Insight June 2021

INSIGHT JUNE

2021

MACULAR DISEASE PATIENTS SPEAK UP Inaugural social impact study reveals where eyecare professionals are falling short.

GETTING TO KNOW NATIONAL OPTICAL CARE Meet the newest player to enter the independent optometry arena.

21/04/2021 2:40:12 PM

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INSIGHT June 2021 Front cover.indd 1

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AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

ARTIFICIAL INTELLIGENCE ENTERS THE CLINIC Making a case for the Australian-developed Eyetelligence AI system.

starts

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May 2021

Now in its tenth year and having been delivered both in-person and virtually across the past few years, the Specsavers Clinical Conference (SCC) is one of Australia and New Zealand’s best-attended optometry professional development events.

Harnessing the large scale data we have available, SCC covers topics relevant to optometrists working in primary eyecare through an ophthalmology-led educational program, delivering content that is impactful to practice as well as an extensive CPD/CD offering.

This year the SCC calendar of free events will run from May until October, kicking off with our first live event in Melbourne on May 18.

To find out more or to register for our in-person or virtual events go to SCC2021.com.au.

INSIGHT JUNE

2021

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

INAUGURAL MACULAR DISEASE STUDY OFFERS FRESH INSIGHT INTO PATIENT EXPERIENCES

The Macular Disease Foundation Australia (MDFA)’s first-ever social impact survey has revealed a quarter of patients have low levels of knowledge of their condition, with roughly the same proportion less than happy with the explanation of their disease by their eyecare professional.

The new report also sheds light on the anxiety among neovascular age-related macular degeneration (nAMD) patients about a proposed Medicare rebate cut for intravitreal injections, and that most early AMD patients are taking supplements, despite the lack of evidence for their efficacy at this stage of disease.

The organisation’s inaugural longitudinal study was prepared

by the Centre for Social Impact and the School of Optometry and Vision Science at UNSW. It involved 2,169 respondents (13.2% response rate) with various forms of macular disease who have been engaged with MDFA for more than two years. It aims to capture patients’ perception on three levels: individual, service and system.

According to MDFA, a key finding indicated that although 97% of respondents could access information about their disease through multiple sources, 25% only had “fair to poor” knowledge of their condition. Many of these respondents tended to have the poorest vision and a non-treatable form of AMD.

were ‘less than happy’ with the explanation of their condition, and 35% were not happy with their eye health professional’s knowledge of available support services.”

The survey involved 2,169 respondents with various forms of macular disease.

“Those with higher levels of eyehealth knowledge tended to report higher levels of life satisfaction, and the majority of patients were happy with the disease information they were given by their optometrist or ophthalmologist, suggesting they are well engaged with eye health systems and supports,” MDFA CEO Ms Dee Hopkins said.

Interestingly, the survey also found 66% of early AMD respondents were taking supplements, despite a lack of evidence to indicate slowing of progression in this group. Among 133 respondents with intermediate AMD – where supplements can slow progression – 35% were not consuming them, mainly because their eye health practitioner had not recommended them.

“Being diagnosed with a new condition can be overwhelming continued page 8

“However, it was found that 23%

RMIT FOLDS OPTICAL DISPENSING PROGRAM RMIT University has announced the closure of its Certificate IV in Optical Dispensing, ending a 52-year history of educating and training Australian optical dispensers.

The Melbourne institute confirmed to Insight it would discontinue the course from semester two this year, with final students to complete their training at the end of this month.

“Courses and programs are regularly reviewed to ensure they align with in-demand skills and industry needs, and some may be discontinued where there is limited student demand,” an RMIT spokesperson said. “In recent years, student numbers have been consistently low for this course.”

In addition to declining enrolments,

it’s understood the university was also unsuccessful in a single provider tender process led by Specsavers, which was awarded to Australasian College of Optical Dispensing (ACOD) at the end of 2020.

It also comes as other optical trainers experience a surge in enrolments after the government announced a wage subsidy of up to $28,000 per employee as part of its COVID-19 economic recovery.

It now leaves ACOD and TAFE New South Wales as the main training providers, with TAFE Queensland still registered and able to discuss delivery options with commercial clients.

Mr Leigh Robinson, who was an RMIT optical student in the

1960s before later becoming a Cert IV in Optical Dispensing teacher at the university from 2008 until present, said staff and students were made aware of the course’s closure in February. He said it came at a time when the qualification was in great demand from ophthalmic practices.

Memories are clouded on the exact dates that optical dispensing training commenced at RMIT, but with the help of esteemed optical teacher Mr Clem Cumming – who taught between 1970 and 2004 – Robinson said its history can be traced to 1969.

Prior to this in the 1960s, there was no formal apprenticeship, continued page 8

KEEPING AN EYE ON THE SKY A pilot's suitability to fly can often hinge on the assessment of an eyecare professional.

While optometrists play a key role today, it hasn’t always been this way. Insight looks back on optometry’s fight for recognition as aviation eye examiners. page 33

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IN THIS ISSUE JUNE 2021

EDITORIAL

FEATURES

NOW’S OUR CHANCE The British Medical Journal couldn’t have put it better in 2014 when it said the health sector – a major emitter of greenhouse gases – should get its house in order “to avoid the paradox of doing harm while seeking to do good”.

The phrase rings even truer today with the health sector contributing to 7% of Australia’s national carbon emission footprint. The Australian Medical Association (AMA) is now calling on the sector to reduce its carbon emissions to net zero by 2040, and RANZCO devoted its latest Eye2Eye magazine to sustainability.

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NEW ARRIVAL National Optical Care outlines its plans for independent optometry in Australia.

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AI ASSISTANCE The professor behind a TGAapproved AI system explains the need to embrace it.

The issue should be front of mind for ophthalmologists, optometrists and practice managers too. While air pollution has been linked with diseases like AMD, practices like ‘wet edging’ in lens production can be resource-intensive – and one can only shudder at the environmental cost of discarded contact lenses and frames, as well as the energy and plastic waste involved in procedures like cataract surgery.

Patients are demanding greater transparency about the origins of products and services, so eyecare professionals should consider how investment in sustainable practices could not only improve the environment, but their livelihoods, in future.

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CROSS-LINKING The procedure revolutionised keratoconus treatment – and there’s more to come.

28

THINKING GREENER Find out how the Australian optical sector is embedding sustainable practices.

EVERY ISSUE 07 UPFRONT

44 MANAGEMENT

09 NEWS THIS MONTH

45 CLASSIFIEDS

42 ORTHOPTICS AUSTRALIA

45 CALENDAR

43 DISPENSING

46 SOAPBOX

While much can be done at the practicelevel, this pressure will inevitably transfer to suppliers. Some are already responding with clean energy to run production sites, and recycled materials in frames (see page 28). Others are reducing emissions in supply chains, and we’ve seen contact lens recycling programs.

While these initiatives go some way, it ultimately requires a coordination on a mega scale. With health spending equated to $7,485 per Australian, the health sector has a major chance to stop contributing to global warming and pollution with its purchasing power. It’s time to take sustainability seriously in the ophthalmic sector, and that starts at both ends.

MYLES HUME Editor

INSIGHT June 2021 5

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UPFRONT Just as Insight went to print, the Pharmaceutical Benefits Advisory Committee (PBAC) recommended Novartis’ treatment Beovu be subsidised through the PBS for neovascular age-related macular degeneration patients who have persistent disease despite prior anti-VEGF treatment.

In the latest decision from a March meeting, the independent expert panel stated: “The PBAC considered that a secondor subsequent-line treatment option of brolucizumab in CNV due to AMD would

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WEIRD

be useful for patients who have ongoing exudation/fluid despite first-line anti-VEGF treatment,” Novartis welcomed the decision and is working with the health department to make the therapy available to eligible patients in a timely manner. IN OTHER NEWS, Optometry Australia’s Optometry Virtually Connected (OVC) event is returning this year. The 2.5-day virtual conference and product showcase is being held from 18-20 June, with up to 30 hours of education on offer. The event was established last year after in-person conferences were cancelled due to COVID-19. “This year’s conference is being hosted on a new digital platform that will create a superior experience for

registration, attendance and networking,” OA stated. FINALLY, Vision Australia was disappointed it has to act as the government’s “accessibility watchdog” after its community had trouble accessing an online COVID-19 vaccine eligibility checker that it says failed to meet basic standards.

The organisation took aim at the Department of Health’s website, saying it didn’t meet Web Content Accessibility Guidelines 2.1 Level AA requirements, which is considered the national and international benchmark for web accessibility. “Ensuring this platform was accessible to all Australians should have been the first priority when it was designed,” CEO Mr Ron Hooton said.

STAT

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WACKY

World Rugby will conduct pilot studies using eye-tracking technology to detect head injuries.

Studies suggest eye movement alters when someone sustains a head injury. Assisting the current head injury assessment process, the technology could prove pivotal in providing rapid analysis of impact.

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Adelaide Crows skipper Rory Sloane spent several weeks on the AFL sidelines after undergoing surgery for a retinal detachment. The 31-year-old suffered blurred vision at the Crows’ training session before consulting with a specialist. Coaches said the injury-prone midfielder would be out for up to a month. n

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NEWS

PATIENT ANXIETY OVER INJECTION REBATE CUT continued from page 3

and there often is a lot of new information to communicate with patients in a limited time. This is a clear demonstration of how patient support organisations, like the MDFA, can offer information and support to both the patient and support time poor optometrists to ensure the messages are received,” Hopkins said.

“One key recommendation from the survey was to align patient engagement between eye health practitioners and MDFA’s services before, during and after diagnosis, and to work with optometrists in further developing stronger patientpractitioner relationships.”

Part of that recommendation also includes working with optometrists and ophthalmologists to relay the MDFA’s support services to patients, as well as discussing with practitioners the appropriate use of supplements for patients.

CONCERN OVER REBATE CUT The future funding model of intravitreal injections is also front of mind for patients with nAMD, the survey found.

In total, 85% of respondents with nAMD were receiving intravitreal injection treatments. Of the remaining 15% who weren’t, 59% said they were having

treatments but stopped, and about 27% said their ophthalmologist had not recommended them.

disease, 92 (5.2%) identified the cost of macular disease as a major concern, with 76 (82%) of those having nAMD.

Another 4.3% indicated costs as the primary barrier. This was reinforced in open-ended responses from some who were concerned about a Medicare rebate reduction for intravitreal injections, proposed by the MBS Review Taskforce in its final report to the Federal Government.

While this number is relatively low, MDFA stated it could be considerable among the 1.7 million Australians with macular disease. As such, one of its four recommendations was to explore how economic disadvantage, and financial concerns and barriers affect those with vision loss.

In its summary, MDFA said most with nAMD could access injections in private clinics, with there being limited capacity in the public system. It stated any change to formal support systems must carefully consider the balance between the public and private systems.

"THOSE WITH HIGHER LEVELS OF EYE-HEALTH KNOWLEDGE TENDED TO REPORT HIGHER LEVELS OF LIFE SATISFACTION" DEE HOPKINS, MDFA

“If the proposed 69% rebate cut for eye injection treatment were to be implemented, we anticipate the number of respondents who stop treatment due to costs to drastically increase in followup surveys, given the overwhelmingly negative response to the rebate cut that we received from patients during consultations to inform our submission to the MBS Review Taskforce’s draft report,” Hopkins said.

In other findings, 75% of respondents using low vision aids saw them as critical for their quality of life. Impact of vision impairment scores also showed for 75% of respondents, macular disease had limited impact on their daily functioning, and caused limited concern over other aspects of their lives. But 14% were highly affected; they tended to be older and solely reliant on age pension for funding their retirement, and had more advanced forms of disease and poorer vision.

Hopkins said the survey provides solid baseline data to inform the proposed ongoing longitudinal study to track changes in quality of life related to vision changes. It will also help monitor which interventions work best and what changes across the system will have the most impact. MDFA plans to repeat the survey each year to follow participants through their disease progression. n

Of the 1,758 people who responded to an open-ended question about their greatest concern about living with macular

CURTAIN FALLS ON COURSE WITH RICH HISTORY continued from page 3

and those entering the optical industry were indentured to their employer who provided on the job training.

“Towards the late 1960s, development commenced toward accreditation of the apprenticeship training course. As any course that attracts government funding, this was not an easy task,” he said.

“Many contributed to the major effort for the course to be approved. Names that come to mind from the time are optometrists John Nathan, Wolf Gartner, Graham Green, union rep – yes, a union rep – Bernard Ericson and lab manager Alan Stark. As well, there was a large group of indentured apprentices who all supported the project by attending the

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INSIGHT June 2021

meetings and enrolling in the first intake.”

In 1969, Robinson said RMIT started formally running the Optical Fitting and Surfacing Apprenticeship course. It had humble beginnings in the basement of Building 33 in Franklin Street with Mr Livio Siviz as the teacher.

At this point, the course was largely theory-based until funding became available to provide equipment for the teaching laboratory.

“Training first focussed toward laboratory requirements in lens fitting and surfacing, until the mid 1970s when modular training was introduced by the Apprenticeship Commission. OPSM, Optical Products, Coles and Garrard, Arthur Cocks & Co and International Optical Co., were the major supporters,”

Leigh Robinson.

Robinson said. In 1999, flexible training was introduced which prompted major changes to the way the course was delivered. The Certificate IV in Optical Dispensing was introduced in 2003, and was a revised syllabus to maintain continuity with NSW where registration was required.

“Across more than 50 years RMIT has produced a great number of qualified optical dispensers through the efforts of many committed optical teachers including, myself, Livio Siviz, Clem Cumming, Bob Gale, John Van Braam, Tony Hood, Ian Rush, Ralph Richter (twice), Steve Maskell, Tim Haigh, Jade Cusworth, Leah Hollway,” Robinson said. n

NEWS

CALL FOR OPHTHALMIC IMAGING STANDARDISATION RANZCO has endorsed calls for ophthalmic device manufacturers to standardise image formats, with proponents stating it is one of the most important issues preventing the profession from greater clinical and academic progress.

The college has endorsed a recommendation by the American Academy of Ophthalmology (AAO), the world’s largest ophthalmic association, urging manufacturers to implement the Digital Imaging and Communications in Medicine (DICOM) standard to facilitate an easier exchange of digital imaging data.

DICOM is the existing medical imaging standard, which includes a system of globally agreed-upon ophthalmological definitions, however compliance is low within the sector.

This is despite the AAO stating adoption of a uniform standard for images could revolutionise ophthalmology practices by promoting more efficient patient care, enabling the creation of comprehensive datasets for research and big data analyses, and developing algorithms for machine learning and artificial intelligence.

Commenting on the recommendation, RANZCO president Professor Nitin Verma said: “Standardising will facilitate greater accessibility of information and enhance efficiency, thus improving the patient’s experience.”

In addition to RANZCO, the recommendation has been supported by the American Society of Retina Specialists, the Asia-Pacific Academy of Ophthalmology, and the UK’s Royal College of Ophthalmologists.

Dr Aaron Lee – an assistant professor and vitreoretinal surgeon at the University of Washington and lead author of a paper describing the issue in the AAO’s journal Ophthalmology – said other medical fields like radiology have blazed ahead of ophthalmology by using the standards to their full extent.

The diversity of imaging devices has made standardisation harder in ophthalmology.

hope is that not only would vendors be willing to adopt and conform to standards but also be willing to define them for new modalities where the DICOM standard does not currently exist. [Our] recommendations … are just the first step in the direction that we need to go.”

According to Lee, a key issue limiting clinical and research progress in ophthalmology is the lack of standards for imaging and functional testing.

He said the AAO has long championed for the DICOM standard, which promotes the seamless sharing of medical images by detailing how to format and exchange images and the information with which it is associated, such as the text description and patient demographic information.

Even though DICOM compliance is considered low for ophthalmic imaging technologies, he said many so-called “DICOM compliant” devices still fail to fully meet the standards.

This means there is no easy way to exchange digital imaging data from one manufacturer’s equipment to another without creating a custom interface.

Another issue is image degradation when devices compress files, which the AAO states could be overcome by using ‘lossless compression’ for pixel or voxel data. This would allow access to the raw data as used by manufacturers.

“In some ways, it is much harder in our field because we have such a diverse variety of imaging devices and testing modalities,” he said.

“It is important for this data to be available from the manufacturers so ophthalmologists can provide the best quality care for our patients," the AAO stated.

“This variety is what makes ophthalmology so rich with information but also makes it difficult for standards to keep up with the constant innovation. My

"Poor image quality can also lead to problems when AI models are being developed or new digital health tools are deployed.” n

IN BRIEF n

MIDO POSTPONED

Organisers of Milan’s eyewear trade show MIDO have announced this year’s event will run in an online format, with the in-person edition not to take place until early 2022. One of Europe’s flagship optical trade events, the show was scheduled to run in-person from 5-7 June 2021, but will shift to an online format due to ongoing uncertainty surrounding COVID-19 and the longerthan-expected rollout of vaccines. Since February last year, MIDO organisers have attempted to set three different dates for the show. The next in-person show will now take place 12 to 14 February 2022.

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TRACHOMA ELIMINATED

The World Health Organisation (WHO) has announced Gambia has eliminated trachoma as a public health problem, making it the second country in WHO’s African Region to achieve this milestone after the Ivory Coast eliminate human African trypanosomiasis in March. A 2018–2019 survey on trachomatous trichiasis – the advanced, blinding stage of trachoma – in Gambia found its prevalence among people aged over 15 years ranged from 0% to 0.02% – under the threshold required for elimination. In the mid-1980s, trachoma was responsible for almost one out of five cases of blindness countrywide.

Australia failed to eliminate trachoma by 2020, and has set a new deadline of 2022.

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AMAZON LETTER

The American Optometric Association (AOA) has written to global e-commerce retailer Amazon over unlawful contact lens sales on its marketplace. The association says posts from contact lens sellers don’t appear to meet The Fairness to Contact Lens Consumers Act’s patient protection provisions requiring valid prescriptions. “This issue is of importance not only to overall patient safety but also because of the significant legal and regulatory requirements related to the sales of contact lenses,” the letter, signed by AOA president Dr William Reynolds, said. “The AOA would like to work with you to determine what can be done to truly put a stop to contact lenses being sold through Amazon.”

INSIGHT June 2021 9

NEWS

'DISEASE DETECTION AND VISION ENHANCEMENT'– CL SEGMENT SET FOR ‘INCREDIBLE ADVANCEMENTS’ "THE NEXT SEVERAL YEARS WILL SEE INCREDIBLE ADVANCEMENTS AND GROWTH FOR AN EXPANDED CONTACT LENS CATEGORY"

Australian researchers have contributed to a new paper offering one of the most comprehensive reviews into the future of contact lenses, with predictions the medical device will extend beyond refractive correction to detect disease, deliver drugs, and incorporate microelectronics to enhance vision in real time.

The paper has featured in Contact Lens and Anterior Eye, the British Contact Lens Association's journal, and will form part of its Contact Lens Evidence-based Academic Reports (CLEAR) series.

It’s been led by one of the world’s foremost contact lens authorities, Dr Lyndon Jones, director of the Centre for Ocular Research & Education (CORE), joined by 13 co-authors including Australians Professor Mark Willcox (UNSW), Professor Padmaja Sankaridurg (UNSW and BHVI) and Dr Alex Hui (UNSW).

“There are a range of diverse technologies that are shaping the future of contact lenses, in some cases already showing their potential in late-stage development initiatives and even commercially-available products,” Jones said.

“Novel biomaterials, nanotechnology progress, unique optical designs, biosensing discoveries, antibacterial agents and even battery miniaturisation and power transfer are coalescing like

Dr Lyndon Jones, Centre for Ocular Research & Education.

LYNDON JONES, CORE

never before. The next several years will see incredible advancements and growth for an expanded contact lens category.”

The authors expect the presence of biomarkers in the tear film will give rise to diagnostic contact lenses to help detect and monitor systemic and ocular diseases. Integrated circuit progress may lead to in-lens intraocular pressure monitoring for glaucoma and even retinal vasculature imaging for early detection of diseases such as hypertension, stroke and diabetes.

reactive oxygen species-scavenging materials – when integrated into lenses – could offer alternative dry eye disease therapies,” the authors noted “Liquid crystal cells could replicate the functionality of the pupil and iris arrangement, autonomously filtering incoming light to overcome physiological defects. Embedded, tuneable spectral filtering has the potential to mitigate colour vision deficiencies.”

According to the paper, drug delivering contact lenses may offer more accurate dosing versus traditional eye drops, increasing the residence time of a drug on the ocular surface with less exposure to elements such as blinking and nonproductive conjunctival absorption, reducing the many known side effects of drugs.

“Delivery might come from in vitro uptake and release, incorporation of drug-containing nanoparticles into contact lens materials during the manufacturing process, and even molecular imprinting to imbue polymers with memory characteristics that aid dispensation,” the authors wrote. “These techniques and related advancements will open up opportunities for contact lenses as theranostics, the multidisciplinary medical field that combines therapeutics and diagnostics." n

For ocular disease treatment and management, contact lenses are offering benefits in terms of fluid dynamics, materials science and microelectronics.

“Dehydration-resistant materials combined with electro-osmotic flow and

SUPPORT RAMPS UP FOR FLAGSHIP OPTICAL SHOW O=MEGA21 organisers are confident of “strongly compliant” COVID-safe event, with more than 80 exhibitors booked, at the time of writing.

well as companies that hadn’t exhibited for some years, and new entrants to the sector. New products are also expected to be launched at the event.

Australia’s largest clinical optometry conference – run by Optometry Victoria South Australia (OV/SA) and the Optical Distributors and Manufacturers Association (ODMA) – will return at the Melbourne Exhibition and Convention Centre 2-4 September 2021.

The trade fair is taking over six of the exhibition bays in the facility, totalling 9,000sqm.

With more than 90% of the trade fair space snapped up within 48 hours of launching the floorplan, at the time of print, there were more than 80 confirmed exhibitors, representing many more businesses and brands. Organisers stated that many past exhibitors are returning, as

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INSIGHT June 2021

This year’s conference will feature several clinical themes including therapeutics, paediatrics, anterior eye and neuro-optometry, glaucoma, myopia and contact lenses.

Up to 22.5 hours of CPD (with assessment) will be available for delegates based on the new Optometry Board of Australia CPD learning requirements. This will include up to five

interactive hours (with assessment) and up to 12 therapeutic hours (with assessment).

O=MEGA21 is being held in Melbourne.

“The conference will be strongly compliant with the strictest of COVID-safe requirements, to ensure delegates can fully enjoy all that O=MEGA21 has to offer with confidence,” an O=MEGA21 statement said.

“On the back of the great success of O=MEGA19 and the current strong desire to return to face-to-face events, there has been huge and immediate support for O=MEGA21.”

The exhibition space will also incorporate feature areas such as a Knowledge Centre where business-focused presentations will take place. n

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NEWS

OCANZ QUIZZES STUDENTS AND EMPLOYERS ABOUT GRADUATES’ READINESS FOR THE WORKPLACE The Optometry Council of Australia and New Zealand (OCANZ) is funding the inclusion of optometry-specific questions into an Australian Government survey to understand how well universities are preparing students for the workplace.

2020 was the first year that OCANZ – an independent external agency that assesses optometry programs in Australia and New Zealand – funded the inclusion of optometry education questions in the Quality Indicators for Learning and Teaching (QILT)’s graduate outcomes and employer satisfaction surveys.

All graduates in Australia are asked to complete the graduate outcomes survey four to six months after completing their course and the feedback obtained helps to improve course development and outcomes for students, focussing on work readiness. There are three data collections each year in February, May and November.

According to OCANZ, feedback from optometry course graduates was positive in 2020, as was the response rate. It will continue to fund optometry-specific questions for the next several years to ensure sufficient, year-on-year data to support course development and position emerging patient needs at the centre of course design.

OCANZ will fund optometry-specific questions for several years to collect year-on-year data.

The 2021 survey process will commence in April/May and will, as in 2020, be administered in two parts. The first will focus on feedback from graduates, and the second on employers’ views.

"ASSESSMENT FROM EMPLOYERS ON GRADUATE OPTOMETRISTS’ READINESS TO PRACTISE IS VITAL TO ENSURE THE HIGHEST STANDARDS IN THE PROVISION OF EYE HEALTH CARE" LYN BRODIE, OPTOMETRY AUSTRALIA

Graduates will be asked questions about their study experience and the extent to which their course prepared them for the workplace.

surveys are about courses and training, not about assessing individual graduates, providers or employers,” OCANZ chair Professor Alex Gentle said.

Mr Peter Murphy, Luxottica’s director of eyecare and community, said as major employers, the company welcomed the feedback the surveys will provide.

“They can only improve the quality of education and training and consequently, raise the work readiness of optometrists as they enter the profession,” he said.

Ms Lyn Brodie, national CEO of Optometry Australia, reinforced the value of employer feedback.

“Assessment from employers on graduate optometrists’ readiness to practise is vital to ensure the highest standards in the provision of eye health care to the community,” she said.

The surveys are delivered by the Social Research Centre and strict privacy and confidentiality guidelines are followed.

If nominated by graduates, employers will be invited to comment on: the skills and attributes needed in contemporary optometry practice; how well higher education is preparing graduates for the workforce; and the employment pathways graduates take after completing their studies.

Last month, Insight reported on the findings of the Grduate Outcomes Survey, which found optometry had one of the highest rates of employment among post-graduates (95%), with initial salaries ranging between $80,000 to $85,000. n

“It’s important to understand that the

GENE THERAPY IMPROVED ‘OPTIC NERVE ACTIVITY’ The managing director of one of Australia’s pre-eminent eye research institutions is a leading scientist behind experiments on mice that have shown promise for developing new gene therapies for both glaucoma and dementia.

neurodegenerative diseases that are caused by multiple factors rather than a single genetic fault. In pre-clinical experiments, the researchers tested a new gene therapy to determine if it could stimulate axon growth and improve optic nerve function.They combined two key molecules into a single viral vector and delivered it to mice affected by glaucoma and dementia.

Professor Keith Martin from the Centre for Eye Research Australia and University of Melbourne, and Dr Tasneem Khatib from the University of Cambridge, have led a pre-clinical study using a new combined gene therapy technique to repair damage to nerve cell transport systems that cause vision loss in glaucoma and memory loss in dementia.

Prior to therapy, both groups had impaired optic nerve function with reduced transmission of electrical signals between the eye and brain. Those with glaucoma also showed signs of reduced vision.

More critically, their findings, published in Science Advances, demonstrate how gene therapies could treat complex

However, after the therapy was delivered, optic nerve activity improved in both groups and the mice with glaucoma

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INSIGHT June 2021

showed signs of improved vision.

There was also a possible small improvement in the mice’s short-term memory, which researchers now plan to test in a larger study to confirm the effect.

Prof Keith Martin, CERA.

The study also took a new approach to delivering gene therapy by combining two molecules thought to improve axon function – brain derived neurotrophic factor (BDNF) and tropomyosin receptor kinase B (TrkB) – in one treatment.

“We reckoned that replacing two molecules that we know work effectively together would help to repair this transport network more effectively than delivering either one alone, and that is exactly what we found," Khatib said. n

NEWS

BROOME CLINIC OPENS WITH HUGE ZEISS DONATION Zeiss has donated a suite of ophthalmic equipment worth an estimated $1.5 million to the Kimberley region’s first permanent eye clinic based in Broome, which recently opened for the first time to patients.

The Northwest Hub is a former backpacker accommodation that Lions Outback Vision (LOV) has been transforming into the new eyecare facility, featuring at least two resident ophthalmologists available for 24-hour emergency support Through a hub-and-spoke model, the centre will service six towns through outreach ophthalmology services and 20 communities through outreach optometry, while providing state-wide telehealth coverage, seminar rooms and open space for community diabetic health education.

Zeiss has provided the hub and the regional spokes with equipment to a level that would be seen in metropolitan centres.

To date, the company has donated a range of new equipment including a Cirrus 6000 OCT with Angioplex OCT angiography, Clarus 700 ultrawidefield retinal camera, IOL Master 700, Humphrey Field Analyser (HFA) 3, Lumera 700 surgical microscope, retinal laser, YAG laser and two slit lamps.

Refurbished equipment as part of the initiative’s “back to the bush program” has also been donated, including three

Broome patient Peter Pigram next to a Zeiss Clarus ultra-widefield retinal camera.

IOL Master 500s and two HFAs. “One of the three goals of the Carl Zeiss Foundation is to promote charitable interests. In this, our 175th year since inception and our 60th year of operations in Australia, we cannot think of a better way to honour this goal than to support the life-changing work Lions Outback Vision through the Northwest Hub will perform,” Zeiss Australasia manager director Mr Joe Redner said.

"THIS BUILDING WILL BE THE HEART OF OUR COMMUNITY FOCUSED ACTIVITIES AND PROVIDE SPACE FOR INTERDISCIPLINARY HEALTH SERVICES" CHRISTINE STOTT, LIONS OUTBACK VISION

Accommodation – donated by Wen Giving Foundation and Hawaiian. In addition, Stott said the facility has received donations from Alcon, Topcon, Novartis, The Fred Hollows Foundation and the WA and Federal governments.

The second part of the refurbishment will commence in early July when the old communal, kitchen and reception areas of the complex will be become office space, consulting rooms, meeting and training rooms and a healthy food kiosk.

“This building will be the heart of our community focused activities and provide space for interdisciplinary health services to work in collaboration,” Stott said.

Currently, McCusker Director of LOV Associate Professor Angus Turner and Dr Vaibhav Shah are the resident ophthalmic consultants permanently located in Broome. Each year a registrar will relocate to Broome for the year. This year Dr Rachael Heath Jeffery is in that role.

“We think this is fully in the spirit of Carl Zeiss, and we wish the new team every success in fulfilling its mission.”

“We also have a resident optometrist, Stephen Copeland, a resident registered nurse, Sarah Burke, a resident Aboriginal Health Worker, Kerry Woods, a resident practice manager, Amy Kerr. In July we will have a second resident optometrist in Broome,” Stott said. “Having three resident ophthalmologists serving the Kimberley region is breaking new ground in eye health services in WA." n

LOV manager Ms Christine Stott said the new equipment was recently installed in the new Kimberley Hub clinic which saw its first patient on 12 April.

The newly opened clinic building is the first part of the renovation of the old Kimberley Klub Backpackers

ITRACK MIGS PROCEDURE LOWERS IOP BY A THIRD Nova Eye Medical has published two-year data for its iTrack ab-interno canaloplasty procedure, which it says showed an average reduction in mean intraocular pressure (IOP) of 30%, irrespective of whether it was performed standalone or with cataract surgery.

The medical technology company that originated in Adelaide and has operations in Fremont, California, announced the results of a peer-reviewed publication of 24-month data for its minimally invasive glaucoma surgery (MIGS) technology.

Published in Clinical Ophthalmology, the retrospective case series by US ophthalmologist Dr Mark Gallardo assessed the efficacy and safety outcomes iTrack in 60 eyes with primary

14

INSIGHT June 2021

the iTrack-alone group, and from 2.5±1.1 to 1.3±1.2 in the iTrack+phaco group.

open angle glaucoma (53 patients).

He compared the efficacy outcomes of iTrack as a standalone procedure (iTrackalone) versus in combination with cataract surgery (iTrack+phaco).

According to Nova Eye, in the iTrackalone group, IOP reduced by 34% from 21.6±5.7 mmHg to 13.8±3.1mmHg. Patients in the iTrack+phaco group achieved a similar IOP reduction, with the mean falling by 31% from 19.8±3.9 mmHg at baseline to 13.2±2.1 mmHg at the 24-month visit (P=0.512).

The reduction in medication use was also statistically significant in both groups at 24 months, the company reported, decreasing from 3.0±0.7 to 2.1±1.3 in

Dr Mark Gallardo, El Paso Eye Surgeons.

The study also assessed iTrack in mild-tomoderate glaucoma compared to severe glaucoma. iTrack achieved similar reductions in mean IOP at the 24-month mark for cases of mild- to-moderate and severe glaucoma at 33% and 34%, respectively.

“Given its benign nature, [iTrack] can be used earlier in the disease process to reduce IOP and alleviate the burden of compliance and side effects associated with medications,” Gallardo said.

"It can also be used in patients with more advanced disease who have previously undergone non-ablative MIGS procedures.” n

NEWS

EDUCATORS UNITE TO BOOST INDIGENOUS OPTOMETRIST NUMBERS ACROSS ANZ Leaders of optometry schools in Australia and New Zealand/Aotearoa have formed a new alliance aimed at strengthening Indigenous eyecare through better student education and increasing the number of Indigenous optometrists.

in the general population. Without further intervention, the paper notes the situation is unlikely to improve. There are thought to be only six Indigenous students across the seven accredited optometry programs in Australia and New Zealand.

Details of the new group called Leaders in Indigenous Optometry Education Network (LIOEN) have featured in a paper, published in the Australian and New Zealand Journal of Public Health.

LIOEN involves Prof Sharon Bentley (Queensland University of Technology), Prof Nicola Anstice (Flinders), Prof James Armitage (Deakin), A/Prof Jason Booth (Flinders), Prof Steven Dakin (Auckland), Prof Garry Fitzpatrick (Western Australia), A/Prof Peter Herse (Canberra), Prof Lisa Keay (UNSW) and Prof Allison McKendrick (UniMelb).

The group is determined to improve Indigenous eyecare by addressing statistics that show optometry has the lowest representation of Indigenous people in Australian health professions (seven out of 5,781 registered optometrists or 0.1%) – well short of 3.3% in the general population. Representation is no better in New Zealand, where an estimated 2% of 931 optometrists identify as Mãori, compared with 16.5%

INTRODUCING

Indigenous students,” the group stated.

UniMelb is involved in the initiative.

“There are two important ways in which optometry schools can reduce eye health inequities. These are: firstly, by integrating cultural safety and Indigenous perspectives into the curricula; and secondly, by improving the recruitment and graduation of

“Although some work has been undertaken to improve cultural safety training in optometry programs, there is variability in the curricula, there are few Indigenous graduates and there are few Indigenous academics involved in programs."

LIOEN members recognised change cannot be achieved without partnering with Indigenous peoples. It'll also require critical individual and institutional reflection, and take considerable time.

“Given limited resources and the enormous workload placed upon Indigenous leaders and educators, working collaboratively with other healthcare professions might increase the effectiveness of Indigenous education networks and the likelihood of sustainability, resulting in a healthcare system free of racism and better health outcomes for all.” n

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NEWS

MOST PRESSING EYE HEALTH ISSUES RAISED WITH PRIME MINISTER The state of public cataract surgery and Indigenous eye health were among the key issues a delegation from the ophthalmic sector raised in a recent meeting with Prime Minister Scott Morrison.

The meeting – arranged by Vision 2020 Australia – took place in the PM’s Canberra office on 16 March and involved Vision 2020 Australia chair and former Liberal MP Mr Christopher Pyne, RANZCO CEO Dr David Andrews, Optometry Australia CEO Ms Lyn Brodie, The Fred Hollows Foundation deputy CEO Mr Nick Martin, Novartis Australia and New Zealand general manager Mr Richard Tew, the University of Melbourne’s Professor Hugh Taylor and Vision 2020 Australia CEO Ms Judith Abbott.

According to Vision 2020, Aboriginal and Torres Strait Islander eye health investment and the need for more public cataract surgeries were among the key talking points.

This was in addition to tackling blindness in Papua New Guinea, opportunities arising from the Royal Commission into Aged Care Quality and Safety, and eye research and innovation.

“The sector values the continued support of the Australian Government and the meeting provided a valuable opportunity to brief our nation’s leader about areas of work that can change the lives of people affected by vision loss, in Australia and abroad,” Vision 2020 Australia stated.

Andrews said Aboriginal and Torres Strait Islander eye health discussions focused on closing the gap in eyecare and eliminating avoidable blindness in these populations by 2025.

“He indicated that the government would support specific efforts to address this. [I] also spoke about the importance of eye research and that Australia is a world leader in this area,” Andrews said.

“Overall, the Prime Minister was open to all the good work being done in the eye sector and he said he will actively consider support for closing the gap when it comes up in budget discussions.” n

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INSIGHT June 2021

CLINIC TO REVOLUTIONISE DIABETIC EYE TREATMENT FOR WA KIDS A new weekly clinic for screening children for juvenile diabetic retinopathy in Western Australia is part of the Lions Eye Institute (LEI)’s first major clinical-research platform for children’s eye health.

The clinic is a collaboration between LEI and Perth Children’s Hospital (PCH), forming part of the new Perron Paediatric Retinopathy Initiative, supported by the Stan Perron Charitable Foundation.

The initiative is spearheaded by the LEI’s Professor Dao-Yi Yu – an internationally renowned expert who has received nearly 30 years of continuous NHMRC research funding – in the field of retinal vascular diseases.

It includes the new clinic and a significant research project that will facilitate the development of new therapies to reverse sight-threatening complications due to diabetic retinopathy.

Based at the LEI in Nedlands, the clinic accepts referrals from PCH’s Endocrinology and Diabetes, and Ophthalmology departments. They are then seen by LEI ophthalmologists Associate Professor Chandra Balaratnasingam and Dr Antony Clark who are conducting the screening, assessment and treatment of children for juvenile diabetic retinopathy complications.

Balaratnasingam said screening children at regular intervals will enable clinicians

LEI ophthalmologists Dr Antony Clark (left) and A/Prof Chandra Balaratnasingam.

to detect the onset of complications at the earliest stages, prior to irreversible structural and functional injury.

“Detecting the earliest changes to the retinal circulation due to diabetic retinopathy is the key to avoiding irreversible vision loss in children.

Understanding changes to the retina through robust screening programs also provides an opportunity to develop better diagnostic techniques and new treatments to prevent disease progression,” he said.

Professor Bill Morgan, managing director of LEI, said the initiative was the institute’s first major clinical-research platform for children’s eye health.

“Our retinal imaging capability through OCT angiography is unparalleled, and our research group has been an international pioneer in much of the work in this field,” he said. n

FUTURE OPTICAL DISPENSERS BENEFIT FROM MAJOR DONATION The Australasian College of Optical Dispensing (ACOD) has received a significant donation of frames with a retail value exceeding $250,000.

Australian frame and sunglass designer Mr Jono Hennessy Sceats has donated more than 1,400 acetate and metal spectacle frames for the college to use in training optical dispensers throughout Australia and New Zealand.

ACOD co-directors and senior trainers Mr James Gibbins and Mr Chedy Kalach estimate it is potentially the most valuable donation of ophthalmic frames for training purposes of any optical college anywhere in Australia.

They described Hennessy Sceats as an “Australian optical industry legend”.

ACOD director James Gibbins (left) with Jono Hennessy Sceats.

“Jono and his wife Louise have been ardent supporters of optical dispensers and their training for decades,” they said.

“Jono lectures ACOD students in frame fashion and design and was a guest of honour at the student graduation event for 2018.” n

NEWS

ONE AUSTRALIAN AMONG TOP 100 RANKED FEMALE OPHTHALMOLOGISTS IN THE WORLD The Save Sight Institute’s Professor Stephanie Watson has been recognised as one of the world’s top 100 female ophthalmologists.

She is the only Australian to make the 2021 Power List of the Top 100 Women in Ophthalmology, a first-of-its-kind list released by The Ophthalmologist magazine that celebrates the impact women have had on clinical practice, research, education and industry.

Professor Helen Danesh-Meyer, from the New Zealand National Eye Centre, University of Auckland, also made the list.

Translating her research findings into two world-first therapies and developing the Save Sight Registries for corneal diseases to hold more than 30,000 visits from more than 600 patients from 82 clinicians worldwide are among her proudest professional achievements.

Watson has also conducted 11 clinical

Goals can be set based on the data and evidence-based research on what is needed to achieve diversity. Leaders need to communicate their goals for diversity and be held accountable for their delivery," she said.

trials (five as chief investigator) and trained 70 eyecare professionals (including 15 corneal fellows) and 25 researchers.

“Training these ‘next-generation eye experts’ is what I’m most proud of, as this has helped build a workforce with the skills needed to save sight and improve patient care into the future,” Watson told The Ophthalmologist.

Prof Stephanie Watson, SSI.

She said recognising the top 100 women in ophthalmology allows the celebration and validation of the nominees’ excellent work.

But she said action is needed to make the field more diverse. As an academic eye surgeon, she is one of only three female professors out of 34 in Australia.

“Without [action], unconscious bias will continue to inhibit change. The first thing we need to do is measure performance in terms of the diversity. The data on diversity can inform the conversation.

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“There are still many examples where diversity is still lacking and action needed. For example, I commonly see conferences where female speakers are in the minority, not present at all, or typically asked to speak on non-surgical subjects or as non-experts despite being excellent surgeons with considerable expertise. If all societies had gender diversity at conferences as a KPI then this could be identified and positive action taken. The conference organisers would be able to deliver a program that caters to the entire audience and provides inspiration to emerging leaders – a win-win.” n

COMPANY

WORLD’S FIRST DRUGRELEASING COMBINATION CONTACT LENS APPROVED Johnson & Johnson (J&J) Vision’s contact lens that also contains an antihistamine drug has been approved by the Japanese government, the first health authority in the world to clear the novel device.

The Japanese Ministry of Health, Labour and Welfare (MHLW) approved the combination contact lens – Acuvue Theravision with Ketotifen – that provides vision correction and contains ketotifen, an H1 histamine receptor antagonist for the prevention of itch associated with eye allergies.

“This approval marks another significant milestone in Johnson & Johnson Vision’s legacy of rethinking what’s possible with contact lenses, and bringing forward innovations to help eye care practitioners better meet the needs of their patients around the world,” Dr Xiao-Yu Song, J&J Vision’s global head of research and development, said.

“Our goal at Johnson & Johnson Vision is to change the trajectory of eye health and we will continue to drive new innovation and technologies that correct, enhance, and restore people’s vision over their lifetimes.”

The company reported that itchy allergy eyes can impact vision, which can become even more problematic for contact lens wearers – most of whom resort to rubbing their eyes.

According to J&J Vision, data shows that eight out of 10 contact lens wearers feel frustrated when their eye allergies interfere with normal contact lens wear. It’s contact lens is designed to help patients wanting to continue wearing contact lenses during the allergy season.

Acuvue Theravision with Ketotifen is the latest innovation in its contact lens portfolio, since introducing the world’s first disposable soft contact lens three decades ago.

“This product is the first in an entirely new contact lens category and brings forward a better contact lens wearing experience for patients with allergic eye itch,” the company stated.

J&J Vision is seeking regulatory approvals in other markets. n

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INSIGHT June 2021

ELLEX AND QUANTEL MEDICAL MERGER TAKES SHAPE The parent company of newly acquired ophthalmic device manufacturer Ellex has announced the appointment of a new CEO, with the entity officially taking over the distribution of Quantel Medical equipment in Australia.

French firm Lumibird Group acquired Ellex-branded lasers and ultrasound for $100 million last year and has since merged the business with its existing ophthalmic lasers and ultrasound subsidiary, Quantel Medical.

Ellex’s integration of the Quantel Medical product portfolio in Australia took place on 9 April.

“As a result of this collaboration, the combined distribution of Ellex and Quantel Medical product portfolios across Australia are able to offer a suite of advanced treatment solutions to drive greater value to ophthalmologist customers,” a company statement said.

“The shared heritage in the development of global, cuttingedge technologies will enable Ellex and Quantel Medical to better meet the needs of physicians and their patients. Both the applications and positioning of the two comprehensive product ranges will provide some of the most advanced ophthalmic treatment solutions covering a broad range of

New Ellex CEO Patrick Maine (right).

pathologies.” Meanwhile, to support the Ellex and Quantel Medical merger, Mr Patrick Maine has been appointed to lead Ellex in Australia as CEO. He is being tasked with accelerating the integration of both businesses.

“It is really exciting for me to help Ellex and Lumibird Medical take full advantage of their combined strengths, providing both a global footprint for all our medical products, and unmatched multi-centre R&D and manufacturing capabilities,” he said.

Maine has significant senior executive experience within the laser industry for science, defence and medical applications, spanning across Europe and the US within parent company Lumibird Group, where he held the position of chief technology officer for the past four years. n

HAAG-STREIT MYOPIA DEVICE ARRIVES IN AUSTRALIA Haag-Streit’s new myopia management platform Lenstar Myopia is now available in Australia through distributor Device Technologies.

Lenstar Myopia comprises the company’s Lenstar 900 optical biometer, along with specialised software called, EyeSuite Myopia.

According to the Haag-Streit, its EyeSuite Myopia software uses the latest axial length growth curves from myopia experts at the Erasmus University Medical Center in Rotterdam, the Netherlands. Leading myopia authorities and optometrists Dr Thomas Aller and Mr Pascal Blaser, of myopia.care, have also been involved in its development.

In addition to precise axial length

measurements, Lenstar 900 is said to contribute to other myopia management factors such as keratometry, providing a range of data for accurate predictions of the myopia’s onset and progression.

Device Technologies product manager Mr Jarrod Power added: “It gives clinicians and their team a valuable tool to visualise and plan treatments, while providing a simple and powerful graphical framework to educate patients and their families. This facilitates the best possible outcomes and helps to build long lasting advocates for their business.”

Lenstar Myopia is available to clinicians now, following Australian registration and product launch earlier in 2021. n

RESEARCH

MODERATE WINE CONSUMPTION MAY LOWER POSSIBILITY OF CATARACT SURGERY A new study involving Moorfields Eye Hospital has found people who consume alcohol moderately have a lower chance of developing cataracts that require surgery, especially if they consume wine.

The new research was published in Ophthalmology, the journal of the American Academy of Ophthalmology, and was conducted by researchers from NIHR Moorfields Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology.

To better understand the association between alcohol and cataracts, the study – the largest of its kind – tracked 490,000 volunteers in the UK. They were enrolled in two different study groups and answered a detailed questionnaire.

After taking into account factors already known to affect cataracts such

as age, sex, ethnicity, social deprivation, weight, smoking and diabetes, the researchers found that people who consumed about 6.5 standard glasses of wine per week (which is within the current guidelines for safe alcohol intake in both the US and UK) were less likely to undergo cataract surgery.

However, people who drank daily or nearly daily had about a 6% higher risk of cataract surgery compared with people who consumed alcohol moderately.

According to the study, wine drinkers benefited the most compared with those who abstained or drank other types of alcohol, showing a 23% reduction in cataract surgery in one study group and a 14% in the other.

In other findings, the researchers observed that compared with participants who drank one to three

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times or less per month, those who drank one to two and three to four times per week had 7% and 6% lower risk of cataract surgery, respectively.

Red wine drinkers had a 14% lower risk.

Moderate white wine/champagne drinkers had a 10% lower risk than those who abstained, while for beer and spirits the risk reduced by 13% and 14%, respectively.

The researchers said the study’s findings were consistent with what has previously been established with red wine and the benefits of diets rich in antioxidants that may prevent the onset of cataracts.

“Cataract development may be due to gradual damage from oxidative stress during ageing,” Dr Sharon Chua, lead author, said.“The fact that our findings were particularly evident in wine drinkers may suggest a protective role of polyphenol antioxidants, which are especially abundant in red wine.” n

Optiko Eyewear in Brisbane's Queen Street Mall.

BUSINESS

w o n k o t g n i t t Ge NATIONAL OPTICAL CARE National Optical Care has arrived by acquiring 14 practices and launching a new buying group and managed services division. CEO MR JASON GOWIE explains the company’s ambitions for the eyecare sector and how it plans to make a positive impact.

O

wners of independent Australian optometrists may have noticed the recent, but discreet, introduction of a new player, in National Optical Care (NOC).

With the acquisition of 14 practices and an alliance with EyeQ Optometrists, it hasn’t taken long for the new group to gather momentum and vital credibility in a sector that’s seen its share of “disruptors” come and go. It’s also just branched out with a subscription-based buying group and managed services division called Optical Growth Partners, with the aim of supporting as many independents as it can.

Mr Jason Gowie and Mr Tomas Steenackers – the duo behind the venture – are no strangers to the healthcare sector, with NOC’s blueprint largely based off Steenackers’ highly successful National Veterinary Care (NVC) business.

Under his leadership, NVC grew its acquired practice network from an initial 34 separately branded clinics to 110 within five years. That’s in addition to 550 independent clinics that subscribed to the company’s buying group and managed services offering.

Meanwhile, Gowie was in the leadership team that took Medibank Private to public listing in 2014, and he’s also held senior roles at Bupa.

But his most relevant experience is in audiology as the managing director of Oticon Australia – one of the country’s largest hearing healthcare companies he helped grow from 69 to 170 clinics, and also took into New Zealand.

The pair came together in 2019 convinced that a healthcare-led ethos 20

INSIGHT June 2021

Jason Gowie, CEO and managing director.

Tomas Steenackers, founder and non-executive director.

that allowed practices to retain their brand and clinical independence would work well in the optical industry too.

“Tomas’ goal in the veterinary sector was to leave a positive impact on the industry, beyond just owning practices, so that’s the philosophy of the model that we’ve brought to the optical industry,” Gowie says.

“The sector is also highly fragmented with a large number of independent practices. There’s probably around 2,800 practices that are non-Specsavers or Luxottica, so there are many who are trying to do the best to deliver quality eyecare and often they’re doing it tough because they don’t have the size and scale to compete.”

RESPECTING IDENTITY To kick-off the venture, NOC acquired the first 14 practices in between November 2020 and January this year. The group is locally funded by private investors in Australia and is poised for more growth later this year.

When NOC acquires a practice, it retains its local brand and practice

teams. They can also continue using their preferred practice management systems and product suppliers, says Gowie: “We don’t do centralised ordering of stock, we don’t think that works because we never know the local demographics as well as the practice team.

“Behind the scenes it’s different because we are taking care of all the stuff most optometrists will tell you they aren’t good at, don’t like – or both. They love the way we have respected the business they have built up over a long period of time, and respect their expertise.”

The group supports its practices with business expertise in marketing, human resources, finance, IT and business development initiatives.

Gowie says building platforms is where NOC aims to drive value to its practices who would have otherwise struggled to do so alone.

In less than six months it has also established a data business intelligence tool and a customer relationship management (CRM) system that displays the performance of each practice and patient behaviour in real time. Its patient communication journeys are also said to be based on global best practice for healthcare organisations.

Soon, the company is looking to introduce AI capabilities to support practices with tasks like answering phones and other tasks. The objective is to free up staff in practice to offer a better support to their patients and improve the customer experience.

NOC is also currently working on training programs to continue developing its staff at all levels.

“Our people are the most important element in the business, and we need to provide a clear path for career progression for everyone involved in the business, including administration and reception staff, practice managers, dispensing and optometry staff,” Gowie says.

“We are committed to becoming an employer of choice by 2023, developing the strongest and most skilled network of optometrists in Australia and New Zealand. We will invest in our team members’ skills, careers, wellness, personal growth, and create opportunities for them to do what they love at the highest standard.”

Gowie says NOC is in discussions with a number of practices across Australia and New Zealand about acquisition opportunities and they will be welcoming more new practices between July and September this year and a third wave of acquisitions in early 2022.

“We would also welcome confidential discussions with practice owners who are considering the next phase for their practice, but have perhaps been concerned about preserving the legacy they have built up over many years,” he adds.

EYEQ ALLIANCE Another major step in NOC’s short, but rapid, evolution has been its partnership with the EyeQ group as an unbranded franchise last November.

The combined entity takes the total national network to 40 practices in all states and territories, except the Northern Territory.

By joining EyeQ, NOC’s practices are benefiting from administrative services provided by the EyeQ franchise network support office. Both companies view EyeQ’s expertise in optometry and NOC’s experience in business growth as an ideal opportunity to create an alliance that leverages the strong trading conditions experienced since mid-2020 in the optical sector.

The partnership has meant EyeQ CEO, Mr Ray Fortescue, is now chair of a new joint-committee overseeing the operations of the EyeQ Optometrists and the NOC alliance. He has remained as chairman of the EyeQ board, as well as a clinical optometrist at the EyeQ Ramsgate practice.

Meanwhile, Gowie has taken on the shared responsibility as CEO of both NOC and EyeQ. Because EyeQ is branded and has a similar approach for each practice – and NOC’s practices are managed as discrete entities that run separately – each has their own teams to help with day-to-day operations.

But Gowie says joining EyeQ has allowed access to its Q Optical Network

Optiko Eyewear in Brisbane's Fortitude Valley, part of the National Optical Care network.

– a new entity that collectively negotiates health fund contracts on behalf of independents. It’s also led to less duplication, and they’re able to develop and share advanced technology platforms.

“We are both very passionate about eyecare-led models of optometry, so that’s why Ray, an experienced optometrist who’s well known in the industry, is chair of the executive committee, while I’m starting to bring both entities under the same umbrella operationally as the CEO,” he says.

“At NOC, we bring strong experience in developing platforms, so that’s HR, business intelligence tools, CRM for marketing, and finance related platforms. All our investments in technology are shared, so the alliance is becoming stronger.”

BUYING GROUP AND MANAGED SERVICES On 1 May, NOC launched what Gowie anticipates will be a disruptive, yet welcome, new offering for independent optometry practices.

Its Optical Growth Partners initiative is a new subscription-based buying group and managed services division for independents and will be based on a set monthly fee across three levels of membership.

“There are several incumbent players, but we think there is an opportunity to put a model in place that’s lower in terms of cost to members, because we can leverage our investment in running our own practices,” Gowie says.

He says a key difference is NOC’s relationships with non-optical suppliers such as insurance, electricity, and other key business operating expenses.

Steenackers formed these relationships years ago at NVC. “We will pass on exactly the same deal we get with our own practices to members, and we have been able to negotiate very strong arrangements on the optical supply side, through the EyeQ group,” Gowie adds.

“We are confident of the value we will deliver to independent practices and as such have put in place a money back guarantee should we not deliver a 200% return on the investment in our membership essentials package within the first 12 months."

NOC’s combined model of acquired practices and managed services has been transported from NVC, where Steenackers grew the managed services side of the business to 550 clinics. In some cases, NVC also presented as willing buyer and succession option for veterinary clinics that were originally part of the managed services community.

With around 650 optometry practices signed on with other competing optical buying groups, Gowie hopes to subscribe 10% of an estimated 2,800 independent practices to Optical Growth Partners within two years.

“We want to make Optical Growth Partners available to any independent practice owner in the industry – regardless of practice size or whether it’s optometry- or dispenser-led,” he says. n

INSIGHT June 2021 21

AI SOFTWARE

ARTIFICIAL INTELLIGENCE

? e o f r o d n ie r f ’s e r a c e ey

Eyetelligence is a new Australian-developed AI system helping clinicians screen for three types of eye disease. PROFESSOR MING HE – the clinical expert behind the software – discusses why optometrists should embrace the technology and its potential in other health fields.

I

t’s one of the ophthalmic sector’s most pertinent questions today: will artificial intelligence (AI) replace eyecare professionals, or complement and enhance their capabilities?

It’s a debate Melbourne’s Professor Ming He is clear on. He’s the clinical expert behind Eyetelligence – a new AI software tool that helps clinicians screen, grade and make decisions for the management of glaucoma, neovascular age-related macular degeneration (nAMD), and diabetic retinopathy (DR).

“The eyecare profession should think of it more as a new model of care. AI will not replace optometrists, but the optometrists with AI will be better off than those without," He says.

A Professor of Ophthalmic Epidemiology at the University of Melbourne and Centre for Eye Research Australia (CERA), He has been working in the field of ophthalmology AI for more than 10 years and is extensively published on the topic. While many platforms focus on glaucoma or more definable DR, the technology he's helped develop is among the first to screen for three forms of eye disease.

Eyetelligence is owned and being commercialised by its namesake Australian company, which is CERA’s commercial partner for a Medical Research Future Fund (MRFF) grant project. Prof He is the company’s chief medical officer. The software secured Therapeutic Goods Administration (TGA) approval last year, bolstered by clearances in New Zealand, Europe and the UK.

algorithm that uses fundus imaging to analyse the retinal microvascular system and detect cardiovascular disease risk. This received TGA approval in March, opening up the technology to other health fields.

The company is keen to point out the system is a “decision support tool”, and not an autonomous diagnostic platform that would remove the need for the involvement of a health professional.

The technology has largely been developed to standardise disease Prof Ming He, chief medical officer. screening and help overcome diagnosis variation in optometry practices. In an ideal world, He says eyecare professionals would make the correct diagnosis each time, but – using glaucoma as an example – he says disease can be complicated.

“Many patients come up as borderline, so eyecare professionals aren’t always sure whether it’s suspect or certain glaucoma, or if the person is normal, for example,” He explains.

Within seconds, the technology analyses fundus images to generate findings with 95% accuracy. It’s the market’s only AI software that runs offline, without the need for image upload to the cloud.

In the optometry setting, He points out most patients are normal, but performing wide-spread visual field and OCT testing on these patients can become expensive and time consuming (10-15 minutes per patient).

At present, the system is mainly being used in optometry practices, which the company hopes to grow even further via a monthly subscriptionbased model. He and the Eyetelligence team have also recently built a new

“We thought there’s an opportunity to develop a tool that uses fundus photos that labels patients as low, medium and high risk, and for those people specified as suspect (medium risk) and certain (high risk) glaucoma,

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INSIGHT June 2021

they can go ahead and be tested with visual fields or OCT. With our product, additional testing can be more targeted, in a limited number of patients.

That’s the value proposition.”

CHANGING PERCEPTIONS ABOUT AI The Eyetelligence software has been developed with a ‘traffic light system’ that’s designed to make it easier for clinicians and staff with differing levels of expertise and experience to detect disease and monitor progression. Results are highlighted with red (high risk) and green (low risk) lights.

With glaucoma detection, the company’s introduced an ‘amber light’ to indicate suspicious/medium risk patients who require closer analysis by the optometrist. The algorithm is trained not only on the easier cases (absolute normal and absolute abnormal) but also challenging cases, such as physiological cupping, localised RNFL defect and disc haemorrhage, as well as those with co-existing eye diseases such as pathologic myopia.

In line with the International Council of Ophthalmology, referrable DR is classified as mild, moderate, severe and proliferative. Consistent with the RANZCO Screening and Referral Pathway for DR, this grading system determines whether a patient should be monitored or referred to an ophthalmologist.

In nAMD, results are displayed as either green (no nAMD present) or red (nAMD is present). An alert will also notify of any images insufficient for disease diagnosis.

In any AI training, He says images need to be appropriately labelled. In this case, the system has been trained to recognise disease features by a panel of more than 10 sub-specialist ophthalmologists, drawing upon 200,000 retinal images for labelling and data validation sets. Each image’s disease and grading requires consensus from three ophthalmologists on the panel before being fed into the algorithm.

“The images came from 20 major eye hospitals in China, who were using many different models of fundus cameras, so the algorithm has been trained on images with great variation and quality,” He says.

“We then validate it and do what we call incremental learning to constantly improve the AI, and make sure the AI developed in the Chinese population performs equally well in the Caucasian, Malay, Singapore, and even Indigenous populations.”

He says the system has 95% accuracy, which is taken from randomly selected population-based data in Australia and Singapore involving tens of thousands of scans. Within a subset of more challenging cases – like suspect glaucoma – he acknowledges the accuracy may not be as high.

“The first concern from optometrists whenever you launch a machine into their practice is, ‘how accurate is this?’. They will try and challenge the machine with a lot of images. They are always looking at things like false negative/positives and say AI isn’t 100% accurate, but then they forget AI is just like humans who also make mistakes. This should be used as a screening tool based on a digital fundus image only, to draw your attention and take a closer look.”

In customer engagement studies, Eyetelligence has interviewed optometrists to understand their views on the challenges and opportunities of AI. Initially many thought they would be out of a job, but He says they’ve come to realise the greater efficiencies and consistency it can bring to their care.

The software uses fundus images and a traffic light system to help screen for disease.

piece of optometry diagnostic equipment without any in-built diagnostic decision support.

The software runs automatically in the background and because it’s an offline solution, it doesn’t require an internet connection. Images don’t need to be uploaded to a cloud and aren’t stored in public servers.

“Many products including one developed by Google require the user to upload the image into the cloud, and then they deploy their graphics processing unit (GPU) – it’s a powerful processor to analyse the images, but that potentially creates two problems. First, it’s not convenient for the user to upload images and wait for results to come back, and secondly, patients’ privacy protection can be affected.

“We decided to simplify the neuron network and make it lightweight to be able to run with a normal GPU, this is one of our innovations.”

Eyetelligence has made subscriptions available for practices with just one retinal fundus camera and PC, and there are bundled options for enterprise clients with six or more cameras and a centralised IT department.

WHERE TO FROM HERE? Another potential advantage of the Eyetelligence system in Australia is its application in Indigenous healthcare settings.

Access to eyecare professionals and reliable internet can be difficult in rural and remote areas, but by embedding the system into GP clinics, doctors could screen for the three types of eye disease, and use the new cardiovascular screening functionality.

Understanding the software’s impact in this and other settings is part of a major $5 million grant He received from the MRFF, which is the largest AI grant of its kind in Australian history.

In addition to “opportunistic screening” in Indigenous clinics and GP practices, the funding is being used to investigate its impact in standardising screening in optometry settings, while the third setting is cardiovascular clinics.

“They also saw that it helped them minimise the risk of missing a diagnosis, so they are convinced of that,” he says.

“This grant is supporting us to prove the real-world impact, its real-world accuracy, and the feasibility of integrating this AI into the current clinical practice system,” He says.

“And ophthalmologists like the product because the AI helps generate a more targeted referral. As an ophthalmologist, you want to see patients who maximise the value of your time, who may need to be operated on or require treatments like AMD injections.”

Overseas, Professor David Friedman at Massachusetts Eye and Ear, Harvard Medical School, has also been impressed by the software’s simplicity and functionality.

SIMPLE INTEGRATION Easy and low-cost integration has been front of mind for the Eyetelligence software developers. For example, He says it will integrate with the practice’s existing PC and digital fundus camera, which, until now, has been the only

The school has signed an agreement with Eyetelligence to trial and validate the system's use in the Mass General Brigham network. Prof He is also collaborating with Friedman on a range of ophthalmology AI related research.

Being able to screen for three types of eye disease, the question begs: what else is on the horizon? There may be more, but He’s bound by confidentiality. n

INSIGHT June 2021 23

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OPHTHALMOLOGY

school A newIN CORNEAL COLLAGEN

CROSS-LINKING PROTOCOL

Corneal collagen cross-linking revolutionised treatment for keratoconus patients when it was introduced in the late 1990s, but it was a one-size-fits-all approach. Two decades later, capabilities have taken a significant leap, reducing risks and improving patient outcomes.

T

he primary goal of corneal collagen cross-linking (CXL) has always been to halt the progression of ectasia, with the most common progressive ectatic disease of the cornea being keratoconus. Widely recognised as a safe and effective procedure, most patients with keratoconus in Australia today are treated with CXL. Dr Brendan Cronin at the Queensland Eye Institute (QEI) is an early adopter of a new CXL protocol (or technique), seizing the advantage it offers his keratoconus patients, who he describes as predominantly in their late teens or early 20s, and male.

For years, the epithelium-off (epi-off) CXL protocol has been the standard, but Cronin hopes more Australian corneal specialists in Australia will switch to the newer oxygen-enhanced epithelium-on (epi-on) CXL protocol, and adopt new topography-guided technology that can customise treatment to the shape of each individual cornea.

QEI was the first clinic in Australia to offer new topography-guided CXL treatment to keratoconus patients, which has not reached the tipping point of becoming mainstream – yet.

“We have now combined oxygen-enhanced epithelium-on CXL with our topography-guided system – the only one in Australia – for over a year. This means people can have their corneal topography and vision improved with faster recoveries, without even having their epithelium removed. It’s definitely the way forward in cross-linking,” Cronin says.

applications following in 1998.

Prior to its introduction, the conservative therapeutic approach for keratoconus involved fitting hard contact lenses to improve best corrected visual acuity.

The only treatment that slowed progression was to control ocular allergies and stop eye rubbing.

These measures still play a role in keratoconus management but don’t halt progression or improve corneal topography.

By contrast, CXL aimed to strengthen Dr Brendan Cronin, Queensland Eye the cornea through a chemical Institute. reaction, a combination of riboflavin (vitamin B2) and ultraviolet (UV) light, to strengthen the crosslinks between the collagen fibres within the stromal layer.

CROSS-LINKING TIMELINE

Although several variations of CXL emerged, the most commonly used and studied was a traditional method called the Dresden epi-off technique, according to Keratoconus Australia. The technique, which gets its name from human studies of UV-induced CXL in Dresden in 2003, became the most widely adopted protocol, and remained so for 15 years, regarded by many as the gold standard.

Corneal collagen cross-linking was first developed in 1997 by a team at Dresden University of Technology in Germany, with the first clinical

In the Dresden protocol, the cornea is anesthetised, the epithelium is removed, and the corneal stroma is saturated with riboflavin for 30 minutes.

INSIGHT June 2021 25

OPHTHALMOLOGY

After the first 30 minutes, the irradiation of the cornea for another 30 minutes begins with UVA light of 3 mW/cm2 for a total of UVA fluence of 5.4 J/cm2. During this time, additional riboflavin is instilled to the corneal stroma every five minutes.

In the shadows of the popular Dresden protocol, scientific and technological advances helped create various modifications to cross-linking techniques, experimenting with key factors including riboflavin formulations, fluence rates, removing the epithelium or leaving it in place, and treatment time.

Researchers were aiming to create the same results of safety and efficacy in the clinical application of CXL in less time and with less patient discomfort.

Cronin says the epithelium is approximately 50 microns thick, and researchers found that soaking the corneal stroma in riboflavin and exposing it to UV light with the epithelium on proved difficult because 50 microns will absorb UV and it won’t go into the stroma.

“It’s like trying to get a suntan with sunscreen on. You need exposure to stronger UV light for a longer period of time,” he says, adding he now chills riboflavin to four degrees to help reduce the sunburn-like pain of CXL. Further research led to the development of ‘accelerated’ CXL, which still involved removing the epithelium, but saturating the cornea in riboflavin for 10 minutes (a third of the time compared to the Dresden protocol) and exposing the cornea to an increased power of UV light (up to 30mW of power).

This accelerated technique led to another discovery.

“The CXL chemical reaction depends on oxygen. When the power, or strength, of UV light is increased, it uses up oxygen in the corneal stroma, preventing cross-linking from occurring. We need to pump in oxygen, to maintain an adequate level of oxygen,” Cronin says.

NEW AND IMPROVED TECHNIQUES Each new discovery has nudged CXL protocol forward but a significant leap in technology has resulted in a new school of CXL that doesn’t require removing the epithelium.

The new techniques include oxygen-enhanced epi-on CXL, topographyguided epi-on CXL, and combined topography-guided transepithelial PRK and CXL. Massachusetts-based Avedro, now owned by Glaukos, has been a frontrunner in this space. Its iLink V technology is the first and only FDAapproved corneal cross-linking procedure that slows or halts progressive keratoconus. Glaukos’ iLink V platform (previously known as Boost) allows surgeons to perform oxygen-enhanced epi-on CXL. Its Mosaic platform for topography-guided CXL is currently under limited commercial release, with QEI home to the only one in Australia.

Which treatment a patient receives depends on the individual.

“Oxygen-enhanced epi-on CXL technique uses oxygen to enhance the collagen cross-linking effect in the cornea for a safer procedure, a faster visual recovery and better patient outcomes,” Cronin explains.

“Topography-guided epi-on treatments plug in a map of the patient’s keratoconus, and the machine applies more UV light to steeper parts of the cornea, effectively customising CXL to each individual patient.”

The goal of the third treatment option, combined topography-guided transepithelial PRK and CXL, is to synergise the effects of the two treatments.

Although expensive, Cronin says no other ophthalmic instrumentation comes comes close to iLink V CXL technology.

“We are already performing the new oxygen-enhanced procedure but the Glaukos FDA study results should be released in the next 12 months on this protocol, seeing it go mainstream.”

GROWING CONFIDENCE Ophthalmic surgeon Dr Nikhil Kumar has been performing oxygen-enhanced epi-on CXL using Glaukos’ iLink V platform at Vision Clinic Sydney for 12 months and commenced his first cases using this protocol at Chatswood Private Hospital in April this year.

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INSIGHT June 2021

Dr Nikhil Kumar, Vision Clinic Sydney.

Dr Alex Ioannidis, Vision Eye Institute.

Prior to adopting this newer cross-linking technique, he was treating keratoconus patients with the Dresden protocol for about 11 years, and then progressed to the ‘accelerated’ epi-off approach.

“From my perspective, the ideal solution is to be cross-linking without removing the epithelium, because removing the epithelium increases the risk of infection, inflammation, and corneal melt,” Kumar says.

“Those complications are significant and vision threatening if they occur.

Despite performing the Dresden protocol – which involves removing the epithelium – for many years, I’ve always been concerned about the potential complications that can arise from removing the epithelium.”

Kumar is aware that for his patients, the act of cross-linking produces pain, and removing the epithelium only compounds that, but there hasn’t been a better alternative – until now.

He has conscientiously followed the evidence-based literature on crosslinking, and says a transepithelial approach – leaving the epithelium intact – trialled several years ago generated discussion but was ultimately flawed and didn’t appear to be equally as effective as the traditional epi-off method.

When he learned of the new oxygen-enhanced protocol, he says it intuitively made sense, and consulting with surgeons at the QEI, who had already adopted it, gave him confidence in its efficacy to the degree that he too invested to offer the procedure to his patients.

“My observations are anecdotal but the anterior stromal demarcation line – the measure of the depth of effect of cross-linking – is deeper than for those patients who had traditional epi-off cross-linking,” Kumar says, noting that patients undergoing the newer procedure also appear to be in less postoperative discomfort.

“It’s a revelation, and it fills me with confidence.”

He says leaving the epithelium on is a leap forward in a procedure that is aiming to improve visual function while being minimally invasive – and ultimately avoiding a corneal transplant – but scientific evaluation of the data is critical.

“Obtaining current evidence is essential. Glaukos is taking time to gather more data before introducing this new protocol to the wider market,” he says.

“It’s a significant leap in cross-linking, and it appears to achieve an excellent penetrative effect, to instil in me the confidence to offer it to patients.”

Although Kumar has not yet taken the next step of offering topographyguided CXL to his patients, he is considering it, and says he is excited for the future of cross-linking.

“If safe and effective, topography-guided cross-linking could become the gold standard of CXL for corneal ectasia; hopefully that can be achieved.”

DATA IS KING Melbourne cataract and anterior segment specialist Dr Alex Ioannidis divides his time between the Vision Eye Institute Clinics, Retina Specialists Victoria and the Mornington Specialist Eye Clinic.

He is aware of the oxygen-enhanced protocol, which he says looks promising as a potential future technique that may become mainstream once published data supports its use.

five years later has stable vision and no further progression detectable on topography.

He currently performs the conventional Dresden epi-off protocol on his keratoconus patients.

“The fact we now have a treatment – cross-linking – has improved awareness and a sense of clinical suspicion when patients present to their optometrist with changing vision,” he says.

“Oxygen-enhanced cross-linking is a very interesting concept, as it potentially enhances the chemical reaction between riboflavin and UV. I’m currently waiting for more data to be published on this treatment,” he says.

“Optometrists are getting better at detecting and referring cases to ophthalmologists because they know that a safe and proven treatment exists for this condition.”

“This is a very exciting development in the field. Leaving the epithelium on also reduces the risk of infection in the cornea, and would significantly reduce post-treatment pain which typically occurs in the first 24-48 hours after epi-off cross-linking.”

It is also a more accessible procedure after a Medicare Benefits Schedule item was introduced in May 2018, providing a significant rebate, Ioannidis says.

“We are therefore potentially looking at a painless procedure with oxygen enhanced epi-on treatments.”

Vast improvement in CXL technology and better patient outcomes is having a flow on effect on corneal transplants.

“The reason we are currently removing the epithelium is that riboflavin poorly penetrates this natural barrier, and the effect of the treatment has been limited.”

In the February issue of Insight, director of the Lions Eye Donation Service Dr Graeme Pollock said keratoconus used to be the most common reason for requiring a donor cornea in Australia – but now it’s Fuch’s dystrophy.

Another limiting factor to performing cross-linking has been severe thinning of the cornea. In the past cross-linking wasn’t recommended for patients if their cornea was too thin, generally less than 400 microns as there was a concern about possible endothelial damage.

Cronin used to preform two corneal grafts or transplants for keratoconus every week – now he performs just a few a year.

FAR FEWER CORNEAL TRANSPLANTS

“Hence it is important to diagnose and treat patients before the disease progresses to a very advanced stage,” Ioannidis says.

“It’s really rare to graft someone for keratoconus. This is partly due to better CXL results but also because optometrists have invested more heavily in detecting keratoconus earlier, resulting in patients undergoing CXL in their late teens and in early 20s,” Cronin says.

Surgeons are now dealing with keratoconus in its earlier stages because there is more awareness from the public, optometrists and ophthalmologists.

Ioannidis has had to perform CXL on a 14-year-old patient, and that patient

“The contact lenses we use to treat keratoconus have also improved out of sight, utilising today’s 3D scan technology to create custom-made contact lenses,” he says. n

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SUSTAINABILITY

een Going grSUSTAINABILITY

IN THE OPTICAL SECTOR

Corporate commitment to environmental sustainability in optical manufacturing is on the rise, and it’s having a trickle-down effect to greener thinking at the practice level. Insight looks at how the optical sector is taking steps to reduce its footprint.

I

n January 2018, China’s importation ban on 24 types of recyclable materials left Australia’s waste management industry reeling.

Described as a wake-up call by some, and a crisis by others, it has prompted the waste management and manufacturing industries to reconsider their methods.

For the optical sector, this could serve as a stark warning – or an opportunity. The production, packaging and disposal of ophthalmic lenses, frames and contact lens waste are issues consumers will increasingly be concerned about, which will be transferred to practices, then ultimately suppliers and manufacturers.

Climate change has also further embedded environmental concerns into the public consciousness, following extreme weather events in Australia.

The 2019–20 Australian bushfire season, colloquially known as Black Summer, resulted in 34 deaths and destroyed 3,500 homes. More recently, extreme weather in March caused severe flooding in New South Wales and Queensland, claiming three lives.

Optometry Australia CEO Lyn Brodie says that as consumers become more environmentally conscious, the profession will need to start finding ways that optometry can reduce its collective footprint.

With the environment and the planet weighing more heavily on people’s minds, “sustainable retail” is on the rise, with consumers evidently choosing to spend more on sustainable products.

According a Forbes report in 2019, 54% of Gen Z (currently aged six to 24 years old) are willing to spend an incremental 10% or more on sustainable products, with 50% of Millennials (also known as Gen Y, currently 25 to 40 years old) saying the same. This compares to 34% of Generation X (currently 41 to 56 years old) and 23% of Baby Boomers (currently 57 to 75 years old), leading the publication to conclude that the quest for sustainability appears to strengthen with every generation in the US.

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INSIGHT June 2021

“We are starting to explore a number of initiatives to understand what might be possible. One area is microplastics which would include disposable contact lens. Ultimately initiatives will be developed to support our members, their patients and broader environment,” she says.

Brodie says there is an increasing awareness of the connection between climate and health.

“To explain what we mean by this, we only need to consider the impact on eye health of the extensive bushfires in 2019–20,” Brodie says, with a NSW survey finding that most people experienced at least one minor health symptom from bushfire smoke in December 2019 to January, including eye and throat irritation.

“As this field gains traction, we need to be at the forefront of understanding and knowledge to lead the profession in dealing with the outcomes, while also work on prevention by finding ways to combat climate change.”

Some medical experts are calling climate change a health emergency, which they say is already contributing to life-threatening illness and deaths. In their view, the Australian healthcare sector is part of the problem – contributing about 7% to Australia’s national carbon emission footprint.

In response to this, the Australian Medical Association (AMA) and Doctors for the Environment Australia (DEA) are calling on the Australian healthcare sector to reduce its carbon emissions to net zero by 2040, with an interim emission reduction target of 80% by 2030.

CREATING A GREENER PRACTICE Adelaide optometrist Ms Margaret Kirkman believes sustainability is “the next big frontier” in the optical sector.

A member of ProVision and Optometry Australia, she says individual actions only go so far but more can be done at an organisational level.

It’s not surprising then that she is “completely behind” ProVision’s decision to take action on sustainability. The network has identified sustainability as an objective in the next three-year plan and notified suppliers in February 2020 of its intent to move towards sustainable product supply.

“We’ve taken a corporate social responsibility position, and although our plans were interrupted by COVID last year, we have re-engaged with suppliers in February this year, and communicated with our members about our intentions in this area,” CEO Mr Steven Johnston says.

“We’re in the midst of conversations with reputable suppliers, asking what their position is on sustainability, and making sure they’re not engaged in modern slavery, taking into consideration that our suppliers aren’t manufacturers; they source product predominantly out of China, including hinges, nose pads, and raw materials for acetate.”

Johnston says it’s a long road, but many sectors are on the same path, including the clothing and textiles, and electronics industries.

“It’s a complex problem, and there’s not a simple answer,” he says. “In three years’ time, we hope to be in a far better position, but we haven’t set targets yet, as we don’t know what position we’re starting from until we’ve established our suppliers’ position on sustainability.”

Johnston says some ProVision members are adopting incredibly good processes in their own practices – solar energy and recycling, for example.

But as Kirkman points out, practices shouldn’t only stock an ethicallysourced range of frames in isolation: this is known as ‘greenwashing’, the process of conveying a false impression that a company’s products are environmentally friendly. Sustainable choices need to be implemented across all facets of the practice.

Kirkman and Johnston agree the layers of plastic and cardboard used in packaging optical products is problematic.

“I’m horrified at the amount of packaging; the volume that comes in is incredible. Each pair of frames has plastic sleeves on the temple, placed in a plastic bag, bubble wrapped, and then wrapped in more plastic. Knowing a supplier that used less packaging would influence my decision-making,” she says.

In 2013, Kirkman installed solar panels at the independent practice she owns – Complete Vision Care – a leased property located in a medical precinct.

“It has massively reduced my power bills, but originally I thought I couldn’t install solar panels because I don’t own the building. That wasn’t the case, and although I don’t own the building, I do own the solar panels. I can sell them if I move. It’s an asset I own that depreciates, so it reduces my tax bill too.”

Safilo introduced its Polaroid Sustainable Collection earlier this year in Australia.

Kirkman – who not only wants to do her part for the environment, but advocate for change too – encourages her patients to recycle, particularly her contact lens patients.

Up until earlier this year, Bausch + Lomb (B+L) have been partnering with TerraCycle, a global leader in recycling hard-to-recycle waste, to recycle contact lenses and packaging over the last four years. It will consider sponsoring the program – which reportedly saved more than 1.6 million pieces of waste from landfill – again in future, but in 2021 B+L has chosen to contribute to a different environmental cause by supporting the Forest Stewardship Council (FSC) initiative. It ensures all marketing materials are certified with a guarantee of environmental and social responsibility, covering both the forests they are sourced from as well as every stage of their production.

Optometrists can continue to recycle contact lens blister packs directly via TerraCycle.

“We’re continuing,” Kirkman says. “I give contact lens patients a white paper bag with the recycling symbol to dispose of their lenses and packaging, and they drop the bag back into the practice.”

Kirkman is also trying to generate less paper waste in her practice, favouring electronic communication with patients – where appropriate – and suppliers.

She says online programs like ProVision’s ProSupply, which offers more than 20,000 supply and fit frame options that can be shipped direct to a practice’s preferred laboratory, are helpful in reducing waste.

“We use display stock to display our range of frames, and a patient’s chosen frame is sent directly from the supplier to the lab. This system generates less paperwork, is more efficient and saves on transport costs. I favour suppliers that use this system. Providing the online catalogue is up-to-date with discontinued stock or frames that are outof-stock, it makes ordering and resupplying stock seamless,” she says.

Kirkman urges practice owners to look at every step of the supply chain.

“Look at sustainability on a human scale; avoid exploitation. A lot of optical products are manufactured in China. It doesn’t resonate with patients to change one element of your practice to be environmentallyfriendly – you need to make changes everywhere.”

For many corporations in the eyecare sector, sustainability has become a key driver across many facets of their business.

INSIGHT June 2021 29

SUSTAINABILITY

Lyn Brodie, Optometry Australia.

Meg Kirkman, Complete Vision Care.

Steven Johnston, ProVision.

Brenton Paris, Zeiss Vision Care.

Ulli Hentschel, Hoya Australia.

Shannon Morrow, CooperVision.

Zeiss, Hoya, and CooperVision have shared with Insight some initiatives they are implementing to protect the planet.

represents superior technology and fits with the company’s sustainability program.

Headquartered in Germany, Zeiss set up operations in Australia in Sydney in 1961, followed by New Zealand in 1978 and Adelaide in 2005 (when Zeiss merged with SOLA Optical, established in 1960 in South Australia). In 2017, Zeiss’ Adelaide manufacturing site relocated from Lonsdale to a new $6 million premises at Tonsley Innovation District.

(Formerly Mitsubishi Motors assembly plant which closed in 2008, Tonsley is Australia’s first innovation district and home to more than 30 businesses).

In terms of plastic waste, Paris says every part of the process is a challenge.

Around that same time [2017], the Zeiss Vision Care strategic business unit began to pool more than 280 initiatives in a global program to drive sustainability. One of those was a shift to solar energy at the Tonsley site.

Mr Brenton Paris is Zeiss Vision Care’s operations manager in Australia and New Zealand. He is responsible for operations across four manufacturing sites: Tonsley, Sydney, Caloundra on Queensland’s Sunshine Coast, and Auckland, New Zealand, overseeing more than 70 employees.

Paris says moving to solar power at the Tonsley laboratory is part of Zeiss’s commitment to environmental sustainability in line with the company’s “green, safe, and responsible” motto. Zeiss’s program to drive sustainability is based on three key pillars: energy consumption, water consumption, plastic waste.

“We’re fortunate to be located in a technology park in Tonsley, with access to renewable energy. A percentage of our power comes from renewable solar – at 60% right now – but plans are in motion to progress to 100% solar power,” Paris explains.

“Where water consumption is concerned, we’re moving away from wet-edging – which involves cutting lenses using a diamond wheel where water acts as a lubricant and wastewater goes down the drain.

Now we’re using dry-edging with CNC-type machinery – and there’s no wastewater,” Paris says.

CNC stands for Computerised Numerical Control. It is a computerised manufacturing process in which pre-programed software and code controls the movement of production equipment.

Paris puts a ballpark figure of more than $1 million to invest in CNC technology in optical manufacturing but says the single investment

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INSIGHT June 2021

“At our Tonsley site, our aim is to produce no landfill. We work with waste disposal providers, such as Veolia, to recycle or repurpose waste, such as waste materials used in concrete manufacturing.”

Although the project is Tonsley-based, Paris says the target is to eliminate landfill across all four Australian and New Zealand sites. But not all initiatives that contribute to sustainable practice are major.

“Small projects, like reducing paper, moving away from printing, and recycling are really in every facet of our business,” he says.

Zeiss has a large recycling program in place, including recycling carboard boxes and packaging materials, and printing marketing pointof-sale materials on recycled materials. Its packaging materials are also produced using recycled materials.

“These are not cost-down or cost-neutral initiatives but there is an expectation to be environmentally aware and responsible. It is expected by our staff, by our clients, and our end customers,” Paris explains.

AN ORGANISATION-WIDE APPROACH The Hoya Group established an Environment, Social and Governance (ESG) committee in August 2019, with the aim of “identifying items that contribute to the long-term growth of [the company], promoting their disclosure and pushing ahead with ESG activities”.

The group identified greenhouse gas emissions, air quality, energy management, water and wastewater management, waste and hazardous materials management and ecological impacts as environmental issues.

It identified supply chain management, materials sourcing and efficiency, and physical impacts of climate change under ‘Business Model and Innovation’.

The company’s Australian national training and development manager Mr Ulli Hentschel says efforts to reduce waste are ongoing across the entire organisation, including offices and the main manufacturing sites and labs.

“Initiatives range from using more sustainable solutions in offices,

such as reusable water bottles and reducing use of plastic in general, to recycling and reducing the overall environmental impact through the production process,” he says.

Hoya’s Australian operations is focused on making steps to improve environmental sustainability – both big and small improvements.

introduced Econyl regenerated nylon in its eyewear collections, starting with the Tommy Jeans line. This was off the back of a partnership with Aquafil, a well-known global company that produces polymers and synthetic fibres.

“Our [Sydney] lab is now operating with 100% LED lighting which is about 80% more energy efficient than our previous fluorescent and incandescent lighting. We’re in the process of switching the packaging for our lens cloths from plastic to paper and have already started distributing with the new packaging,” Hentschel explains.

Earlier this year, Safilo has also launched a Polaroid Sustainable Collection. The collection is made from eco polyamide, a bio-based plastic with more than 40% derived from renewable resources: from castor oil, a renewable feedstock, that’s responsibly farmed. It also incorporates eco acetate, derived from cellulose (cotton), as well as recycled metal and dedicated packaging made with recycled paper.

“Wherever possible we use recycled boxes. Naturally we recycle all of the paper and board used in our labs and offices. We avoid having single use items in our staff kitchens and have provided insulated water bottles to all Hoya employees.”

“We are committed to leading the way in our approach to our products and packaging without using new resources and without compromising the quality of our frames, thereby continuing to offer the same level of impeccable quality, Safilo Group Angelo Trocchia adds.

SUSTAINABLE FRAMES

WHAT ABOUT CONTACT LENSES?

Elsewhere, Italian eyewear supplier Safilo, announced in March it will begin incorporating two new materials by global advanced materials manufacturer Eastman – headquartered in the US – in its latest move to introduce more recycled products into its frames.

CooperVision is also working to minimise its environmental impact and operate more sustainably.

Eastman’s Acetate Renew and Tritan Renew materials form part of a broad portfolio of sustainable resins the company produces. Safilo will first use Eastman Tritan Renew in its Polaroid line in January 2022.

The two materials will then be progressively rolled out across its broad portfolio of optical frames and sunglasses, which comprises numerous licenced and proprietary brands.

The Eastman deal follows an announcement in 2020 when Safilo

Contact lenses manufacturing poses one dilemma – but disposal for the end-user poses another. A few years ago, researchers in the US investigating what happens to contact lenses after use surveyed 139 people, including both contact lens wearers and non-wearers. They found that 15 to 20% of contact lens wearers were flushing contacts down the sink or toilet. Discarding contacts lenses in this way may ultimately end up contributing to microplastic pollution in waterways, posing a potential threat to aquatic life.

Another experiment, on 11 different types of contact lenses,

SUSTAINABILITY

found that most lenses are denser than water, meaning they’ll sink.

This could be particularly dangerous for bottom-feeders on the seafloor that may ingest the microplastics from the lenses.

Sydney-based marketing communications manager, Ms Shannon Morrow, says CooperVision is prioritising environmentally responsible practices across four key areas: water, energy, recycling, and people.

“We are working to minimise environmental impact and operate more sustainably, from production improvements designed to conserve water to efforts that recycle nearly 100% of the plastics used in production,” she says.

In 2019, the Puerto Rico Aqueduct and Sewer Authority awarded CooperVision for the fifth consecutive year with its Pre-Treatment Excellence Compliance Award. Given to the company’s contact lens production and packaging facility in Juana Diaz, Puerto Rico, the recognition is based on adherence to operating permit conditions, made possible by ongoing investment in the site’s sustainable infrastructure and employee training.

In the same year, CooperVision launched an initiative in Sweden that offers consumers free soft contact lens recycling for all brands and manufacturers. The company said its contact lens recycle program aims to reduce plastic waste by providing a practical and easy way for wearers to recycle lenses as well as blister and foil packaging.

More recently, the company’s US headquarters in California announced a partnership with Plastic Bank to make CooperVision’s clariti 1 day portfolio of lenses the first net plastic neutral contact lenses.

Plastic Bank is a social enterprise that builds ethical recycling

Zeiss Vision Care, located in Adelaide's Tonsley Innovation District, draws 60% of its electricity from solar, with plans to increase its reliance to 100%.

ecosystems in coastal communities, reprocessing the materials for reintroduction into the global supply chain. Under the agreement, for every box of clariti 1 day distributed in the US, CooperVision funds the collection, processing and reuse of general plastic waste that is equal to the weight of the plastic contained in clariti 1 day lenses and packaging.

Morrow says the program is likely to be expanded into other regions, including Asia-Pacific. n

AVIATION

Keeping an eyeON THE SKY A pilot's suitability to fly can often hinge on the assessment of an eyecare professional. While optometrists play a key role in pilot vision assessments today, it hasn’t always been this way. Insight looks back on optometry’s fight for recognition as aviation eye examiners.

A

s optometrist Mr Tony Gibson flew over Victoria and Queensland in the early 1970s, leaning out the window of a chartered light aircraft to photograph features on the ground, you’d be forgiven for wondering if he’d lost his bearings.

It sounds far removed from the vocation that’s led him to Eyecare Plus Mitcham, Victoria, where he practises today alongside colleagues and optometrist daughter, Riki.

But back then, Gibson had commenced a Master’s degree at the Optometry Department in Victoria commissioned by the Aviation Medicine section of the Department of Civil Aviation. His expertise was called upon after pilots who failed existing visual acuity standards challenged the outcomes, claiming they had been determined arbitrarily and that reading letter charts with or without correction was unrelated to visually navigating an aircraft.

At the time, the Optometry Department and Victorian College of Optometry – under the late Professor Barry Cole – was involved in visual ergonomic research projects investigating colour signals and target movement detection, so the project was a good fit.

After interviewing pilots of varying experience about which terrain features

they used to navigate, Gibson captured the images from above and set up a basic simulation model to test the navigation task and visual acuity on a standard chart with up to 3 dioptres of blur, simulating uncorrected myopia.

In the end, he showed the pilots’ performance worsened around 6/9 and 6/12, but after that it plateaued. He concluded that an uncorrected limit was irrelevant for pilots, as long as they can be corrected to the required standard. Australia’s aviation authorities listened and changed the visual acuity standards, opening an aviation career pathway for many pilots who were otherwise shut out under the old rules.

“The department changed the regulations and said we don’t mind what your uncorrected vision is, as long as you can be corrected – and they also stipulated that you need to carry a second pair of glasses,” Gibson recalls.

“It was estimated that the probability of losing one pair of glasses is 1 in 10,000, and if you’ve got another pair in your bag it’s 1 in 100,000, so there is a better chance of the wings falling off or the engine stopping, so it was decided that it was an acceptable risk.”

FIGHTING FOR RECOGNITION In addition to this work, Gibson was involved in training designated aviation

INSIGHT June 2021 33

AVIATION

medical examiners (DAMES) who needed to complete modules on vision defects and flying as part of their training course (ACCAM). Professor Algis Vingrys was a Qantas pilot in a previous career who had been a subject in Gibson’s initial study and subsequently became interested in optometry as a career. Together, they presented the vision training day to the DAME course participants.

What’s ironic is that – while they could help establish new aviation standards and even run ophthalmic courses to update doctors on vision and eye problems – optometrists weren’t allowed to examine the pilots themselves. This was a job left for designated aviation ophthalmologists (DAOs).

This all changed in 1996 when ophthalmologist Professor Nitin Verma – the current RANZCO president – asked if the ACCAM DAME aviation medical course could be run in Papua New Guinea to train local aviation medical doctors who could not afford to do the program in Victoria.

En route to Port Morseby, the chartered executive jet was being flown by the then aviation medicine director, so Gibson seized the opportunity to point out the fact optometrists were unable to test pilots, despite some being highly trained in relevant fields, such as visual ergonomics.

Eventually, Gibson, South Australian optometrist Mr Neil Murray and Vingrys, were allowed to perform vision exams on pilots in the mid-1990s – a first for the profession.

This small group of optometrists were given the title of ‘designated aviation ophthalmologists’, and then ‘designated eye examiners’. This was until 2011 when the Civil Aviation Safety Authority (CASA) realised the title wasn’t embedded in legislation.

This served as the catalyst for the authority to formalise an agreement with Optometry Australia (OA) to establish a network of credentialled optometrists (COs) trained to conduct vision and eye examinations for pilot licensing.

After playing a considerable part in advocating for optometry’s involvement in aviation eye exams, Gibson and Murray – now a senior lecturer and clinical supervisor at the Flinders University optometry school – began running the course and still curate its material.

Today, the introduction of COs has also meant a greater geographical spread of aviation eye examiners in Australia, something that is closely watched and regulated by OA and CASA. EXAMINING PILOTS To date, there are around 155 COs and 145 DAOs involved in aviation eye examinations for approximately 30,000 Australian pilots and 1,000 air traffic controllers each year.

According to CASA, more than 80% of flight information is acquired by pilots visually from aircraft instruments or through visual information outside the cockpit. Good visual function is necessary for safe performance of most of the aviation activities including pre-flight checks, takeoff, navigation, landing and proper use of displays, dials, gauges, and maps in modern cockpits.

airbus simulator.

Optometrist Tony Gibson with an

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Pilots with

a Class 1 licence (commercial) and Class 3 (air traffic controller) are required to have an aviation eye examination performed by a DAO or CO when they first have their licence issued. Once they turn 60, eye exams are performed every two years. During the intervening years, DAME doctors perform frequent overarching aviation medical exams which involves a rudimentary eye test – if issues are spotted pilots are referred to a DAO or CO for further assessment.

Although visual environment and demands vary with different aviation operations and medical standards, for commercial pilots some of the main criteria include; distance visual acuity of 6/9 or better in each

“WE ALWAYS ADVISE YOUNG COLOUR DEFECTIVE APPLICANTS, ESPECIALLY THE RED DEFICIENT PROTANOPICS, THAT THEIR FLYING CAREER OPTIONS MAY BE LIMITED” TONY GIBSON, EYECARE PLUS MITCHAM

eye separately and 6/6 or better binocular (with or without correcting lenses); being able to read (with or without correcting lenses) an N5 chart binocularly in the range of 30 to 50cm, as well as an N14 chart binocularly (with or without correcting lenses) at 1m.

For contact lens wearers, pilots need to be able to wear them for twice the projected flight or duty time without deterioration in visual acuity or discomfort. Also, the pilot must have backup spectacles available and pass the appropriate standards with them immediately after removing their contact lenses.

Colour perception is also a major factor, and can often be a determining factor in whether a person is fit to become a pilot.

Gibson says if pilots fail the Ishihara screening test, they can be referred for a Farnsworth Lantern test. This test was initially developed 70 years ago for maritime signal recognition and involves showing a pair of vertically oriented lights consisting of combinations of either red, green or white. The test subject is asked to identify the two colours, in nine different parings. If passed, the pilot is regarded as “colour defective safe” but if failed then further tests or an occupational field test can be arranged.

“In some cases, pilots with colour vision issues can get through to gaining their commercial pilot licence but they may never get a job because the employers have the right to demand their own standards and may reject an applicant with a significant colour vision deficit,” Gibson says.

He says this has led to a lot of controversy, with some colour-defective pilots saying better instrument design is required, or correct colour detection isn’t important, and that there shouldn’t be any colour vision regulation.

“I don’t agree with this view,” Gibson says. “A protanopic subject might match a full 100% bright red light with a 30% dull yellow light and declare them to be identical which in my view is a safety issue. Colour displays are common in the aviation industry such as electronic displays, colour coded radar and warning signals.”

“We always advise young colour defective applicants, especially the red deficient protanopics, that their flying career options may be limited.”

“WHEN A PILOT IS AT CLOSE TO 10,000 FEET AND ISN’T USING ADDITIONAL OXYGEN, THEIR PERIPHERAL VISION IS GOING TO REDUCE”

Gibson says visual field loss and glaucoma is a common defect in older pilots, which can have serious ramifications for their careers.

“The question becomes how significant is it, is it going to impinge on their ability to do the job and how often should we be reviewing these pilots? Sometimes their careers are on the line and it can be an important and emotional situation. We always reinforce that CASA are interested in keeping them flying and not stopping them, but it just needs to be in a safe manner,” he says.

NEIL MURRAY, FLINDERS UNIVERSITY

One issue Gibson sees with current testing methods is the use of the binocular Esterman screening test for visual fields. It uses bright targets and binocular viewing and is difficult to fail. He’s seen examples of stroke victims who can obtain a strong 85% seen score and being declared as safe to drive despite missing 50% of their visual field on monocular testing.

“That might be good if you’re testing a grandfather’s ability to drive the car down to the shops but it’s a different issue when you’re in charge of a plane full of passengers,” he explains.

“We always use threshold monocular field tests as a baseline and can now do binocular threshold testing on the Medmont perimeter.

Monocular visual field greyscale maps can also be superimposed to gain an impression of where both eyes share significant losses. This provides a more valid evidence-based result and can inform the CASA aviation medical staff on the area of shared loss from they can determine the operational safety risk of the field defects.”

He continues: “The regulator must establish the likelihood and

consequence of a critical visual cue being hidden by a binocular field loss and determine if a safety issue is present.”

In other cases, Gibson has seen keratoconus patients who can achieve good results with contact lenses but do not achieve the required corrected vision with backup spectacles.

“One pilot could pass with specs in one eye but failed in the other. We did the exam and spelled out the facts in a detailed report explaining that the pilot was binocular with good vision and comfort using his RGP lenses, but a backup spectacle option was not practical for his more affected eye,” he says.

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AVIATION

“He was approved as a commercial pilot to use his monocular backup glasses when required. His limited depth perception with the backup spectacles precluded him from low level flying such as crop dusting or helicopters. He was not interested in these activities and delighted to continue his commercial role as a pilot of twin-engined light aircraft.”

BECOMING A CREDENTIALLED OPTOMETRIST When optometrists subscribe to the CASA credentialled optometry course, Murray – who helped advocate for optometry’s recognition in aviation alongside Gibson – says many often remark on the fact they’re resurrecting knowledge and skills they learned at university.

Physiological issues associated with flight, including hypoxia, fatigue and illusions are taught as part of the course, while optometrists should look for the likelihood of incidents that could occur mid-flight such as a retinal attachment or acute angle-closure glaucoma attack.

an upskilling assessment to satisfy CASA’s contracting requirement to make sure these optometrists remain competent, so it needs to be worth their while.”

Koh says OA intends to run the course every three years.

“From a job satisfaction and scope-of-practice point of view, the optometrists that do see a lot of aviation patients enjoy it,” she says.

“As optometrists we get fixated on visual acuity and ocular disease often, and there are many other functional aspects such as contrast, colour vision, ocular movements, glare sensitivity and visual illusions that are taught at university but don’t get many opportunities to apply that knowledge in the context of occupational vision such as with our aviation patients.”

Alongside Gibson, Murray attends aviation and aerospace conferences to get the most updated information in the field, with the most relevant aspects incorporated into the CO course.

“FROM A JOB SATISFACTION AND SCOPE-OF-PRACTICE POINT OF VIEW, THE OPTOMETRISTS THAT DO SEE A LOT OF AVIATION PATIENTS ENJOY IT”

“When a pilot is at close to 10,000 feet and isn’t using additional oxygen, their peripheral vision is going to reduce, for example, so there is quite a widespread grounding in all these functional issues that are specific to aviation, which isn’t necessarily taught to ophthalmologists who don’t do any aviation specific training,” he explains.

Murray says optometrists need to keep detailed records of their pilot examinations which can be audited. They also need be able to perform tests like gonioscopy and indirect ophthalmoscopy and confirm they have access to equipment such as a contrast sensitivity charts and glare testing equipment.

SOPHIE KOH, OPTOMETRY AUSTRALIA

The introduction of COs, he says, has helped overcome maldistribution of aviation eye examiners, which once meant pilots in isolated areas needed to travel hours to see a DAO. Optometry Australia (OA) national professional services advisor Ms Sophie Koh says CASA is satisfied with the number of COs, but there are still some geographic gaps, particularly in the rural and regional locations near growing airfields.

“And it’s not just defence, but other types of airfields. In regional places like Karratha in WA and Port Lincoln in SA, we have been supportive of optometrists in those areas and the need for them to be credentialled to support the aviation community,” she says.

“In metro CBD areas we tend to have saturation and the question of: ‘why don’t we just accredit everyone that’s interested?’, is always there. The argument is we don’t want optometrists to end up seeing one aviation patient per year. There’s no incentive to do so. There are certain clinical competencies each optometrist needs to upkeep, including familiarity with the aviation standards and CASA’s medical record system and statutory declarations, annual fees and paperwork too.

Prof Qantas pilot-turned-optometrist le). (midd

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Algis Vingrys

She continues: “Optometrists also have to pay a fee annually to maintain their accreditation with us and every four years they need to have

SPACE FLIGHT AND BEYOND An intriguing component of the CO course is the issue of spaceflight, and what role eyecare professionals may play.

Murray says aviation medical examiners are required to be part of the Australasian Society of Aerospace Medicine (ASAM), which is optional for eye examiners. Via ASAM, he’s become involved with the Royal Australian Air Force and completed the ASAM course on space medicine which involved presenters from NASA. In recent years, NASA has been working to solve a major issue with astronauts who return from the International Space Station with lasting changes in their visual acuity, referred to as spaceflight associated neuro-ocular syndrome (SANS).

“The micro-gravity situation in Low Earth Orbit is such that there is no gravitational effect to keep the spinal fluid towards the lower lumbosacral areas of the spine and this fluid moves more towards being within the skull,” Murray explains.

“This in turn raises the intra-cranial pressure on the brain causing a number of structural and functional changes. There is swelling of one or both optic nerves between the brain and the back surface of the globe of the eye. Additionally, there is increased fluid pressure within the orbital fat that is behind the globe of each eye. This pressure flattens that back surface of each eye, reducing the overall length of the eye, and making the astronaut’s eye focus become more hypermetropic. There are also changes within the retina and choroid of the eye.”

Murray says with an impending boom in space tourism, the industry is beginning to think about the potential implications.

“We’re already discussing what happens in a few years’ time when people go into space, and how we should be advising them.” n

ORTHOPTICS AWARENESS

THROUGH THE EYES OF AN ORTHOPTIST In partnership with Insight, Orthoptics Australia is marking this year’s Orthoptics Awareness Week (31 May-4 June) with five articles, themed: ‘A day in the life of an orthoptist – through my eyes’. It features orthoptists who are advancing eye research and contributing to innovative models of care in various clinical settings across Australia.

THE ROLE OF AN ORTHOPTIST IN CLINICAL TRIALS The world of ophthalmic clinical trials is a field I knew little about until undergoing clinical placement at the Lions Eye Institute (LEI) as part of my orthoptics degree in 2018.

Later that year, the experience inspired me to move from Melbourne to Perth to begin my career as an orthoptist.

When I started in the LEI’s clinical trials department I met a friendly team consisting of clinical trial co-ordinators, clinical trials assistants, ophthalmologists and orthoptists. I was one of three orthoptists, but the team has since grown to five, as well as a phlebotomist and a research nurse.

Trials at LEI vary from natural history studies, to pharmaceutical sponsored studies, investigator-initiated trials and external clinical trials. The orthoptist’s role varies from imaging or testing best corrected visual acuity, to coordinating patient visits and maintenance and calibration of equipment.

We’re involved in many multi-centre clinical trials, so to ensure the data is comparable to that being collected elsewhere, protocols and assessment specific manuals dictate the way we conduct our assessments.

Some of these manuals can be lengthy, but they specify how these images need to be captured, labelled, saved and exported. Often the imaging modalities include anterior segment photography, retinal photography using both wide-field and standard retinal cameras, fluorescein angiography, microperimetry and dark adaptometry.

As clinical trials orthoptists at LEI, we also play a unique role in nonophthalmic trials for conditions like cystic fibrosis, kidney disease or various cancers. Often the products under investigation can have side effects in the eye. Alongside a designated ophthalmologist and sometimes an optometrist, orthoptist’s provide a thorough eye assessment and report this to the site running the trial in a timely and succinct manner.

In a pre-trial process, orthoptists are consulted on whether conducting the sponsor-requested assessments are feasible in our clinic, and whether

other assessments are clinically indicated.

When we see patients, we then help explain what it will entail from an ophthalmological perspective. Often patients have only ever been to a primary healthcare provider for their eyes and don’t have problems apart from refractive errors.

Understandably, they’re Imaging forms part of the orthoptist's tasks in studies. sometimes anxious about changes that may occur with their eyes. Our clinical understanding as orthoptists enables us to explain these changes and answer questions they may have.

Globally, new ideas being explored in ophthalmic trials range from a topical therapy for cystoid macular oedema, to a port delivery system that dispenses ranibizumab over a period of months. There are also conversations around the patent expirations of Eylea and Lucentis in the coming years that may result in biosimilars. The world of ophthalmic clinical trials is ever-changing and there’s always something exciting in the pipeline.

ABOUT THE AUTHOR: SACHINEE JAYASURIYA has been working as an orthoptist at the Lions Eye Institute and the Perth Children’s Hospital since graduating from La Trobe University in 2018.

Extended versions of these articles can be found at www.insightnews.com.au

INSIGHT June 2021 37

PLAYING A GREATER PART IN GLAUCOMA PATIENT CARE As part of the orthoptic team at the Royal Brisbane and Women’s Hospital (RBWH), I’m part of a multidisciplinary eye healthcare team, caring for patients with various ocular and systemic health issues.

More recently, the orthoptic team has been involved in the establishment of the Glaucoma Collaborative Care Clinic (GCCC). The aim of the program has been to guide collaborative care of patients who are identified as glaucoma suspects, at risk for future development of glaucoma and early but stable glaucoma patients.

The GCCC enlists the participation of the patient’s community optometrist and GP, to monitor their condition on a regular basis, with less frequent reviews at the hospital ophthalmology department. The RANZCO Referral Pathway For Glaucoma Management guidelines have been the basis for the development of the GCCC protocols. The orthoptists’ role in the GCCC has been twofold: the accurate assessment of patients who may qualify for inclusion in a collaborative care program, and patient education.

The assessment involves key orthoptist skills, including identification of significant family and past ocular history, identification of systemic risk factors, OCT, visual field testing, pupil assessment, colour vision testing, Goldmann applanation tonometry and comparison with iCare tonometry, pachymetry, disc assessment and fundus photography to record disc appearance.

Orthoptists then interpret these results and classification is made according to the RANZCO guidelines. Our assessment is discussed with one of the ophthalmologists and a plan for appropriate patient management is made. If the patient qualifies for the collaborative care program, a report is prepared for the optometrist and GP, detailing our findings and outlining the requirements of the program.

Patient education is another essential skill to develop patient understanding

of their condition or disease risk. We can also reassure the patient of their continued care and clarify how the GCCC program will work to achieve this.

Emphasis is given to the frequently asymptomatic nature of glaucoma and we stress the need to undertake regular testing with the participating optometrist.

Keeping their optometry appointments increases the likelihood of any changes being identified and allows immediate referral back to the care of the hospital ophthalmology team.

The GCCC cares for early stage, suspects and at risk glaucoma patients.

The GCCC at RBWH is yet to have any patients return for routine or early review as requested by their local optometrist. At that point, orthoptists will be again integral to the determination of stability or progression of the patient’s condition, and to continued patient education. The GCCC team are enjoying the development of a collaborative relationship with community optometrists and GPs. References are available in the online version of this article.

ABOUT THE AUTHOR: MARION GAUSSEN is a senior orthoptist at the Royal Brisbane and Women’s Hospital.

She also works in two private ophthalmology clinics in Brisbane. She has been involved in glaucoma care for over 25 years.

BLINDNESS, LOW VISION AND THE ORTHOPTIC ASSESSMENT It’s likely patients will see an orthoptist when first referred to Vision Australia. Our orthoptists are specialists in low vision and blindness and can functionally assess vision, prescribe low vision aids, and provide practical advice.

In most cases, a vision assessment will be the first step. This sets a baseline for understanding their functional and practical vision. The orthoptist will compare the patient’s vision with that of the referring ophthalmologist or optometrist to check for any deterioration.

Our orthoptists can assess the functional vision of a patient carefully and accurately, and have various aids and magnifiers to trial. The focus is on individual needs such as watching TV, studying and playing sport. Many are concerned about reading and up-close tasks, so the orthoptist spends considerable time assessing near vision.

An orthoptic assessment consists of multiple tests, including visual acuity, contrast sensitivity, visual fields and determining how lighting impacts vision. A visual aid may be prescribed, alongside recommendations tailored to the person’s needs at school, home, university or workplace.

An important part is to help the client and their family better understand the underlying eye condition, its implications and visual consequences.

Visual loss can be overwhelming and it’s important to understand patients’ feelings and experiences. We emphasise the options available and reassure them that as a Vision Australia client they will be supported during their life journey with a visual impairment.

Vision Australia’s orthoptic assessment is client-centred and holistic in nature and, as such, doesn’t end when a patient’s functional vision has been determined.

When a patient is unable to read or see things up close, they may also have problems with tasks like cooking, dressing, grooming, shopping and

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keeping fit. Therefore, an initial assessment will, in many cases, lead to them being referred to one of Vision Australia’s 12 specialised services such as an occupational therapist and activities of daily living providers.

It may also include an orientation and mobility specialist to help them move around, and helping them join Vision Australia’s library where they can access thousands of publications via a Wi-Fienabled device or smartphone.

Vision Australia orthoptists devote a lot of time to assessing near vision.

They will also be presented with the latest technologies, along with funding options for services and aids. The orthoptist will help identify if a particular service or a mix of services.

For many people living with vision loss, they’re concerned about what they can’t do. The orthoptist wants to show what’s possible and getting them the right support is a major step in that.

ABOUT THE AUTHOR: NABILL JACOB is the clinical relationship manager at Vision Australia and Orthoptics Australia board member. He’s been a senior orthoptist at St Vincent’s Hospital Sydney, corneal transplant coordinator at the Save Sight Institute and worked in private practices in Sydney.

CLINICAL RESEARCH AND A NEW RETINAL CAMERA Orthoptics is a versatile field with many opportunities. Whether it’s in education, research, private or public settings; it means working with a variety of other individuals and health professionals to deliver the best quality care.

test for Alzheimer’s disease, we hope to fill that gap.

Being an orthoptist is more than just providing eyecare, it requires good critical thinking skills and scientific curiosity.

It could also accelerate research efforts to delay, prevent, or even cure the disease, as scientists take a more targeted and less invasive approach to testing new drugs and treatments.

At the Centre for Eye Research Australia (CERA), orthoptists are involved in world-leading vision research focussing on making a real difference for patients. There are many passionate orthoptists who don’t have a direct patient contact role working in areas like data analysis, research, governance and clinical trial coordination and management.

As a member of CERA’s Ophthalmic Neuroscience Unit, my role includes clinical testing and retinal imaging of research participants using highly specialised technology to assess, detect and monitor various eye diseases.

This information helps us to conduct translational research.

For me, clinical research is not only a fulfilling career that has benefitted my knowledge and skills, it’s also a challenging one – filled with endless hypotheses and possibilities (and ethics applications).

Our team’s focus has been on developing an eye scan that’s cheap, quick and non-invasive for the detection of amyloid beta in the retina.

Amyloid beta, a characteristic of Alzheimer’s disease, is a protein deposited in the brain over many years and recent research has indicated it also accumulates in the retina. Using specialised colour imaging, cameras developed by our team will measure amyloid beta deposits years before signs of cognitive decline. Hence, people at risk could then be referred for confirmatory tests including PET scans and lumbar punctures.

We hope this camera will become a screening test offered as part of a routine eye test by an optometrist or orthoptist, to identify where people are on the risk spectrum and monitor progression. As there is currently no screening

Darvy Dang (left) with CERA's Ophthalmic The test is currently Neuroscience Unit. offered to volunteers in the Healthy Brain Project, a study of healthy middle-aged adults with a family history of Alzheimer’s that aims to identify risk factors. This research brings leading eye researchers from CERA together with Healthy Brain Project investigators, neuropsychologist Dr Yen Ying Lim, of the Turner Institute for Brain and Mental Health, Monash University and neurologist Dr Nawaf Yassi, of the Royal Melbourne Hospital.

The best part of being an orthoptist is working hard to get the best possible outcome for patients or research participants and seeing improvements and happy results.

ABOUT THE AUTHOR: DARVY DANG is an orthoptist and clinical trial coordinator for the Ophthalmic Neuroscience Unit at the Centre for Eye Research Australia.

NO DAY IS THE SAME IN THIS ORTHOPTIST’S CLINIC A clinical orthoptist of six years, I’m currently the orthoptist to Dr Ross Fitzsimons who specialises in strabismus and refractive surgery.

But I also see various patients within my own orthoptic clinic, including managing amblyopia and myopia progression in children and young teenagers, and management options for diplopia. Because the practice has an associated day surgery, I assist the surgeon with post-operative cataract surgery and pre-op IOL corneal markings.

In a multi-doctor practice, my orthoptic clinic serves as a hub for ophthalmologists and their patients to provide comprehensive orthoptic assessment and treatment options. I can spend more time with patients requiring either orthoptic treatment or opinion and thoroughly engage in patient education – essential for best patient care.

To illustrate the benefit of private orthoptic services in a large ophthalmology practice, a recent example was a 77-year-old man with near horizontal diplopia due to convergence insufficiency and a poorly controlled near exophoria secondary to advanced Parkinson’s disease.

Managing this type of strabismus can be difficult as convergence exercises are sometimes ineffective and the risks of strabismus surgery can outweigh the benefits. Practical treatment often involves prism glasses or occlusion. This patient also had moderate nuclear cataracts, blepharitis and dry eyes which may have exacerbated his symptoms. He preferred to stay in a wheelchair due to his risk of falls.

Working with his ophthalmologist, I fully utilised my clinic to relieve his symptoms as much as possible, including a careful refraction with base-in prisms, in-depth patient education and counselling of realistic expectations as well as short- and long-term management. The patient loves reading and preferred to remain binocular, so occlusion was avoided.

With these findings, I provided a full report to the ophthalmologist and our collaboration meant he could read much more comfortably at home.

Our practice is involved in new retinal diseases and glaucoma clinical trials. Many other clinics worldwide are also conducting research in these areas, which means research into strabismus can often be overlooked. Working with Dr Fitzsimons and the strabismus team allows us to attempt to bridge this gap and there is a seemingly endless amount of strabismus and Having his own orthoptic clinic allows paediatric related research areas Linden Chen to better educate patients. to explore. Recently with the combined efforts of Dr Elizabeth Baek, Dr Fitzsimons, Dr Parth Shah and myself, we published our research paper comparing objective and subjective ocular torsion in normal patients, which to our knowledge had not been explored up until now.

There are several follow-up projects planned related to this.

There are many individual and altruistic benefits one may find in orthoptics, with many chances to grow with continuous learning and teaching.

ABOUT THE AUTHOR: LINDEN CHEN obtained his Masters of Orthoptics in 2014 at The University of Sydney and has been a clinical orthoptist at Marsden Eye Specialists for seven years. His interests include strabismus, paediatrics and neuro-ophthalmology.

INSIGHT June 2021 39

RECRUITMENT Wodonga, Victoria.

Nikki Hall, Specsavers Wodonga.

g n i t a u d a r G IN THE COVID-ERA

Deciding to practise in a regional community can expose new optometrists to a variety of pathology and lifestyle opportunities. Two graduates discuss their decision to go regional, and the most important factors when it came to choosing their employer.

T

he year before Ms Nikki Hall embarked on a post-graduate optometry course at the University of Melbourne (UniMelb), her father suffered serious ocular trauma in a rural workplace accident.

“There is no doubt that the graduate recruitment landscape in 2021 is being shaped by the impact of COVID-19 across Australia in the past year,” he says.

He was fencing on their Porepunkah cattle farm in northeast Victoria when a piece of wire struck his eye. Being in a remote area, access to eyecare was limited. It’s an all too familiar story: her father was sent to three different hospitals, before eventually receiving care more than 12 hours later.

“While we aren’t seeing any reduction or difference in the number of graduates being placed in 2021 and we would have liked to have taken on many more, we are seeing more and more graduates join regional locations as the result of less movement and vacancies across metro locations.”

Many years earlier, Hall had completed a biomedical science degree at Deakin before working in research for two years, but she longed for a career with more face-to-face interaction. Her father’s eye injury was all the motivation she needed to pursue an optometry career, with the hope of one day returning to her rural roots to improve eyecare accessibility and inspire others into the industry.

To address maldistribution demonstrated in its modelling, Specsavers has also been intentional in its placement of new graduates. Regional and rural graduates have more than doubled since 2018, with the figure now almost on par with the number of graduates employed in metro stores.

Hall is now fulfilling this goal through a graduate position at Specsavers Wodonga, located on the Victorian side of the border with New South Wales, after graduating from her four-year UniMelb course in 2020.

“During my final year placement at Specsavers I noticed a higher volume of patients, so as a graduate I was excited to be exposed to a lot of different cases and pathology,” she says.

COVID RESHAPING GRADUATE LANDSCAPE According to Mr Raj Sundarjee, director of professional recruitment at Specsavers Australia and New Zealand, Hall is among an increasing number of graduates choosing the rural lifestyle.

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“As you would expect with ongoing border restrictions, interstate movement is also lower. However, positively we are seeing more students open to moving interstate as confidence in border stability grows in 2021,” Sundarjee says.

With this in mind, the company has been evolving its Graduate Program to match the changing optometry landscape. Sundarjee says Specsavers is proud of the initiative, which aims to deliver relevant content, opportunities and support to graduates over two-years.

“The Graduate Program’s dedicated focus on mentorship has never been more vital than over the past 12 months, providing a personal approach to professional development during those first few years as a qualified optometrist,” he says.

“This is complemented by in-store experience practising full-scope

optometry to build upon knowledge and skills, as well as access to professional events, courses, experiences and a wide support network of peers and mentors. There is also a wealth of professional and personal benefits, including being part of an optometry team on the vanguard of clinical benchmarking and technology to deliver industry-leading health outcomes and prevent avoidable blindness.”

For Hall, mentorship played a major role in her choosing Specsavers.

In addition to a relocation allowance and bonus for choosing to work regionally, she was attracted to the franchise model consisting of a partner optometrist and partner dispenser, who offer input from the clinical and retail sides of the business.

“From an optometry perspective, I liked their clinical workflow, having access to pretesting information, as well as the use of OCT and visual fields made me feel more comfortable as a graduate optometrist,” she says.

“I’ve always wanted to move back to the country. Many rural areas can be at a disadvantage when it comes to accessibility to eyecare, it’s nice to feel like you’re contributing to something bigger.”

Liam Hua, Specsavers Mt Gambier.

Basing herself in a regional practice, Hall can also extend her repertoire of skills beyond refraction. She’s seen multiple patients with foreign bodies, and cases of anterior uveitis, optic neuritis, retinal detachment, bilateral disc odema and Sjogren's syndrome.

Choosing the Wodonga store has also meant she’s just an hour’s drive from her Porepunkah hometown. She’s also living with two graduate optometrists from her year who work in other practices in the area – they’ve become a useful sounding board when she returns from work.

CHOOSING REGIONAL OVER METRO After a disrupted year of learning in 2020, recent graduate optometrist Mr Liam Hua placed a greater emphasis on finding an employer who could provide substantial support for his transition into the workforce.

He had offers from other corporates and regional independents, but Specsavers’ mentorship program is what prompted him to accept a position at the company’s Mt Gambier store in South Australia, which has a population of around 28,300.

“I did my placement there and really liked the team, and the community was the type of rural town I was looking for,” he says.

“The mentor program on offer was also appealing in that it was very structured and organised. I felt I needed that extra support after COVID disrupted my learning. The program goes for two years, and you have a senior optometrist in the store to support and guide you, providing advice on certain clinical scenarios and other aspects.”

After completing placements during his final year of post-graduate studies at Flinders University, Hua says it became clear he wanted to work in a regional practice. Like Hall, he was keen to use his full set of skills in a practice with a high patient load. He also knew it would make him available to a larger pool of employers.

“I wasn’t opposed to going to metro areas, but I wanted to develop my skills and clinical acumen further, and in the city, I was sceptical as to whether I’d be able to do that to the same degree,” he says.

“It was about making sure I practise the skills I learned from university.

The scale is quite intense because we service a 50km radius at least, so that’s a lot of patients, pathology, and interesting cases. Decision making is something I also struggled with at university – that was another reason why I leaned toward rural practice, because I’m keen to develop that aspect of being an optometrist.”

Although he wasn’t purely financially motivated, he says the salary was competitive to offers he received from other regional practices. But he was particularly impressed with the responsiveness of the recruiters who provided clarity around such an important decision.

“The recruiter I had was very organised and proactive. They had answers

Specsavers Mt Gambier in South

Australia.

when I needed them, compared perhaps to some other experiences I had. I liked having that level of organisation and response,” he explains.

From a personal point of view, Hua was also ready to be independent and move away from Adelaide where he was raised and studied: “I wanted to be close enough to home where it’s just a drive away (4.5 hours) if I really needed it, but not close enough where I would drive back every weekend, so it was good from a personal development point of view as well.”

He also wasn’t sure what would happen to his social life, but he has been pleasantly surprised with how easily he has integrated into the regional way of life.

“It’s been better than I was expecting which is really nice. I thought it would be a lot harder to meet friends, but I was very fortunate to have a welcoming roommate, a solid community of young professionals, and other people like the Specsavers team who have been supportive and made the transition a lot easier,” he says.

“I actually haven’t had a dull weekend yet. I thought I’d be spending more weekends in at home, but I’ve been out and about, hikes, wild berry picking, BBQs and pubs – I’m probably more socially active here than I was in Adelaide, which is crazy to think.” n

INSIGHT June 2021 41

TECHNOLOGY AND DIGITAL INTEGRATION BREANNA BAN IS A SENIOR ORTHOPTIST AT A NEW SPECIALIST PUBLIC HOSPITAL IN QUEENSLAND WITH A DIGITAL FIRST STRATEGY. SHE DISCUSSES THE EFFICIENCIES, SAFETY AND SATISFACTION NEW TECHNOLOGY BRINGS TO THE CLINIC.

O

ften when performing orthoptic diagnostic testing, patients will express how fortunate they are to have access to advancing technology.

BREANNA BAN

"THESE ADVANCEMENTS IN TECHNOLOGY DECREASE THE CHANCE OF HUMAN ERROR WHEN MANUALLY ENTERING PATIENT DETAILS INTO THE MACHINE"

Having the opportunity to contribute towards a new orthoptic department at the Surgical Treatment and Rehabilitation Service (STARS) – a new public hospital with a digital first strategy – has been an incentive to consider how to capitalise on improving patient care with the use of new digital systems.

STARS is part of Metro North Hospital and Health Service in Brisbane.

In addition to the environmental benefits of a ‘paper lite’ service, there are many clinical benefits associated with continual evolving and emerging technology.

Creating an eye healthcare service model with digital integration provides an opportunity to improve how healthcare is delivered. This begins from the moment the patient arrives at the hospital to check in. At STARS the patient can check in for their appointment through an automated selfservice kiosk by scanning the barcode on the appointment letter or swiping their Medicare card. Once checked in, the clinic is notified of the patient’s arrival and they will be advised by the kiosk of any additional waiting times or if the clinic is running behind.

The patient is also provided the option of having a text message sent to their mobile phone when it’s time to go to the ophthalmology waiting room.

This emergent technology improves patient satisfaction with an option to spend any extra waiting time in the retail and food precinct rather than an ophthalmology waiting room. It also provides clarification of when they can expect to be called through for their consultation. The hospital has support readily available to help any patients unsure about how to check in through this digital system.

Our clinical workflow processes are utilising a software application that indicates the stage of the consultation

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the patient is at. Orthoptists work closely with the ophthalmologist and the introduction of this software has enabled a streamlined method of communication between the professions. The administrative officers, orthoptic team and ophthalmologists have access to an overview of who is seeing which patient in which room and the amount of time spent with the patient. The application enables the orthoptist to write comments regarding the status of the appointment such as ‘waiting for OCT’ which assists with the overall clinical flow and awareness of the patient session.

On completing all assessments, the orthoptist will note on the digital application which room the patient is set up in ready for the ophthalmologist.

The department has implemented a helicopter workflow model where the ophthalmologist will work out of two rooms and alternate between them. This method helps decrease waiting times for patients and considers patient safety by reducing the likelihood of a fall for elderly patients needing to navigate into multiple waiting rooms.

Digital integration within the department assists with efficiency and patient safety. One of the software platforms being utilised in our service enables the patient’s details to be automatically sent across from the patient database to the modality worklist on the ophthalmic equipment.

These names automatically appear in the worklist on the machines once the patient has checked in and then disappear from the machine after their scans are completed.

These advancements in technology decrease the chance of human error when manually entering patient details into the machine, which increases productivity and efficiencies.

During busy clinical sessions with a high volume of patients to see, this digital integration also helps streamline the orthoptic consultation. The orthoptist can spend more time engaging with the patient and has the ability to see a higher volume of patients throughout

The new public hospital – Surgical Treatment and Rehabilitation Service (STARS) in Brisbane.

the session instead of spending time typing all the patient’s details into each machine. Another advantage and workflow efficiency of digital integration is managing the patient’s clinical documentation. All orthoptic clinical documentation is typed directly into the electronic medical records and signed electronically. The department has created auto-text templates to minimise the time it takes to type up these notes and allows the orthoptist to spend more time consulting with the patient.

These digital systems at STARS provide enhanced patient outcomes and experiences by supporting essential face-to-face orthoptic interaction to deliver quality healthcare. n

ABOUT THE AUTHOR: BREANNA BAN is the senior orthoptist at the Surgical Treatment and Rehabilitation Service (STARS). STARS is newly opened specialist public hospital with a digital first strategy. The service is part of Metro North Hospital and Health Service (MNHHS) in Brisbane, Queensland.

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

DISPENSING

TRAINING SURGE – A RAY OF LIGHT AUSTRALIAN OPTICAL DISPENSING IS AMID ONE OF ITS MOST TRANSFORMATIONAL PERIODS THANKS TO A FORTUITOUS TRAINEE WAGE SUBSIDY PROGRAM. TRAINER VIRGILIA READETT EXPLAINS THE IMPACT IT’S GOING TO HAVE.

I

f knowledge is power, by extension the current surge in optical dispensing training will empower individuals and their workplace.

VIRGILIA READETT

"CUSTOMERS WILL RECEIVE FAR BETTER SERVICE, BUSINESSES WILL GENERATE A HIGHER RATE OF SALES WHILE REDUCING NONADAPTS AND WASTAGE"

The incentives for training and the incredible take up across the optical industry have been one of the positives to come out of 2020.

As an example of this, Australasian College of Optical Dispensing (ACOD) founder and director Mr James Gibbins has told me the college has seen an increase in enrolments every year since launching five years ago, even though this was modest for much of 2020 due to COVID-19.

But since October, the enrolment rate has taken off due to the Federal Government traineeship support program (Boosting Apprenticeship Commencements – BAC) and this enrolment increase is continuing right now due to a recently announced extension.

How have individual students been affected? For many, these training incentives mean an opportunity for training they may not have had, or at least had so soon.

Also, if we increase the skill base by qualifying optical assistants to become optical dispensers, customers will receive far better service, businesses will generate a higher rate of sales while reducing non-adapts and wastage. The lens labs will receive a higher quality of ordering and reduced demand for warranty replacements, and the dispensers themselves will no doubt experience a higher degree of confidence, job satisfaction and sense of professionalism.

Current ACOD student from Tasmania, Mr Oliver Burdon, explained to me that completing his Cert IV was something he’s wanted to do since starting in optics.

For him, the BAC subsidy made it more alluring for his employer, and probably accelerated the process. But, one way or another, he would have looked to enrol at some point and gain the qualification.

When asked what this qualification will mean for him personally Oliver said: “It means a solid knowledge base and gives me the confidence to help train my

The Australasian College of Optical Dispensing has welcomed hundreds of new enrolments this year.

optical assistants to an industry standard.

It will help open doors for my career and will open the gates to further study and qualifications in the industry. Gaining my Cert IV will lead me to a greater appreciation of what I’m dispensing dayto-day and allow me to work closer with my optometrist and lab.”

This positivity spreads. Empowering individuals will also benefit their team, their practice, and their customers. Mr Haydn Williams, optometry partner at Specsavers Charlestown, NSW, who currently has three team members enrolled with ACOD, has told me his team members will have increased autonomy in their roles.

He also believes they will have greater confidence to work as an individual within a team which should have a flow on effect to new employees. Greater confidence and increased ability to help people will also equal increased satisfaction. Armed with greater knowledge and increased responsibility, he says it’ll also give his staff a greater sense of pride in their work.

But why is this so important and so exciting? Because of the quality of service our customers will receive. The reason we do what we do – to assist the wider community to access their best vision.

Haydn’s prediction for his customers was: “better bespoke advice and increased ability to help efficiently.”

COVID fast tracked innovation in many industries including the training sector. For students like Oliver, he’s studied in person and online through different providers over the years and he’s now found he’s nailing the balance between online and in person teaching through ACOD. Like many other students, he likes the structure of learning at his own pace between workshops. Information is easily accessible, and if he gets stuck, the teachers are an email away.

To cope with the surging demand in enrolments, James Gibbins and the team at ACOD have responded swiftly and increased capacity significantly in recent months. We’re aware that we’re working in the midst of a transformational period for our industry, one that will see literally hundreds of qualified optical dispensers released into our industry over the next couple of years, re-invigorating our industry for years to come.

The future of dispensing is bright indeed, for business, employers, employees, and customers. n

VIRGILIA READETT teaches with ACOD and has been in optics since 2012. She holds a Certificate IV in Optical Dispensing, Certificate IV in Training & Assessing, and a Bachelor of Arts majoring in Communications.

INSIGHT June 2021 43

MANAGEMENT

SEXUAL HARASSMENT: COULD YOU BE LIABLE? SEXUAL HARASSMENT HAS RECEIVED A LOT OF MEDIA ATTENTION IN RECENT MONTHS. MANAGING CASES IN THE WORKPLACE CAN BE CHALLENGING. AVANT’S SONYA BLACK EXPLAINS WHAT IT IS AND EMPLOYERS' LEGAL OBLIGATIONS.

C

hloe has just started working as an optometrist in an exclusive city practice owned by Fred.

Fred asks his senior optometrist, Barry, to mentor Chloe.

SONYA BLACK

"AN EMPLOYER CAN BE LIABLE FOR SEXUAL HARASSMENT IF THEY HAVE NOT TAKEN APPROPRIATE STEPS TO ELIMINATE OR MINIMISE THE RISK"

During his initial meeting with Chloe, Barry makes suggestive comments, including: “You, my dear, have the most beautiful figure” and “I cannot believe that a woman like you doesn’t have a husband.”

Chloe laughs off the comments. But, gradually, Barry starts to make lewd jokes.

Chloe finds Barry’s jokes offensive but doesn’t want to create a fuss given she just started in the business.

Barry starts sending Chloe text messages outside work hours, including: “I can’t stop thinking about you”, “What are you doing tonight?” and “Fancy a drink?”.

Chloe reports Barry’s behaviour to Fred.

Fred dismisses her concerns and says, “Oh, don’t worry about Barry. He’s a good guy but sometimes he takes things too far.

Just ignore him.”

WHAT IS SEXUAL HARASSMENT? Under Australian law, sexual harassment is conduct that needs to meet three elements. It must be: 1. Unwelcome.

2. Of a sexual nature.

3. T hat a reasonable person (aware of the circumstances) would anticipate it could possibly make the person experiencing the conduct feel offended, humiliated or intimidated.

Sexual harassment is unlawful under discrimination legislation in areas including employment, service delivery, accommodation and education.

In certain circumstances, sexual harassment may be a criminal offence.

Sexual harassment laws do not prevent workplace relationships based on mutual attraction or consensual behaviour.

WHAT ABOUT BARRY’S BEHAVIOUR? 1. Was Barry’s behaviour unwelcome?

This will depend on how Chloe perceived Barry’s behaviour. It is clear from the scenario that Chloe did not welcome the comments, jokes and texts even if she

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laughed off the initial comments. The first element has been met. It is irrelevant that Barry’s behaviour may have been fine with other people in the business (such as Fred) or was an accepted feature of the workplace in the past.

2. Was Barry’s conduct of a sexual nature? Under Australian law, conduct of a sexual nature includes: • Making an unwelcome sexual advance or request for sexual favours.

•E ngaging in other unwelcome conduct of a sexual nature (including making statements of a sexual nature to a person or in the presence of a person, whether verbally or in writing).

It can include physical and non-physical conduct, as well as in person or through social media. Some examples include: • Staring, leering or unwelcome touching.

•S uggestive comments or jokes.

•U nwanted invitations to go out on dates or requests for sex.

Sexual harassment can occur via social media.

COULD FRED BE LIABLE? Yes. An employer can be liable for sexual harassment if they have not taken appropriate steps to eliminate or minimise the risk of sexual harassment.

These steps include: •U ndertaking a risk assessment.

• I ntrusive questions about a person’s private life or body.

•D eveloping a clear policy.

• Unnecessary familiarity, like deliberately brushing up against a person.

•E nsuring compliance with the policy.

•E mailing pornography or rude jokes.

•D isplaying images of a sexual nature around the workplace.

Barry’s behaviour falls into the category of conduct of a sexual nature, so the second element has been met.

3. Would a reasonable person consider Barry’s conduct could have offended, humiliated or intimidated Chloe?

Unwelcome conduct of a sexual nature will constitute sexual harassment if a reasonable person who was aware of the circumstances would anticipate the possibility that the recipient would feel offended, humiliated or intimidated. It doesn’t matter that Barry may not have intended to offend, humiliate or intimidate Chloe.

Barry’s behaviour will constitute workplace sexual harassment even though he sent texts to Chloe’s personal mobile phone from his personal mobile phone. Once again, Barry’s behaviour ticks the sexual harassment boxes so now all three elements have been met.

•T raining staff.

•D eveloping a process for managing complaints.

Fred can find further information in the Australian Human Rights Commission’s Endling workplace sexual harassment: a resource for small, medium and large employers and Sexual Harassment: Know where the line is. He should also refer to Safe Work Australia’s Preventing workplace sexual harassment: national guidance material.

Ultimately, Fred needs to take Chloe’s complaint seriously, investigate and take appropriate action depending on the findings. He should protect Chloe by appointing another mentor and rostering Barry and Chloe separately (if possible) until the investigation is complete.

Fred can also call his medical defence organisation for specific advice. n

SONYA BLACK is Avant’s Special Counsel, Employment. With over 20 years’ experience as an employment lawyer, she advises doctors and medical practices across Australia on a broad range of employment issues.

2021 CALENDAR JUNE VISION EXPO EAST New York, USA 2 – 5 June east.visionexpo.com

ASO EXPO 2021 Melbourne, Victoria 4 – 6 June Info@asoeye.org

5TH ASIA-PACIFIC GLAUCOMA CONGRESS Virtual 4 – 8 June apgc2020.org

MIDO EYEWEAR SHOW Virtual 5 – 7 June mido.com

OPTOMETRY VIRTUALLY CONNECTED Virtual - Australia 18 – 20 June ovc.delegateconnect.co

9TH WORLD GLAUCOMA E-CONGRESS Japan 30 June – 3 July worldglaucomacongress.org

JULY SYDNEY EYE HOSPITAL ALUMNI MEETING Sydney, Australia 23 July ranzco.edu

To list an event in our calendar email: myles.hume@primecreative.com.au

AUGUST

NOSA ANNUAL CLINICAL AND SCIENTIFIC MEETING

OPHTHALMOLOGY UPDATES!

Canberra, Australia 30 September – 3 October kathpoon@bigpond.com

Sydney, Australia 28 – 29 August ophthalmologyupdates.com

SEPTEMBER O=MEGA21 Melbourne, Australia 2 – 4 September omega21.com.au

SILMO PARIS Paris, France 24 – 27 September en.silmoparis.com

OCTOBER AUSCRS 2021 Noosa, Australia 20 – 23 October www.auscrs.org.au

NOVEMBER RANZCO ANNUAL SCIENTIFIC CONGRESS Brisbane, Australia 19 – 23 November ranzco.edu

SPECSAVERS – YOUR CAREER, NO LIMITS Full-time Optometrist Opportunity – Specsavers Glendale, NSW Specsavers Glendale has a full-time optometrist opportunity. This store has a patient focused mentality which can be seen by its investment in the latest technology and focus on team development. Glendale has a focus on team culture and development which you can see in their supportive and friendly store. Rosters will include weekend work which is rotated amongst the optometry team.

All Specsa ve stores rs no with O w CT

Full-time Opportunity – New Zealand Thinking of a sea change, or want to return to NZ? With 56 stores across New Zealand Specsavers has an abundance of opportunities for experienced optometrists. Whether you enjoy the hustle and bustle of city life, or prefer the relaxed outdoor lifestyle, we can offer you the perfect location. At Specsavers you will be working with the latest technology, including an OCT in every Specsavers NZ store.

SPECSAVERS HIGHEST MOBILE OPTOMETRY PACKAGE EVER! Specsavers is looking to grow our community based Mobile Optometry Teams in WA, QLD & ACT. You will experience a diverse demographic of patients and see a wide variety of cases, whilst being able to explore different regions of Australia. We are looking for optometrists with a minimum of 3 years’ experience who have the desire and flexibility to travel. As a Specsavers optometrist, you will work with state-of-the-art equipment, receive a fantastic salary package including benefits and continuous support towards your ongoing professional development.

Graduate Opportunities – Western Australia The Specsavers Graduate Recruitment team are currently recruiting for a number of vacancies in Perth, WA. If you relocate with friends, you will avail of our ‘Go with a Friend’ incentive. Whether it be for a new challenge, or perhaps starting afresh and relocating for different lifestyle – a move to Western Australia could be your first step in strengthening your professional career. All Specsavers stores are equipped with the latest optometry equipment including OCT, and you will gain exposure to a wide range of pathology across a loyal patient base.

Opportunity for an experienced Optom to earn over $200K! Specsavers Emerald has an exciting opportunity for an experienced Optometrist looking to take the next step in their career. 2-test room store with state of the art equipment - including OCT, the opportunity to mentor graduates and final year students, supportive and welcoming team to help you settle into the community along with a loyal patient database and mixed demographic including pathology. Not sure if partnership is right for you? Why not try before you buy! Full time permanent or 12-24-month fixed term can be discussed. Relocation support available.

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: Joint Venture Partnership (JVP) enquiries: Marie Stewart – Recruitment Consultant

marie.stewart@specsavers.com or 0408 084 134 Australia Employment enquiries: Madeleine Curran – Recruitment Consultant

madeleine.curran@specsavers.com or 0437 840 749 Locum employment enquiries: Cindy Marshall – Locum Team Leader

cindy.marshall@specsavers.com or 0450 609 872 New Zealand employment enquiries: Chris Rickard – Recruitment Consultant

chris.rickard@specsavers.com or 02 7579 5499 Graduate employment enquiries: apac.graduateteam@specsavers.com

SOAPBOX

TRAINING IS EVOLVING WITH THE TIMES me was to always give of your time and energy wholeheartedly because those who do are more than compensated for their effort.

In my years working at Sydney Eye Hospital, I saw this in the culture of teaching. Every day one or more consultants gave dedicated teaching, often out of their own time.

This generosity was not lost on the students, who as a result, put real effort into their learning. I also think of my own mentors who made themselves available with their time and sage advice. This has had a great influence on my willingness to devote time and effort to my trainees.

W

hen asked to write this piece on training I had to reflect on the moments in my career that led to training being such an integral part of what I do. Small things that add up over a lifetime and mould you. Partly it was luck and opportunity, having great leaders and mentors, and having a partner who was also passionate about teaching.

I also reflect on what I have learned by teaching and about teaching. I now realise what I thought was an effective style of training in the past looks very different today. I wonder what else needs to change in the coming decades of my career to ensure the training of the next generation of eyecare professionals is even better than before.

Teaching and learning styles are rapidly changing, and – for the most part – for the better. I recall my first degree was taught in a typical didactic fashion. So, when I started medical school some years later, I was excited to experience a totally new style of learning, which was group-based problem solving. We, the students, were encouraged to determine what we needed to know and seek those answers. What I realised at that time was that if learning is exciting and selfdriven it becomes passionate learning

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and thereby deep learning. I took this forward with the motto that everything I taught should be relevant and rousing.

But we now know that passionate teaching alone may not be enough.

Whereas when I first graduated, medical education was somewhere between didactic learning and an informal apprenticeship, now it is becoming a true science, with a large body of literature to guide it.

Gone are the days of “eminencebased teaching” and to replace it is evidence-based teaching.

The example that comes to mind is that of “pimping”. This is the common practice of asking students increasingly difficult questions, on the spot, until they fail. A kind of trial by fire or a form of hazing disguised as educating.

The weight of pedagogical evidence shows that this style of teaching is both ineffective and actually leads to harm to those being “pimped”.

When I was made aware of the body of literature around this, I was forced to change my teaching style and now I actively avoid this in favour of a more guided learning style.

My other great influence has been my mentors and these great men and women taught me many things. The summary of what they passed on to

Lastly, when I am choosing topics to teach, I try to give thought to the curriculum I am creating. I am aware that selecting topics I think are important is a trap and that it is more important to cover topics that will actually be of use to the student in front of me, not a generic syllabus.

This can be achieved by not only finding out where a particular trainee’s understanding is at, but also where they want to take it.

Teaching for me is a joy. The variety is the spice that keeps my week interesting: optometry students, therapeutics candidates, medical students and ophthalmology registrars.

We are privileged in medicine to have the opportunity to teach. We are also living through a time of meaningful change in health education. By combining care for our trainees, passion for teaching and evidencebased education I derive great pleasure and I hope my experience inspires others too. n References are available in the online version of this article at www.insightnews.com.au.

Name: Dr Nick Toalster Qualifications: BAppSci Optom (Hons), MBBS (Hons), FRANZCO Business: Okko Eye Specialists and Royal Brisbane & Women’s Hospital Consultant Position: Ophthalmologist Location: Brisbane Years in profession: 15

MEDICAL EDUCATION WAS SOMEWHERE BETWEEN DIDACTIC LEARNING AND AN INFORMAL APPRENTICESHIP, NOW IT IS BECOMING A TRUE SCIENCE

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and are the most prescribed eye drops for glaucoma in Australia1 Xalatan and Xalacom are now proudly brought to you by Aspen.

Made by the original manufacturer.

✔ Include brand name on script

✔ Brand substitution not permitted

If clinically necessary for the treatment of your patients, consider prescribing by brand.

PBS Information: Xalatan (latanoprost 0.005% eye drops, 2.5 mL) and Xalacom (latanoprost 0.005% + timolol 0.5% eye drops, 2.5 mL) are 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.

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 09 December 2019) Minimum Product Information: XALACOM® (latanoprost 50 µg/mL and timolol 5 mg/mL) Eye Drops. Indication: Reduction of intraocular pressure (IOP) in patients with open-angle glaucoma and ocular hypertension who are insufficiently responsive to other IOP lowering medications. Should not be used to initiate therapy. Contraindications: Reactive airway disease including bronchial asthma (or history), or severe chronic obstructive pulmonary disease (COPD). Sinus bradycardia, sick sinus syndrome, sino-atrial block, second or third degree atrioventricular block, overt cardiac failure, or cardiogenic shock. Hypersensitivity to ingredients. Precautions: Beta-blocker systemic effects: cardiovascular/respiratory reactions; first degree heart block; cardiac failure; severe cardiac disease; severe peripheral circulatory disturbance/disorders; mild/moderate COPD; consider gradual withdrawal prior to major surgery; Beta-blocking ophthalmological preparations may block systemic beta-agonist effects (inform anaesthetist); history of atopy or anaphylactic reaction; caution in hypoglycaemia or diabetic patients, hyperthyroidism, myasthenia gravis; concomitant beta-blocker or prostaglandin not recommended. Ocular Effects: 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; herpetic keratitis; filtration procedures; corneal diseases; contact lenses; elderly; children; driving or using machines. See full PI for details Pregnancy: Do not use in pregnancy (Pregnancy Category C) Lactation: Do not use in breast feeding mothers. Interactions: oral calcium channel blockers; catecholamine-depleting drugs or beta-adrenergic blocking agents; antiarrhythmics; digitalis glycosides; parasympathomimetics; narcotics; monoamine oxidase (MAO) inhibitors; CYP2D6 inhibitors; adrenaline; antidiabetic agents; thiomersal. See PI for details. Adverse Effects: For complete list see full PI. Ocular: eye irritation; hyperaemia; abnormal vision; visual field defect; iris hyperpigmentation; eyelash and vellus hair changes; conjunctivitis; blepharitis; corneal disorder; eye pain; keratitis; photophobia; cataract; conjunctival disorder; errors of refraction; macular oedema; corneal calcification; corneal oedema and erosions; blurred vision; dry eyes; periorbital and lid changes resulting in deepening of eyelid sulcus; darkening of skin of eyelids, skin reaction on eyelids; diplopia; ptosis; choroidal detachment (following filtration surgery). Systemic: Serious respiratory and cardiovascular events (e.g. worsening of angina pectoris, atrioventricular block, cardiac failure, cardiac arrest, respiratory failure, pulmonary oedema, asthma); herpetic keratitis; chest pain; anaphylaxis; skin rash; headache; depression; myalgia; arthralgia; dysgeusia; vomiting; abdominal pain; sexual dysfunction. 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 21 February 2020) References: 1. IQVIA Dec 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: February 2021 AF05537 ASP2433