 lux. Are your customers working at the dining table?

Once you have a better understanding of workplace tasks, the visual standard needed, oculo-visual levels and illumination, you can start recommending relevant products. Think outside the products you usually supply to achieve the best holistic result for the customer – task lighting for example. On a side note, have they had a pre-employment assessment to ensure the workplace does not cause any harm?

Let’s put this together for a specific profession: healthcare workers. One needs to drill into the specific tasks for the

profession and the person’s workplace.

As part of the workplace survey, some ocular hazards may be: impact, splash of biological substances or chemical solutions, chemicals (drugs, disinfectant or cleaning materials), and optical radiations from medical lamps, lasers and, of course, any physical hazards present.

What are their specialised visual tasks?

This could be reading coloured labels, small font, low contrast labels, indicator strips, utilising various digital devices, with different working distances, font sizes, screen sizes and illumination.

Considering this brief assessment, what products can be recommended? Obviously start with appropriate visual correction to ensure they can read at all working distances, including the small font. The client also requires specific spectacles to protect against splashes. Which leads to the next question, how often do you recommend safety glasses for healthcare workers?

By asking questions and taking an interest in your customers’ visual needs at home and work, can you then recommend appropriate solutions. n

ABOUT THE AUTHOR: CHEDY KALACH is a director of the Australasian College of Optical Dispensing. Since 2009 he has lectured throughout Australia and New Zealand across a variety of topics such as ophthalmic optics and business management. He is also the advisory board secretary of new dispensing network Optical Dispensers Australia.

INSIGHT May 2022 53

AN AUSSIE ORTHOPTIST WORKING IN GLOBAL PUBLIC HEALTH STUART KEEL BECAME INTERESTED IN PUBLIC HEALTH WHILE WITNESSING STARK EYE HEALTH INEQUALITIES AS PART OF THE FIRST NATIONAL EYE HEALTH SURVEY. THE EXPERIENCE HAS TAKEN HIS CAREER TO THE HEADQUARTERS OF THE WHO.

I

’m an Australian orthoptist currently working as a technical officer within the Vision and Eye Care Programme at the World Health Organization (WHO), Geneva.

In this role, I support the development of technical guidance and tools that aim to assist countries to strengthen the delivery of eyecare within their health systems.

STUART KEEL

“THE BEAUTY OF THIS PROFESSION LIES IN THE COUNTLESS OPPORTUNITIES WE HAVE TO CONTRIBUTE IN WAYS THAT ALIGN WITH OUR VALUES”

My eyecare journey began at La Trobe University in Melbourne where I completed a Bachelor’s Degree in Orthoptics and Ophthalmic Science. After several years working as an orthoptist within a range of public and private clinical settings in Australia, I ventured back to where it all started, La Trobe University, to embark on a PhD in ophthalmic epidemiology. While undertaking this, I had the opportunity to be involved in the education of orthoptic students and held positions with Orthoptics Australia, including honorary president of the Victorian branch.

My interest in public health began when I joined the Centre for Eye Research Australia (CERA) as a post-doc fellow where, during travels around Australia as part of the National Eye Health Survey, I witnessed first-hand the stark eye health inequalities experienced by many segments of the national population, including the Indigenous population and those living in rural and remote communities. As an active member of the CERA-WHO Collaborating Centre for Prevention of Blindness, I benefitted from exposure to projects on international eyecare, such as working with WHO Western Pacific Office in Manila to evaluate progress at the mid-point of the ‘Universal Eye Health: a Global Action Plan 2014-2019’.

After several years working in academia, I commenced a position within WHO’s headquarters in Geneva as a technical officer for the Vision and Eye Care Programme in 2019. This represented an exciting time to be involved in global public health in the field of eyecare; the year 2020 marked the end of WHO’s global initiative ‘Vision 2020: The Right to Sight’, and new strategies were being discussed to address the current and projected population eyecare needs.

Since 2019, the Vison and Eye Care

54

INSIGHT May 2022

Stuart Keel (far right) at the launch of the ‘World report on vision’ with the World Health Organization director general Dr Tedros Adhanom Ghebreyesus (fourth from right) and others.

Programme at WHO has played a role in several key developments that have helped shape the new eyecare agenda for the coming decade, including: I. P roducing WHOs first World report on vision (2019) that sets forth several actions that governments, nonstate actors and WHO can take to address the key challenges facing the eyecare sector; II. The resolution titled: ‘Integrated peoplecentered eyecare, including preventable vision impairment and blindness’, that was endorsed by member states at the 73rd World Health Assembly (WHA73.4) in 2020; III. Preparation of recommendations on global targets for 2030 focusing on two global tracer eyecare indicators, effective coverage of cataract surgery and refractive error, that were subsequently endorsed by the 74th World Health Assembly in May 2021.

To support countries with the implementation of the actions outlined in these high-level documents and global commitments, the WHO team in which I work with other international experts, has developed a range of technical tools that will be launched in 2022.

Some of which include (i) a package of evidence-based eyecare interventions to assist countries in making decisions

on which interventions to prioritise and how these can be budgeted at each level of care; (ii) an eyecare competency framework to assist in workforce planning and development; and (iii) an eyecare indicators menu and resources to facilitate data collection to ensure robust monitoring of progress towards achieving these new proposed actions and targets When I started my career as an orthoptist, never did I imagine it would lead me to the head office of the world’s leading public health agency. However, the beauty of this profession lies in the countless opportunities we have to contribute in ways that align with our values and personal purpose. I hope my journey helps to inspire other orthoptists to continue their meaningful and important work, no matter the stage of their career or setting they work in. n

ABOUT THE AUTHOR: Australian-trained orthoptist STUART KEEL is a Technical Officer of the Vision and Eye Care Programme at World Health Organization in Geneva. He has previously been a post-doc fellow at the Centre for Eye Research Australia and honorary president of the Orthoptics Australia Victorian branch.

ORTHOPTICS AUSTRALIA strives for excellence in eye health care by promoting and advancing the discipline of orthoptics and by improving eye health care for patients in public hospitals, ophthalmology practices, and the wider community. Visit: orthoptics.org.au

MANAGEMENT

WHEN DO YOU NEED AN INTERPRETER? MRS 'K' GREETS YOU WHEN SHE ARRIVES FOR AN EYE EXAM WITH HER DAUGHTER. IN RESPONSE TO QUESTIONS, SHE SMILES AND NODS, BUT STRUGGLES TO ANSWER. AN INTERPRETER MAY BE REQUIRED, SAYS PATRICK CLANCY.

H DR PATRICK CLANCY

“RELYING ON THE PATIENT’S RELATIVES OR FRIENDS TO INTERPRET CAN BE RISKY AND MAY BE INAPPROPRIATE”

ealthcare practitioners have a duty to take reasonable steps to communicate effectively with patients – including using qualified language interpreters wherever necessary.

However, recent research suggests that culturally and linguistically diverse patients are not always being offered access to professional interpreters.

Think about how much information you exchange in even the most straightforward patient consultation. As well as being a professional responsibility, it’s in your interests as well as the patient’s that you communicate effectively and avoid misunderstandings. The clinical risks of miscommunication are clear: inadequate history taking; missed or delayed diagnosis; patients not being able to follow treatment plans. Other reported issues can include longer consultations, additional referrals and tests, and complaints due to lack of informed consent to treatment.

There may be multiple reasons why interpreters are not offered: concerns about cost, time taken to access, being unsure how to access interpreters, not recognising an interpreter is required, waiting for a patient to ask, or assuming a family member can translate.

USE PROFESSIONAL INTERPRETERS WHEREVER POSSIBLE Professional codes of conduct require practitioners to be familiar with and use qualified language interpreters wherever necessary. This includes access to sign language interpreters if required for deaf or hearing-impaired patients.

Relying on the patient’s relatives or friends to interpret can be risky and may be inappropriate.

Patients may be unwilling to disclose clinical issues to a family member, particularly a child. Even if their conversational English is good, a relative or friend may not be able to translate medical terminology. Family members may also filter what they relay to the patient. Even if this is wellintentioned, out of a desire to soften the message, or please the practitioner, it means the patient does not receive the information they need.

IDENTIFY THE NEED FOR AN INTERPRETER There are several guides to help practitioners identify when an interpreter may be needed (see references in the online version of this article). Often it is as simple as asking open questions.

While ‘yes’ or ‘no’ answers can mask a lack of understanding, having the patient describe their symptoms or repeat back what you told them can make it easier to spot language barriers.

ACCESSING PROFESSIONAL INTERPRETERS Make sure that the practice team understand how to access professional interpreters when needed. Practices may have posters or signage letting patients know they can ask for an interpreter and the languages available. (For more information on interpreter services, see the references listed in the online version of this article).

Patients sometimes feel concerned about involving an interpreter. It’s often helpful to reassure them that your discussion will be confidential. An interpreter can help you explain this part if necessary.

SAVE TIME BY COMMUNICATING CLEARLY Whether or not you are using an interpreter, clear communication can take time, but generally saves time and misunderstandings later.

If you haven’t worked with an interpreter, it can feel a little awkward to get the balance right. Key tips include: • A llow time initially for the patient to speak with the interpreter and to feel comfortable and confident about the arrangement, especially if the interpreter is on the phone.

• S peak directly to the patient and engage with them rather than asking the interpreter to relay questions.

“Do you have pain?” not “Can you ask the patient if they have pain?”.

• P ace your communication. Think about how much information you deliver at once. Pause so the interpreter has time to relay the information.

• I t can also be helpful to signpost the

Professional codes of conduct require practitioners to be familiar with and use qualified language interpreters wherever necessary.

consultation – explain the steps you will be working through – so both the patient and interpreter know what’s coming.

• Allow plenty of time for questions. iagrams and other materials may • D also be helpful.

THINK ABOUT FOLLOW-UP Ensure the patient knows how to get in contact if they have questions, and check whether they wish you to share their personal information with any family members or support people. n NOTE: Supporting resources and reference material can be found in the online version of this article.

Disclaimer: This article is intended to provide commentary and general information. It does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practise proper clinical decision making with regard to the individual circumstances.

ABOUT THE AUTHOR: DR PATRICK CLANCY is a senior medical adviser in the Advocacy, Education and Research team at Avant. He has been a doctor for over 25 years and was previously a member of a state medical board. Clancy has presented and written widely on medico-legal topics, with a focus on minimising the risks faced by doctors.

INSIGHT May 2022 55

CAREER

People

ON THE MOVE Insight's monthly bulletin to keep the Australian ophthalmic sector updated on new appointments and personnel changes, nationally and globally.

KYLEE HALL PROMOTED TO THE HELM OF CYLITE Cylite’s former Vice President of Sales and Marketing, Ms Kylee Hall, has taken over as CEO from the company’s Founder and Director, Dr Steve Frisken. Frisken will continue in an executive leadership role to provide operational and innovation guidance to the company. Previously Manager of Zeiss Australasia’s Medical Division, Hall took time away from the profession to pursue an Executive MBA, before joining Cylite in February 2020.

“With over $25 million in private and government investment to date and a solid roadmap for the future, I am looking forward to establishing Cylite as world leader in digital health,” she said.

GLAUCOMA AUSTRALIA SEEKS NEXT CEO Glaucoma Australia CEO Ms Annie Gibbins is leaving the organisation after four and a half years. Gibbins, first appointed in 2018, came to the role with an agenda to reform and modernise the organisation, overseeing a dramatic rise in referrals and integration with Oculo platform. She has helped GA drive greater risk awareness and improve treatment adherence.

Gibbins will now spend more time on her other passion empowering women to achieve business success. She also hopes to spend more time with her grandchildren and perform admin work for the Australasian College of Optical Dispensing, operated by husband Mr James Gibbins.

OPTOMETRIST CONTINUES IMPORTANT DIABETES WORK Primary Care Diabetes Society of Australia (PCDSA) has welcomed Dr Amira Howari as its newest Board Member. Having type one diabetes for almost 30 years, Howari arrives with her lived and clinical experience as a senior clinical optometrist specialising in diabetes, working in interdisciplinary primary care settings. She has taken up several roles including Diabetes Australia Ambassador, Member of the Diabetes and Endocrine Network at the agency of Clinical Innovation (NSW Health), a UNSW Guest Speaker and Clinical Supervisor and former Optometry Australia Board Councillor (NSW/ACT).

AUSSIE FIRM OPTHEA APPOINTS NEW CHIEF MEDICAL OFFICER Melbourne biopharmaceutical company Opthea has made Dr Joel Naor its new Chief Medical Officer.

California-based Naor is an ophthalmologist and has over two decades of experience leading clinical development programs that target retinal conditions.

Most recently, he served as Vice President of Clinical Science and Development Operations at Kodiak Sciences Inc. Previously, he was the Chief Medical Officer for Macusight until it was acquired by Santen in 2010, and subsequently served as Vice President and Head of Global Medical Affairs for Santen.

ESSILORLUXOTTICA REVEALS NEW HEAD OF ANZ WHOLESALE BUSINESS Experienced Essilor business leader Mr Marco Caccini has been appointed to lead the new EssilorLuxottica Wholesale Business for Australia and New Zealand. Caccini assumes the role that will see Mr Stephen Locke, Luxottica’s Country Manager of Wholesale ANZ, and Mr Pierre Longerna, Essilor’s ANZ Country Manager, now reporting directly to him.

Caccini joined Essilor, now EssilorLuxottica, in 2000 as Director of the US Supply Chain before taking on more responsibility in the US and Europe in strategic, commercial, and operational roles.

NOVA EYE MEDICAL BOSS JOINS GLAUCOMA ADVISORY BOARD Nova Eye Medical President Mr Joe Bankovich has been appointed as an Industry Representative to the American Glaucoma Society Foundation Advisory Board. Established in 2011 with more than 1,500 members, the foundation runs programs to support glaucoma research and education. It also provides a platform for physicians, researchers and the US Food and Drug Administration (FDA) to collaborate in the development of the regulatory science that guides the approval of new glaucoma diagnostic technologies and surgical devices.

Do you have career news to share?

Email editor Myles Hume at myles.hume@primecreative.com.au to be featured.

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2022 CALENDAR MAY 2022 BARCELONA SPECS Barcelona, Spain 7 – 8 May info@barcelonaspecs.com

10TH SUPER SUNDAY CONFERENCE Sydney, Australia 22 May optometry.org.au NATSIEHC22 Darwin, Australia 24 – 26 May Indigenous-EyeHealth@unimelb. edu.au

JUNE 2022 NOSA ANNUAL CLINICAL AND SCIENTIFIC MEETING Canberra, Australia 9 – 12 June kathpoon@bigpond.com

JULY 2022

To list an event in our calendar email: myles.hume@primecreative.com.au

AUGUST 2022

OSHOW2022

AUSCRS

Sydney, Australia 27 – 28 May marketing@odma.com.au

Noosa, Australia 3 – 6 August auscrs.org.au

PROVISION NATIONAL CONFERENCE

Kuala Lumpur, Malaysia 3 – 6 August apgcongress.org/

NSW RANZCO & OPHTHALMOLOGY UPDATES! Sydney, Australia 27 – 28 August ranzco.edu

NORTH QUEENSLAND VISION Cairns, Australia 9 – 10 July optometryqldnt.org.au/nqv

OCTOBER 2022

6TH ASIA-PACIFIC GLAUCOMA CONGRESS

SEPTEMBER 2022

Melbourne, Australia 21 – 23 October eventbrite.com.au

EYECARE PLUS NATIONAL CONFERENCE 2022 Broadbeach, Australia 28 – 30 October web.cvent.com

VISION EXPO WEST

RANZCO 53RD SCIENTIFIC CONGRESS

Las Vegas, US 14 – 17 September west.visionexpo.com

Brisbane, Australia 28 October – 1 November ranzco2022.com/

SPECSAVERS – YOUR CAREER, NO LIMITS Graduate Opportunities – Australia and New Zealand

All Specsa ve stores rs now with O CT

The Specsavers Graduate Recruitment Team has 5 regional opportunities for the Specsavers ‘Early Bird Package’ which offers our highest sign on bonus yet. With continued growth in providing eyecare to patients across ANZ, now is an exciting time to join a company that is leading and defining the future of the optical profession. At Specsavers you will have access to cutting edge technology and be part of the driving force bringing Optometry into the forefront of the healthcare industry. Email apac.graduateteam@specsavers.com today to find out more.

Interested in relocating to NZ?

From the North to the South Islands, Specsavers has a range of opportunities for NZ optometrists. Be equipped with the latest ophthalmic equipment (including OCT in every store) and develop your clinical experience across a range of interesting conditions and an ever-growing patient base. You will also have the support of an experienced dispensing and pre-testing team, the mentorship of store partners and access to an exemplary professional development program. There’s no place like home – so if you’re ready to return, let us help you.

Optometrist Joint Venture Partnership opportunity – Wangaratta & Benalla, VIC

SP EC TR VISI UM T -A NZ .CO M

SO LET’S TALK! In a few short years, Specsavers has achieved market leadership in Australia and New Zealand with more people choosing to have their eyes tested and buy their prescription eyewear from Specsavers than any other optometrist. To learn more about these roles, or to put your hand up for other roles as they emerge, please contact us today: QLD, NT, SA, Vic & Tas Optometrist enquiries: Marie Stewart – Recruitment Consultant

marie.stewart@specsavers.com or 0408 084 134

Rare opportunity for an experienced Optometrist to join Specsavers as a Joint Venture Partner across our Wangaratta and Benalla stores. Wangaratta is centrally located in the north-east of Victoria and has plenty to offer including festivals, markets, rivers, national parks, gardens, eateries, nearby wineries, and historic towns. Benalla is a town that lies on the Broken River, a short drive from Wangaratta. Across both stores, there is 7 test rooms, 17 dispense points, 2 dedicated Audiology rooms, over 2100 frame count, and state-of-the-art equipment including OCT.

WA, NSW & ACT Optometrist enquiries: Madeleine Curran – Recruitment Consultant

Optometrist opportunities in Regional South Australia

cindy.marshall@specsavers.com or 0450 609 872

Looking for a relaxed yet prosperous and affordable lifestyle, ease of travel, low population density, safety, and an abundance of cultural and leisure activities? Then South Australia is just what you are looking for. As a Specsavers Optometrist you will have the opportunity to work with market leading equipment – including OCT, be supported by experienced retail teams and have access to excellent opportunities for further career development and specialisation. Full or part-time roles considered. Extremely attractive salaries including relocation support, birthday/volunteer leave, Specsavers Perks staff discount program, free glasses, and friends and family discounts.

New Zealand employment enquiries: Chris Rickard – Recruitment Consultant

Victoria and Tasmania Locum Availability Specsavers are looking for locum optometrists, we have several vacancies across Vic/Tas in both regional and metro stores. We are looking for locums who have a real passion to provide the best service to our customers. To learn more about these great opportunities, please reach out for a confidential conversation on how we can assist your locum lifestyle.

madeleine.curran@specsavers.com or 0437 840 749 Locum employment enquiries: Cindy Marshall – Locum Team Leader

chris.rickard@specsavers.com or 0275 795 499 Graduate employment enquiries:

apac.graduateteam@specsavers.com

SOAPBOX

ACCELERATING TREATMENTS FOR IRDs

BY A/PROF FRED CHEN

R

esearchers, including myself, at Lions Eye Institute (LEI) are developing treatments for genetic eye diseases, including gene replacement therapies for Usher syndrome and novel drugs for retinitis pigmentosa (RP) and Stargardt disease.

Until now, our work to discover new treatments and cures for these inherited retinal diseases (IRDs) has gone well, but progress is set to accelerate rapidly once the first stem cell robot in Western Australia for eye research arrives at LEI, thanks to a generous $750,000 donation.

Cell culture automation will free researchers from the most repetitive tasks, allowing us to focus on the business of understanding and treating blinding diseases.

To understand the function and purpose of a stem cell robot, first it’s important to remember IRDs are the most common cause of blindness in children and working aged adults.

They are caused by mutations in genes only expressed in the retina.

However, access to retinal tissues from IRD patients for research is limited.

Skin or blood cells are an alternative tissue source to study these diseases.

While there are some things we can learn about gene expression from skin and blood, to understand what is happening in the eye we need access to retinal cells.

To gain access to retinal cells derived from patients with blinding diseases, the Ocular Tissue Engineering Laboratory has established WA’s first cellular reprogramming facility at LEI. Skin cells harvested from our patients can be reprogrammed into stem cells, which can then be converted into retinal cells, as well as other human cell types. These retinal cells share the same genetic profile as the patient who donated the skin cells, including the genetic determinants of their retinal disease, making them an ideal tool for uncovering the molecular mechanisms of the disease and screening of potential treatments.

But cellular reprogramming and

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stem cell differentiation are timeconsuming, laborious processes.

Like embryos, stem cell cultures must be nurtured by prolonged daily routines during the three- to fourmonth reprogramming and validation process. Once stem cell lines have been generated, production of retinal cells can take an additional three to eight months of culture work.

These heavy demands have led to the development of several robotic systems that take over the burden of repetitive daily tasks such as feeding cells. In 2014, Melbourne’s Centre for Eye Research unveiled the country’s first stem cell robot, ‘Pierre’, which was heralded as a significant new asset for Australia’s research community.

In 2018, I met Bronwyn and Andrew Doak and their sons Eamon and Kealan, who have been diagnosed with Usher syndrome. It’s an exceptionally rare and cruel disease. Babies are born deaf, and towards their teens become affected by RP that causes night-blindness, loss of peripheral vision (or tunnel vision) and, eventually, blindness.

The Doak family was excited to hear about the cutting-edge research taking place in our laboratory and made it their mission to ensure we had the resources necessary for achieving the goal of developing IRD treatments.

In 2020, Eamon became a Telethon Star, sharing his story to promote funding of Usher syndrome research. After hearing this at the 2021 Telethon Leeuwin Lunch, philanthropist Rhonda Wyllie generously pledged to fund WA’s first stem cell robot at LEI. With Rhonda’s support, LEI has partnered with laboratory automation company TECAN to develop a stem cell robot for our laboratory. The acquisition of this high-tech machinery will dramatically increase the amount of cell culture work that can be performed, fast-tracking sight-saving research into treatments for patients with IRDs. We are extremely grateful for Rhonda Wyllie’s generous support, which will help ensure WA remains at the forefront of translational research.

Because the stem cells being produced at LEI can potentially be converted into any cell type, the stem cell robot will likely

A/Prof Fred Chen with Eamon Doak who has Usher syndrome.

impact other areas of research in WA. LEI scientists are collaborating with researchers at the Ear Science Institute Australia, who are producing inner ear tissues from LEI’s Usher patient stem cell models to examine disease biology in the ear, as well as the eye.

Automation of retinal and inner ear organoid production on the stem cell robot will help to establish WA’s world-leading position in Usher syndrome research. In the future, we hope to extend our disease modelling capabilities to include other organs, such as brain, heart and liver and offer hope to patients who previously were resigned to a lifetime of illness. n Name: A/Prof Fred Chen Qualifications: MBBS (Hons), PhD (London), FRANZCO Organisations: LEI, Centre for Ophthalmology and Visual Science, The University of Western Australia, Royal Perth Hospital, Perth Children's Hospital.

Position: Head of Ocular Tissue Engineering Laboratory, consultant ophthalmic and vitreoretinal surgeon.

Location: Perth Years in profession: 20, clinical practice and research.

IN THE FUTURE, WE HOPE TO EXTEND OUR DISEASE MODELLING CAPABILITIES TO INCLUDE OTHER ORGANS, SUCH AS BRAIN, HEART AND LIVER.

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INSIGHT

Alcon Toric IOLs lead the way in astigmatic correction ®

†1

MAY 2022

Alcon® Toric IOLs allows you to correct even the smallest amount of astigmatism‡2-5 Most cataract surgery patients present with some level of corneal astigmatism.§6 The Alcon® Toric IOL portfolio, with cylinder powers from T2–T9, accommodate a wide range of astigmatic correction needs, from high to low.2-5 Built on the heritage of the proven AcrySof ® platform, Alcon® Toric IOLs offer exceptional performance with outstanding refractive predictability7-10 and rotational stability7-10 for you and your patients.

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References: 1. Market Scope Data. Q2 2021 in Australia and New Zealand. 2. AcrySof® IQ Toric Directions for Use. 3. Clareon® AutonoMe® Toric Directions for Use. 4. AcrySof ® IQ PanOptix® Toric Directions for Use. 5. AcrySof ® IQ Vivity ® Toric Directions for Use. 6. Ferrer-Blasco T et al. J Cataract Refract Surg 2009;35:70–75. 7. Lee BS and Chang DF. Ophthalmology 2018;125(9):1325–31.

8. Levitz L et al. Asia Pac J Ophthalmol (Phila) 2015;4(5):245–9. 9. Oshika T et al. Eur J Ophthalmol 2020;30(4):680–84. 10. Lane S et al. J Cataract Refract Surg 2019;45:501–506. ©2021 Alcon Inc. Alcon Laboratories (Australia) Pty. Ltd. ABN 88 000 740 830. Phone: 1800 224 153. New Zealand NZBN 942904703 0480 Phone: 0800 809 189. ALC1430b 09/21 ANZ-ACO-2100002

WWW.INSIGHTNEWS.COM.AU

Based on market size and unit share from Q2 2021 compared to AMO, Zeiss, and Bausch & Lomb/Dorc in select markets. ≥0.65D of corneal astigmatism. § Refractive and keratometric data from 4540 eyes of 2415 patients.6 †