Reforms to optometry Medicare items are coming in 2025, but do they go far enough? 18
CREATING JEWELLERY FOR THE FACE
Why eyewear from a South Australian workshop is landing on the faces of global celebrities
AUSTRALIAN CATARACT SURGERY UPDATE
The key moments that sparked the refractive cataract surgery movement
Paediatric Myopia, Keratoconus, Diabetic Retinopathy and Inflammatory Eye Disease.
These are just some of the topics confirmed for this year’s Specsavers Clinical Conference.
Bringing together optometry and ophthalmology professionals from across ANZ, with up to 20+ hours of CPD available across two days, this event is not to be missed.
Book your tickets now at: specsaversclinicalconference.com.au
September 14-15
Gold Coast + livestreamed across ANZ
OPTOMETRY MEDICARE CHANGES COMING INTO EFFECT EARLY 2025 REVEALED
Funding to implement a raft of recommendations from a review of optometry Medicare items – most notably an additional visual field test within a 12-month period –has been granted by the Federal Government.
As part of its Federal Budget 2024-25, handed down in May 2024, the government revealed it had accepted the majority of the recommendations made by the MBS Review Taskforce relating to optometry items; the latest in a process that has taken several years.
The changes will come into effect from 1 March 2025 and are a win for the sector, said Optometry Australia, which had been “actively advocating” for the changes.
One of the biggest changes is a new item for a third visual
field test in a 12-month period for patients with a high risk of glaucoma progression.
“It’s pleasing to see that the association’s advocacy has been impactful,” said OA CEO Ms Skye Cappuccio.
“These are positive changes, particularly the introduction of a third annual visual field item, the removal of the same practice requirement for billing 10912 and 10913, and removal of co-claiming restrictions on domiciliary visits.”
(See breakout box on page 8 for more details).
However, further changes were “sorely needed” to better align optometry Medicare fees with the cost of providing care. OA’s estimates drawn from analysis of practice costs indicate the actual cost of providing a comprehensive
The Federal Government says it is investing $8.5 billion of new money into health this budget. Image: Pada smith/stock.adobe.com.
consultation in a sustainable business model is over $50 more than the Medicare scheduled fee. Cappuccio said this remained a focus of OA’s ongoing advocacy.
OA would also continue to push for an increase to the domiciliary item fee to better reflect the true cost of travelling and providing care outside of practice, she
GEORGE & MATILDA SURPASSES 100 PRACTICES WITH BIGGEST ACQUISITION TO DATE
George & Matilda Eyecare
(G&M) will pass the 100-practice milestone with the acquisition of 26-practice optometry network, National Optical Care.
The acquisition, subject to key terms of the transaction being met, is G&M's biggest yet and coincides with its eighth anniversary. Previously, the network's largest purchase was one of its very firsts: Eyelines, a 10-practice business in Tasmania in 2016.
In the National Optical Care deal, while business ownership will change, its practices will retain their local brand identities and there will be no changes to its team or their employment conditions, a
joint- statement said.
Once completed, the G&M network will increase to more than 120 practices, servicing over 140 communities through its various outreach programs, employing more than 600 people across Australia.
“I am delighted to announce the merger with National Optical Care,” G&M CEO Mr Chris Beer said. “This merger creates a much larger community of like-minded optometry practices.
“Our investment allows our partners to continue to grow, while giving them access to back-end support like best-available technology, data analytics, targeted marketing, human resource
support, increased buying power and supply chain support.”
He added that G&M supported its partners in maintaining their local clinical independence.
“Everyone is unique and independent and that is just the way we want it to stay.”
National Optical Care entered the scene a few years ago after acquiring its first 14 practices between November 2020 and January 2021. Around the same time, it formed a partnership with the EyeQ Optometrists, bringing a total national network of 40 practices for the combined entity.
page 8
said. The organisation believes increasing the optometric domiciliary loading to $85.00 per visit (paid proportionally for multiple patients) would ensure the ongoing provision of timely and affordable access to eyecare for elderly Australians in aged care.
Currently, a domiciliary visit performed on one patient at a single location on one occasion (item 10931) attracts a fee of $25.65 and a benefit of $21.85 (85%).
Additionally, OA said it was working with relevant experts to consider Medicare changes necessary to support effective myopia management.
Revamping the optical events calendar
The latest from the Optical Distributors and Manufacturers Association (ODMA)'s O-SHOW24 in Sydney, as well as plans to bring back the popular ODMA Fair from 2025. page 51
Image: ODMA.
• Experience chamber stability independent of IOP and flow
• Virtually eliminates post occlusion surge: IOP recovery in about 200ms
It’s been 75 years since Sir Harold Ridley implanted the first intraocular lens –produced by Rayner.
41 Operation inflammation
AUSCRS 2024
Why international speakers are lining up to present at the Australian ophthalmology event on Hamilton Island.
Hannah Peltzer breaks down the essentials for optometrists when confronted with a case of uveitis (0.5 CPD).
48 Tailored experience
How independents can find financial stability and patient loyalty through their progressive lens offering.
It’s fascinating to think about how healthcare will be delivered in future, and recently I had two encounters that made me realise we are on the
The first occurred at a recent audiology conference where one of the major provider networks showed me how a patient requiring a hearing aid adjustment can open an app and connect in a video call with the hearing professional. From there, the hearing aid can be tuned from the
The second experience saw me visit an OPSM store in Sydney where EssilorLuxottica took me through its new remote optometry service (more details to come in a future edition). In this model, regional patients visit their nearest OPSM where a technician performs testing before the optometrist tunes in via videolink to run the consultation. It’s helping reduce the wait time for routine eye exams by increasing the availability of eyecare in under serviced communities.
New ways to deliver eyecare more efficiently and effectively is a hot topic in the ophthalmic industry. Travelling to appointments is one of the biggest barriers, especially for chronic conditions. The key is striking the balance between what tests need to be done in person, and what can be done at or near home by the patient themselves or ancillary staff.
There’s implications for the workforce too. Working from home is now commonplace for the office worker, and could be soon for optometrists. With new-found flexibility, think what remote optometry could mean for a practitioner who is immunocompromised, returning from a workplace injury, or has young children. Removing the need to see patients in-person or commute will ensure more optometrists can practice, while making the profession more attractive.
It's also interesting to think about potential productivity gains later down the track, where optometrists with a quieter day can pick up appointments in other suburbs. Australia’s timezones mean an eastern optometrist could work later in the day and service WA too.
With Specsavers also working on remote optometry, it seems the technical hurdles have largely been addressed. The next step is scaling up and perhaps convincing policymakers that remote optometry should be covered by Medicare. This will create greater equality for regional and remote Australians subjected to the 'tyranny of distance'.
MYLES HUME Editor
UPFRONT
Just as Insight went to print, Mr MARK VAN STAVEREN , a well known Australian optical industry figure, passed away after battling cancer. He died on 31 May 2024, two days after his 64th birthday. As well as being a partner in VS Eyewear alongside his brother John, he was an accomplished optical dispenser and owner of Hastings Optical, which he established in 1988 in the namesake regional Victorian town. He leaves behind his wife Carolyn, sons Alex and Adrian, daughter Tessa, and two grandchildren.
WEIRD
Eye drops have been shown to shrink cataracts in animal models. After six weeks of treatment with lanosterol, lens cloudiness and cataract size decreased in dogs. Similar results were seen in experiments with human lens cells and rabbit lenses on lab dishes. “The most important implication is that we can treat cataracts with an eyedrop, not surgery,” the researchers told Live Science
WONDERFUL
A 91-year-old man has made history by becoming the first patient in England to receive a certain artificial cornea. Mr Cecil Farley underwent an endothelial keratoplasty to receive the EndoArt artificial cornea by EyeYon Medical. Only 200 have been implanted globally. EndoArt is reportedly the first artificial endothelial layer for select eyes with chronic corneal oedema.
WACKY
IN OTHER NEWS , a new study has shown COVID-19 can breach the blood-retinal barrier (BRB) during systemic infection and damage the eye. In PLOS Pathogens, the researchers suggested SARS-CoV-2 ocular exposure does not cause lung infection and moribund illness despite the extended presence of viral remnants in ocular tissues. In contrast, intranasal exposure induced a hyperinflammatory immune response in the retina. They also found long-term exposure impacted visual function of mice, and the spike protein caused microaneurysms, retinal atrophy, RPE mottling, and vein
occlusion. FINALLY, specially-trained optometrists can deliver selective laser trabeculoplasty (SLT) safely for glaucoma, a paper published in Eye by Moorfields Eye Hospital and UCL’s Institute of Ophthalmology has revealed. The program included six glaucoma-specialist optometrists across 240 laser procedures. It found 100% compliance with procedures, while one eye (0.4%) developed post-laser corneal haze and another (0.4%) cystoid macular oedema; both resolved without permanent impact. Nine eyes (3.7%) had an IOP spike. There were no sightthreatening adverse events.
Buyers and sellers of independent optometry practices in Australia can expect the business to be worth 2.8-3.5 times the net profit. Page 59
Complete calendar page 60
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Researchers have developed the first 3D printable ocular resins with the potential to offer more complex and customisable IOL designs. In the study published in Current Eye Research, the researchers created lens-like 3D objects using stereolithography. The lenses were found to have good clarity, biocompatibility, and were foldable when injected into a human lens capsule.
24 – 27 July
2024
The popular Australian Society of Cataract and Refractive Surgeons conference is heading to Hamilton Island, an ideal winter get away for ophthalmologists and other practice staff. office@auscrs.org.au
24 – 25 August
The conference is a chance to brush up on common subspecialty topics ophthalmologists may be curious, or have forgotten, about. ophthalmologyupdates.com
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INDEXATION FREEZE ON COST OF PBS MEDICINES
continued from page 3
Addressing ‘placement poverty’ In other Federal Budget announcements, the government established the Commonwealth Prac Program, effective July 2025, to provide students studying teaching, nursing, midwifery and social work funding for placement experience.
Expected to benefit 68,000 students in these professions with a $320 weekly payment during their mandatory placements, the measure excluded optometry – a profession on the 2023 Skills Priority List.
Allied Health Professionals
Australia (AHPA) CEO Ms Bronwyn Morris-Donovan said it was a step in the right direction but highlighted that optometry was among jobs listed on the 2023 Skills Priority List that would not receive this funding.
“’Placement poverty’ is real for many students of other allied health disciplines where mandatory placements are just as extensive, if not more,” she said.
Cappuccio said OA recognised the challenge of maintaining a liveable income confronted many optometry students on placements and it was advocating for this program to be extended to support the profession.
Other highlights from the health budget affecting the ophthalmic sector include funding to support the government’s commitment to index Medicare items from 1 July 2024.
There’s also a one-year freeze on
Optometry Medicare changes coming into effect 1 March 2025:
• C omprehensive consultations: Combine items 10912 and 10913 and remove the same practice restriction.
• Visual fields: Introduce a third computerised perimetry test in a 12-month period where indicated by the presence of glaucoma with a high risk of clinically significant progression. Reword the explanatory notes to emphasise the need for providers to clearly document the rationale underlying the need for the practitioner to perform a computerised perimetry test.
• Domiciliary visits: Items 10931 to 10933 will be replaced with a single item covering all domiciliary visits. The co-claiming restrictions on domiciliary visits will be removed, enabling the billing of a short consultation (10916 and 10918) and computerised perimetry (10940 and 10941) at domiciliary visits.
• Contact lenses: Combine items 10921, 10922, 10923 and 10925 into one item number and reword the explanatory notes to remove the requirement to deliver the lens.
• Foreign body removal: Amend the descriptor for item 10944 to clarify the requirement for complete removal of the rust ring with a ferrous embedded foreign body, and to provide more clarity around when this item can be claimed.
• Residual vision: Amend Item 10942 to reflect current best practice for testing of residual vision.
Source: Optometry Australia.
maximum PBS co-payments, affecting patients who access eye drops for glaucoma and dry eye, among other diseases, as well as intravitreal injections for macular disease. It means the price will remain at $31.60, or $7.70 per medicine for concession card holders and pensioners.
“So, medicines stay cheaper, instead of rising with inflation,” Federal Health Minister Mr Mark Butler said.
Regarding public hospitals – where cataract surgery wait times remain an ongoing issue – the government will provide more funding to state-run facilities from 2025–2030, increasing the Commonwealth contribution to the cost of care to 45%, from around 40%, over the next 10 years.
Overall, Australian Medical Association
“THIS IS A WIN-WIN POLICY, WITH AN APPROXIMATE 20% HEALTH LEVY ON SUGARY DRINKS RAISING AROUND $1 BILLION EACH YEAR.”
PROF STEVE ROBSON, AMA
(AMA) president Professor Steve Robson said there was little that was new in this year’s budget, representing “a real loss of momentum” towards a more efficient and sustainable health system. He cited preventive health as one of the biggest losers, with a missed opportunity to raise billions of dollars by introducing a sugar tax on sweetened drinks. It’s a move the Australian Society of Ophthalmologists supports due to the impact of type 2 diabetes on vision loss.
“This is a win-win policy, with an approximate 20% health levy on sugary drinks raising around $1 billion each year – money that could be invested into measures that reduce pressure on our stretched health system,” Robson said.
G&M HINTS AT MORE ACQUISITIONS ON THE HORIZON
continued from page 3
EyeQ and National Optical Care then parted ways in 2022 after a two-year alliance, with the former then acquired by EssilorLuxottica in January 2024.
National Optical Care founder and managing director Mr Tomas Steenackers said after exploring various options, G&M is a business that is most aligned to its values and passion for delivering the “highest possible standard of specialised eyecare to patients and local communities”.
“This is a merger of two aligned, patient-focused optical businesses and
the merger will be good for the future of our employees, our patients and our communities.”
National Optical Care practices are located across the east coast of Australia, with 15 practices in Queensland, six in NSW, three in ACT and two in Tasmania.
G&M said it remained “proudly Australian owned and operated and is now the largest independent optical care provider in Australia”.
Beer said G&M was currently in discussions with more prospective partners across Australia and is expected to make further announcements over the coming months.
Image: AMA.
Image: George & Matilda.
Tomas Steenackers (left) and Chris Beer.
OPTOMETRY WORKFORCE REACHES 7,000 MILESTONE
The number of registered optometrists in Australia has surpassed 7,000, according to the latest official statistics, as the proportion of female optometrists nears 60%.
The numbers are detailed in the Optometry Board of Australia (OBA)’s quarterly statistics covering the 1 October 2023 to 31 December 2023 period.
The number of registered optometrists continues to climb, now reaching 7,083.
Compared to the same time last year, that’s 287 more optometrists, a 4% jump.
Optometry Australia CEO Ms Skye Cappuccio said the sector had seen significant growth in the optometry workforce in recent years, which is expected to continue.
“Workforce growth is primarily being driven by increasing graduate numbers, rather than by immigration,” she said.
“As a result, we see increasingly higher number of younger optometrists in the workforce – over a quarter of Australian optometrists are now 29 years or under.
An important focus for us as an association is ensuring we are supporting younger members navigate the early years of their career, and to ensure there are opportunities
for them to pursue fulfilling careers.”
Anecdotally, universities are reporting high employment rates among their optometry graduates.
The nation’s newest optometry school, at the University of Western Australia, recently celebrated its first graduate cohort. All 40 students secured employment, with 90% staying to work in WA.
Although there’s debate about whether Australia needs more optometrists, in 2023 Specsavers commissioned Deloitte Access Economics to conduct another workforce report.
It forecasted a shortage of 1,102 full time equivalent (FTE) optometrists in 2042, representing an undersupply of more than 1.5 million clinical optometry hours, or approximately a 12% shortage, compared to the total hours of eyecare expected to be in demand by Australians by then.
Meanwhile, the latest OBA statistics showed the state or territory with the largest increase in optometrists was Victoria, with 108 more than a year ago, taking its total to 1,965.
NSW had the most optometrists overall
with 2,207, climbing by 55 during the past 12 months, followed by Queensland 1,413 (up by 34), South Australia 479 (up by 32), Western Australia 558 (up by 30), Northern Territory 40 (up by four), and ACT 110 (down by nine).
Feminisation of the workforce also continues. There are now 4,188 registered optometrists – representing 59% of the workforce – and 2,895 male practitioners.
The latest report also included statistics on optometrists who identify as Aboriginal and/or Torres Strait Islander, of which 14 said they do.
More than 25% of optometrists are now 29 years or under. Image: Viacheslav Yakobchuk/ stock.adobe.com.
IN BRIEF
DRY EYE DEVICE
Laser technologies company Lumibird Medical has launched C.DIAG in Europe. It is described as the first automated diagnostic platform for the ocular surface incorporating AI based on algorithms derived from more than one million clinically validated images. “With C.DIAG, we are the only player in this market to offer an automated diagnostic aid platform, the most comprehensive on the market, integrating numerous examinations, with AI and an autofocus HD camera for unrivalled image quality and automatic, accurate and reproducible results,” Lumibird dry eye product manager Ms Delphine Southon said. Mr Jean-Marc Gendre, CEO of Lumibird Medical, said the company's C.SUITE offering now consists of C.DIAG alongside its C.STIM IPL treatment.
COMPLETE PAIR
Safilo Australia, with CR Labs, is bringing Carrera Authentic Prescription Lenses to the Australian optical market, in the latest development as part of the companies’ Full Circle Program. Each pair of Carrera Authentic sunglasses and prescription glasses come complete with Carrera Logo engraving on the lens, as well as a Certificate of Authenticity card. “Both the frames and lenses come with market-leading warranties to reinforce the quality of the brand and performance of the product,” Safilo said. With this, Mr David Pearson, senior commercial director for APAC, said Safilo and CR Labs were empowering independent optometry to engage patients like never before. “The result is a ‘complete’ eyewear offer that matches lenses perfectly with the shapes, curvatures and designs of Carrera frames and sunglasses,” he said.
MOGAD BREAKTHROUGH
Blindness and paralysis can be devastating consequences of little-known Myelin oligodendrocyte glycoprotein antibody disorders (MOGAD), but an Australian collaboration is looking to change this. Often referred to as “a cousin of multiple sclerosis” due to shared symptoms, MOGAD is an autoimmune condition where the body attacks a protein in the brain, resulting in a swollen central nervous system. Immunosuppressants can prevent relapses – which occur in 40% of cases – but side effects mean it is vital to identify patients needing ongoing treatment. In the Journal of Neurology, Neurosurgery & Psychiatry, the researchers detail how in 25% of patients the antibody did not bind at the dominant epitope, resulting in relapse. This was most common in those affected by vision impairment (lesions on the optic nerve) at disease onset versus those experiencing movement issues (lesions on the spinal cord).
OPHTHALMIC FIGURES FEATURE IN KING’S BIRTHDAY HONOURS LIST
The 2024 King’s Honours Birthday list has recognised 737 Australians for their conspicuous service, including six members of the Australian ophthalmic community for their contributions to ophthalmology, optometry and Indigenous eye health.
Professor Glen Anthony Gole has been awarded Member of the Order of Australia (AM) in the General Division for “significant service to ophthalmology, tertiary education and to professional organisations”.
Based in Queensland, he began practising ophthalmology in 1990. He started as a visiting ophthalmologist at Queensland Children’s Hospital and became head of the department in 1995 before moving on to become director of ophthalmology from 2010-2018. Concurrently, he was an Associate Professor of Ophthalmology at the University of Queensland from 1991-2009. Since 2010, he has been a professor at the same institution, with research interests in retinopathy of prematurity, retinoblastoma, amblyopia and strabismus, and glaucoma.
Overseas, he has volunteered as a paediatric ophthalmologist with the Sight for Life Foundation in Vietnam, Bangladesh and Laos.
Dr Diana Bronwen Semmonds, from NSW, received an AM for “significant service ophthalmology, to regulatory bodies and to professional organisations”.
She was the vice president of RANZCO from 2016-2018, chair from 2001-2012 and board director from 2009-2018. Additionally, in RANZCO’s NSW branch, Dr Semmonds held the position of chair from 1999-2001. She has been the principal ophthalmologist at St Leonards Eye Centre since 1985. At the Sydney Eye Hospital, Dr Semmonds has been a visiting medical officer in the Intraocular Implant Unit since
1988, director of the Sydney Eye Hospital Foundation since 1997 and was chair of the alumni association from 2008-2012.
Board chair at the Royal Victorian Eye and Ear Hospital (Eye and Ear) since 2015, Dr Sherene Devanesen also received an AM for “significant service to community health through governance and administrative roles”.
Meanwhile, Dr James Edward Elder from Victoria has been awarded the Medal of the Order of Australia (OAM) for his “service to medicine as an ophthalmologist”.
At the Royal Children’s Hospital in Melbourne, he held the position of director from 1990-1993 and director from 1994-2009 and has practised at the Royal Women’s Hospital since 1992.
Moreover, Dr Elder was awarded the RANZCO Teacher of Excellence award in 2015 and 2020, an Achievement Award at the Asia-Pacific Academy of Ophthalmology in 2017, and the Elizabeth Turner Medal by the Medical Staff Association of Royal Children’s Hospital in 2022.
Ms Helen Christine Summers was awarded an OAM for “service to the community of the Northern Territory, and to optometry”.
She is the senior optometrist at Helen Summers Optometrist, Bupa Optical in Darwin. Summers has been an emeritus member of Optometry Australia since 2021 and chair of the Australian Optometric Panel from 2012-2021. She is also a past member of the Aboriginal and Torres Strait Islander Eye Health Working Group. Additionally, she held the position of director of Guide Dogs SA/NT from 2005-2019.
Summers has been awarded many accolades throughout her career including the Australian Businesswomen’s Network Hall of Fame in 2014; Business Owner Award at the Telstra Australian Business Women’s Awards in 2013; Business Woman of the Year, Business Innovation Award, and Business Owner Award at the Telstra NT Business Women’s Awards in 2013. She has also volunteered with Australian-run not-for-profit Cambodia Vision.
Finally, Ms Emma Elizabeth Stanford from Victoria has been awarded an OAM for “service to Indigenous eye health”. Stanford has been a senior research fellow in Indigenous Eye Health Unit at the School of Population and Global Health at the University of Melbourne since 2017 and was a research fellow in the same department from 2009-2017.
CLOCKWISE: Emma Stanford, Helen Summers, Dr Diana Semmonds and Dr Sherene Devanesen. Images: Supplied.
Comparable high levels of UCDVA § and CDVA
Similar dysphotopsia profile with lower incidence of optical side effects
High degree of patient satisfaction for daily life activities
Enhanced spectacle independence from far to intermediate distances
CERULEA CLINICAL TRIALS TO BOOST ACCESS TO SIGHT-SAVING THERAPIES
The Centre for Eye Research Australia (CERA) has established Cerulea Clinical Trials, a new specialist ophthalmic clinical trial facility in Melbourne which is expected to bring more international trials to Victoria.
Launched on Word Clinical Trials Day by Victorian deputy premier and minister for Medical Research, Mr Ben Carroll, the centre will provide people living with vision loss and blindness early access to sight-saving therapies.
Cerulea is supported by a $10 million investment from Breakthrough Victoria and is expected to deliver clinical trials to more than 2,500 Victorians a year over the next decade and create 50 new jobs.
A fully owned, not-for-profit subsidiary of CERA, Cerulea will specialise in advanced therapeutics to prevent and treat blindness, including gene and cell therapies, biologics and medical devices.
The clinical trial centre will also collaborate with pharmaceutical and medtech companies and be the home of clinical research conducted by scientists from CERA and ophthalmology researchers with the University of Melbourne’s Department
of Surgery. It will test new therapies for eye conditions such as age-related macular degeneration (AMD), diabetic eye disease, glaucoma, inherited retinal disease (IRD) and other rare genetic eye conditions – with a major focus on trialling new therapies for diseases that currently have no treatment or cure. In the next year, Cerulea expects to begin new clinical trials on gene therapies for retinitis pigmentosa and Stargardt’s disease. It is also expected to boost local research, ensuring that new eye treatments and devices developed in Australia are trialled locally where
At the opening, Victorian deputy premier and minister for medical research Ben Carroll (right).
they can benefit Australian patients first.
“There is a growing pipeline of discovery with new medicines and devices being developed around the world and Cerulea Clinical Trials provides the perfect location to conduct these trials,” Cerulea CEO Ms Michelle Gallaher said.
The aim is to build a specialist clinical trial centre that cements Victoria’s reputation as a world leader in preventing blindness and reducing the impact of vision loss, she said.
“Cerulea aims to provide the best possible experience for patients, researchers, clinicians and industry partners.”
Professor Keith Martin, Cerulea chair and CERA managing director, said the new centre was a major boost for eyecare and eye research in Victoria.
“Cerulea will support the work of lab-based scientists to develop innovative new treatments to prevent vision loss and restore sight,” he said.
“It will also benefit local eyecare professionals who will be able to improve the quality of care they provide to their patients by providing them access to emerging treatments in clinical trials.’’
NEW LOOK FOR INDIGENOUS EYECARE WITH GADIGAL EYE CENTRE
Sydney/Sydney Eye Hospital (SSEH) has established its Gadigal Eye Centre – a pioneering Aboriginal and Torres Strait Islander eye clinic, coinciding with Reconciliation Week events in May 2024.
Formerly known as the Bicentennial Clinic and located in the South Eastern Sydney Local Health District (SESLHD), the Gadigal Eye Centre will be a hub for outreach to Aboriginal and Torres Strait Islander people, providing in-person services as well as virtual care capabilities for eye patients in regional NSW.
According to Ms Jennie Barry, general manager at SSEH and Prince of Wales Hospital, a three-phase plan will ensure the new clinic reflects a culturally safe space for Aboriginal and Torres Strait Islander patients and meet the growing need to support care closer to home.
“Our vision to name the Gadigal Eye Centre is reflective of South Eastern Sydney Local Health District’s commitment to accessible eye health services to our Aboriginal and Torres Strait Islander patients,” she said. “Together our two ophthalmology services
at Sydney/Sydney Eye and Prince of Wales Hospitals will lead eye services and our virtual capability through this collaborative centre, thanks to funding from Sydney Eye Hospital Foundation.”
Barry added the name acknowledges the Gadigal people, the original custodians of the land around Sydney’s central business district.
“We want this to be a welcoming and safe environment, clinically and culturally, honouring the rich history of the Gadigal people through landscaping and art,” she said.
New technology will be introduced so that ophthalmic specialists at SSEH and Prince of Wales Hospital can extend their service delivery to patients in regional and remote communities.
The Sydney Eye Hospital Foundation is the funding partner of the centre. Image: Sydney Eye Hospital Foundation.
Dr Andrew Chang, head of ophthalmology, said the Gadigal Eye Centre would be a fully equipped virtual clinic benefiting patients across the state.
It will include Sydney Eye Hospital’s telehealth capability – Tele-Vision. This virtual technology will work in partnership with
local hospital teams across both clinical and emergency settings.
Dr Chang added that Tele-Vision is possible through specialist retinal cameras installed in collaboration with regional clinics connecting to the Gadigal Eye Centre. The cameras can be used by non-ophthalmic specialists such as GPs and nurses along with experienced ophthalmologists in the field at outreach centres.
FEELS LIKE NOTHING THANKS For Nothing!
Helps resist deposits and bacteria for a clean lens‡4–12 Approaches 100% water at the surface†2,3 Introducing TOTAL30TM: Combines Water Gradient and Celligent® technology for a reusable lens that feels like nothing, even at day 30.*1
*>70% of wearers agreed with ‘These lenses were so comfortable I didn’t feel anything’ and ‘I did not have to think about my contact lenses today’ (n=66).1 †Based on in vitro measurements of unworn lenses.2,3 ‡OPTI-FREE Puremoist used for cleaning, disinfecting, and storing, following package insert directions. Tested against 5 strains of P. aeruginosa (MCC 3478, 3480, 3481, 7142, ATCC 10145) (p<0.0001 for all) and E. coli (p<0.01).4–12
Johnson & Johnson (J&J) has launched its newest eye health innovation in Australia, ACUVUE OASYS
MAX 1-Day spherical contact lens and ACUVUE OASYS MAX 1-Day MULTIFOCAL contact lens.
The lenses will be available to wearers in Australia from 1 July 2024.
“Through a deep innovation heritage in eyecare, Johnson & Johnson has seen how the needs of contact lens wearers have changed over time. In the age of digital technology and a persistent trend towards longer screen time, it is our role to continuously predict, adapt, and innovate to support our wearers’ needs,” said Ms Michelle Ho, business unit director for Johnson & Johnson Vision Australia and New Zealand.
“There’s a huge need for innovation like ACUVUE OASYS MAX 1-Day, that has been informed by wearers and eyecare professionals, priming it to keep up with the lifestyles of all Australians, and address eye strain as a result of longer days and increased time looking at digital devices.”
Through a combination of new technologies, ACUVUE OASYS MAX 1-Day lenses have been built for reliable comfort and performance, a statement said.
J&J said its TearStable Technology maximises tear-film stability and locks in moisture for exceptional all-day comfort, 2 while the OptiBlue light filter has the highest level blue-violet light filter in the industry at 60% ‡,1 to help reduce light scatter and increase visual clarity, day and night. In addition, ACUVUE OASYS MAX 1-Day lenses block 99.9% UVA rays and 100% UVB rays.††,§§, 3,4 ACUVUE OASYS MAX 1-Day builds on the ACUVUE portfolio of products, which J&J said "is unbeaten in comfort across 29 clinical studies".‡‡ In clinical trials of ACUVUE OASYS MAX 1-Day, nearly 90% of wearers reported all-day comfort and a reduction in tired eyes from digital devices, and nearly 100% agreed the lenses provided clear, reliable vision. 2
ESSILOR STELLEST LENS DEMONSTRATES CONTINUED LONG-TERM EFFICACY
A five-year clinical study of the Essilor Stellest lenses has demonstrated continued long-term efficacy in controlling myopia progression and axial elongation.
The controlled, prospective, randomised clinical trial, which began in 2018, was conducted at the Eye Hospital of Wenzhou Medical University in Wenzhou, China.
The age of the children at enrolment in 2018 was eight to 13 years old. To assess the long-term efficacy, the study was extended from the original two-year clinical trial to five years.
The data showed that Essilor Stellest lenses slowed myopia progression by 1.75D*1 and axial elongation by 0.72mm**1 on average over five years for all subjects, compared to the extrapolated control group, showing conclusive evidence of their efficacy in slowing down myopia progression in children in the fifth year.
The data also showed that the efficacy in slowing myopia progression and axial elongation was sustained in older children (up to 18 years old), as the children who completed the fifth-year study were aged between 13-18 years.
It is planned to continue the study for two more years, to gauge the seven-year myopia control efficacy of the lens.
Mr Norbert Gorny, chief scientific officer
at EssilorLuxottica, said: “We are excited to be able to share the latest five-year findings of Essilor Stellest lenses as long-term clinical data is essential to showcase the continued efficacy and performance of the lens in children.
“As we already know that every dioptre matters, we look forward to sharing scientific data and insights on interventions to address myopia, to bring us all one step closer to protecting the vision of young patients.”
He added: “We will also continue to integrate scientific knowledge with innovative technologies to create the future of myopia control spectacle lenses so that the next generation can see more and be more.”
NOTE: A full list of references is available i n the online version of this article.
VISION EYE INSTITUTE AND SIGHT FOR ALL COLLABORATE
Vision Eye Institute (VEI) is collaborating with Sight For All to help the Australian charity advance eyecare for underprivileged communities around the world.
“Although VEI’s 29 clinics and day hospitals are located throughout Australia, we are very much aware of the millions of vision-impaired people beyond our shores, which is exactly what Sight For All was set up for,” VEI CEO Ms Amanda Cranage said.
Australian ophthalmologists Dr James Muecke AM, Professor Robert Casson and Associate Professor Henry Newland in 2009.
Prof Casson said the organisation’s aim was to make communities self-sufficient, rather than reliant on external support. This means providing equipment and training to increase the ophthalmic capacity in target communities, before phasing out support once local doctors are suitably trained.
NOTE: A full list of references is available in the online version of this article.
“We are thrilled that this partnership will extend our impact on the lives of individuals in all communities.”
Sight For All was established by South
Every year, more than 120 eyecare professionals, including VEI doctors, donate more than 10,000 hours of their time to deliver intensive, in-country training.
The study will continue to gauge the seven-year myopia control efficacy of the lens. Image: EssilorLuxottica.
Amanda Cranage, Vision Eye Institute. Image: Vision Eye Institute.
ACUVUE OASYS MAX 1-Day contact lenses became available from 1 July. Image: Johnson & Johnson.
DIGITAL CATARACT WORKFLOW CUTS CLINIC COSTS
A Brisbane eye clinic has published a new paper showing a cost-reduction of 35% per patient when using the ZEISS EQ Workplace digital cataract workflow for toric IOL planning when compared with a manual approach.
The study by Dr Matthew Russell and optometrist Ms Inez Hsing, from OKKO Eye Specialist Centre, was published in Clinical Ophthalmology on 25 May 2024, and evaluated the efficiency and associated costs of EQ Workplace alongside a manual cataract workflow system for patients with astigmatism presenting for cataract surgery.
The study involved 60 patients with bilateral cataract requiring toric IOLs. Thirty were assigned to go through the manual cataract workflow while the remaining 30 progressed through the digital workflow using EQ Workplace running on FORUM.
According to the authors, each step of pre-operative data acquisition and analysis was timed. Steps in each workflow were divided into presurgical planning time and total workflow time, the latter including the time required to input toric data into ZEISS CALLISTO eye system where markerless toric IOL alignment occurs. Secondary outcomes
Workplace was 6.51 ± 0.65 minutes, while for the manual workflow it was 12.32 ± 0.56 minutes (p < 0.001).
Similarly, median total workflow time using a digital workflow process was 6.93 ± 0.57 minutes and 13.49 ± 0.47 minutes using a manual workflow process (p < 0.001).
“Evaluating the staff remuneration during presurgical planning and the operating costs associated with running EQ Workplace, there was a cost-reduction of 35% per patient when using the digital cataract workflow process,” the authors wrote.
“Using a digital cataract workflow process is more efficient and provides staff cost-savings
compared to a manual workflow process when planning for toric IOL implantation.”
The authors noted their findings supported other studies showing a digital workflow in cataract surgery is beneficial.
“In [our] study, we specifically focused on the processes involved in planning for the implantation of toric IOLs and did not include surgical time. Our results suggest that a digital workflow not only reduces time and cost, thereby allowing support staff to be more efficient and increasing clinic throughput, but it also invaluably offers increased peace of mind by lowering the risk of transcription and human error,” Dr Russell and Hsing wrote.
They also said the potential improvements in clinic staff efficiency and cost-savings associated with EQ Workplace offset the initial investment and subscription fees associated with running and maintaining the platform.
“Moreover, while outside the scope of this paper, we believe that the cost-savings of AU$10,000 (US$6,600) is conservative when considering the mitigation of transcription errors and the potential costs associated with surgically rectifying an incorrectly positioned IOL,” they added.
Specialist Centre.
The return rate of KeepSight patients
Data collected by Specsavers has revealed KeepSight – Australia’s diabetes eye check reminder program – is significantly enhancing patient adherence to regular eye health appointments. Patients enrolled in the program are returning to their optometrists more frequently for essential eye health appointments than those not registered in the program.
Since KeepSight’s inception in 2018, Specsavers has monitored the regularity that patients with diabetes return to their optometrist for an eye health check. Deidentified patient data over this period reveals program participants, who receive additional clinical reminders to book an eye examination, are 20% more likely to attend an appointment within two years compared to non-registered patients with diabetes.
According to Specsavers, which recently reached one million appointments registered with KeepSight, routine eye tests are vital for people with diabetes, as they can help to prevent severe complications from diabetes-related eye diseases, such as diabetic retinopathy. Early detection of vision changes makes these conditions treatable, helping to avoid vision loss.
Dr Ben Ashby, Specsavers clinical services director ANZ, highlighted the program’s impact on patient health outcomes.
“With almost six years of data, we can see a year-on-year trend emerging. It’s clear that those patients who consent to be part of the KeepSight program are more likely to return to see their optometrist for their essential eye health checks,” he says.
"As a founding partner of KeepSight, these results are a source of immense pride for Specsavers. The dedication of our optometrists in consistently registering patients to the program, and with the help of our industry partners, we’re really making inroads in our mission to ensure no one in Australia goes needlessly blind due to diabetes.”
Specsavers optometrist Mr Yong Su says flagging every consenting patient with diabetes in KeepSight is part of his process in the test room.
“Regular eye checks are crucial for people with diabetes, and I think KeepSight reminders help busy people remember to prioritise their eye health. The additional prompts help people stay on top of their scheduled appointments, which can help to reduce the risk of complications and helps to preserve their vision."
EARLIER DETECTION OF DIABETIC RETINOPATHY
An essential component in avoiding preventable vision loss for people living with diabetes is the early detection of changes in the eye. Advanced ophthalmic technology, such as OCT, is helping optometrists detect vision-limiting conditions like diabetic retinopathy earlier than ever before. Currently, there are more than 1.5 million Australians with diagnosed diabetes, and one in three of them will have some level of diabetic retinopathy.
This year’s National Diabetes Week theme emphasises the impact technological advancements have had on diabetes care. The non-invasive 3D eye scan completed by OCT provides optometrists with detailed insights into the eye health of diabetic patients, enabling earlier treatment and ongoing monitoring.
Dr Ashby says the use of OCT as part of every Specsavers eye test, at no extra cost to patients, is helping to drive better eye health outcomes for all Australians.
“OCT is an important tool in patient care as it means optometrists are picking up small changes in the eye much sooner than they would have with standard eye testing equipment. This is particularly important for people with diabetes as we can monitor changes and refer them to an ophthalmologist as needed,” he says.
Ms Taryn Black, Diabetes Australia chief strategy officer, says the optimised recall communication framework of KeepSight complements test room technology by sending reminders and prompts at the appropriate time and making the process of booking an appointment easy.
"Optometrists are at the forefront of our battle against diabetes-related vision loss. Their ability to detect and monitor diabetic retinopathy in its early stages is crucial in stopping people with diabetes from experiencing vision loss. KeepSight’s impact in increasing the number of people attending regular and ongoing eye checks demonstrates the importance of this collaborative effort," she says.
"KeepSight's success is a testament to the collective work of Diabetes Australia, Specsavers, the Australian Government and other program partners. Each reminder sent and appointment attended brings us closer to a future where diabetes-related vision loss is a rarity rather than a common occurrence.”
NOTE: To find out more about KeepSight, visit www.keepsight.org.au. References will appear in the online version of this article.
Image: Specsavers.
Specsavers data shows a trend of patients who are part of the KeepSight program returning for an eye check more frequently than patients with diabetes who are not part of the program.1
ABOVE: OCT has been highlighted as one of the most influential pieces of technology to detect and monitor retinal changes in people with diabetes.
Optos multimodality
See the bigger picture with more images, information, efficiencies.
optomap is multimodality imaging technology, able to generate high-resolution 200° ultra-widefield (UWF™) images to visualise vitreoretinal, retinal and choroidal layers from pole to periphery.1
9 * modalities including OCT make a practice…
Images: Peter Coombs.
Jewellery
for the face
PETER COOMBS goes by the title designer, jeweller and metalsmith, but eyewear is the vehicle that has taken him around the world and into the presence of people like Sir Elton John. From his South Australian studio, he speaks to Insight about his love of creating handmade luxury eyewear.
In a modern eyewear world dominated by computer-aided design (CAD), mass production, large margins and a handful of materials, speaking with Mr Peter Coombs feels like seeking shelter from the harsh elements of a capitalist society.
Every piece of eyewear he constructs is deliberate, considered and crafted with artisanal expertise. His creations are brought to life in a studio adjacent to his Adelaide home – one of those “lucky finds” once owned in the 1880s by a family working with farm machinery. Stepping inside the workshop today, one will find Coombs surrounded by various hand tools, machines and drawings he uses to form and colour various precious and refractive metals into luxury eyewear.
Some of these are one-off commissioned pieces, while others form part of collections with anywhere from 10 to a few hundred units, purchased by eyewear lovers globally. Price points start at $950 and, in rare cases, can reach five figures – and everything in between.
“I recently had a lady who tried on an existing frame, and I said, ‘You know I could make that three millimetres shallower and it would be much better’. That’s the beauty of what we’re able to do, instead of being stuck with ‘almost right',” he says.
“Maybe the optometrist selling glasses wants people to keep buying more, but I make and design my eyewear with such care that it’s got potential to last
forever – I don’t want it to break. I’ve had frames come back and I’ve refinished them; being raw titanium that we’ve re-polished or ceramic-coated to transform them. There are no lost components.”
It’s this attention to detail that has allowed Coombs to carve a niche for almost four decades as one of Australia’s foremost eyewear designers. His expertise is complemented by his wife, Rebecca, who he considers a “marketing genius” involved with the development of collections and the driving force behind various campaigns.
Coombs’ frames have been recognised with international design awards in Japan and Australia and appeared in museums and private collections globally. They have also been worn by the rich and famous, including actress Raquel Welsh, Richard Pryor’s wife or European football managers – often unbeknownst to him until someone makes a throwaway comment, he’s tagged on social media or is contacted for a repair.
“You make these beautiful things and then you send them out to the wild,” he says.
“Some mornings I wake up to messages from America, Italy, Greece or wherever with people who have been checking out the website, saying they are interested in certain pieces, and you often wonder how you ended up at the end of their rabbit hole.”
But not all clients emerge in this fashion. The most famous wearer of Peter Coombs Design Eyewear is Sir Elton John who owns 26 pieces from the South Australian.
It was a relationship that started in 1987. Only two years earlier, Coombs had made his first pair of spectacles while studying for a Bachelor of Design (majoring in Jewellery and Metalsmithing) at the University of South Australia. At the time, people were concerned about Pine Gap, Roxby Downs, the Cold War and there was acid rain in Europe. They were reminiscent of ‘Jules-Verneunder-the-sea-the-apocalypse-is-coming’ which he says was the happening thing in the 1980s – “clunky but funky”.
By 1987 he ventured out to Los Angeles to showcase some jewellery designs. He was amazed at how freely people shared their contacts, leading him to l.a.Eyeworks, a cool boutique on Melrose Avenue frequented by those seeking luxury eyewear.
“I sat down with one of the owners and she was looking at my stuff and began asking how I did certain techniques – it was an interesting meeting of the minds,” he recalls.
“In the conversation I said, ‘I’d love to get my frames on someone like Miles Davis’. I was 21 at the time, and she gave me that smile your great aunt gives when you’ve said something charmingly naïve. But the first frame she bought from me became Elton’s in two or three days.”
What unfolded was a “surreal” client relationship through the 1990s for Coombs who created eyewear for Elton and many others.
“Apart from what used to go through l.a.Eyeworks, I saw him before concerts a few times,” he says. “This was a time before mobile phones, and you’d get a message on your answering machine or a fax, and sometimes you’d wonder if it was a prank. You’d get details of a meeting in a hotel or sometimes backstage at a concert, and then show up with your creations.”
KNOWING YOUR LIMITS
Doing business with musical royalty sits in contrast to a childhood that Coombs spent in a rambling seaside house in Adelaide – where his love for materials began. The wooden rear section of 1800s era house was partly pulled down and rebuilt, so he and his siblings were never short on supplies to build treehouses, or control panels for spaceships.
“We had hammers, nails and screws – and we had space, there was just so much freedom.”
With an accountant father, his business-orientated family offered seed investment to other businesses. At one stage they owned a Paddle Steamer which did five-day cruises on the Murray River.
“My weekend job was working in the galley and cleaning. It was the analogue
Peter Coombs is one of Australia’s foremost eyewear designers and producers.
age, so there were always people around; fitters and turners, blacksmiths, and carpenters to work alongside and learn from.”
At the University of South Australia, he made all sorts: rings, pendants, perfume bottles, knives, goblets, plus more. But when he wasn’t creating, he was at the beach, and it occurred to him that he could make his own eyewear.
“It turned out I was pretty good at it. I loved that there was no hard and fast way. The only proviso is you’ve got to have a way to hold two lenses in front of the eyes.”
Sterling silver, nickel and black chrome were the first materials he used. Today, he performs a lot of titanium and aluminium forming.
“A big part of materials is learning to play with them and testing them until they break. You need to see how far you can push something before you gain a good understanding of what’s possible,” he says.
“Working with titanium, there’s so many grades. There’s super hard titanium that’s almost impossible to drill. At the other end, how do you find that balance of bending something that’s not going to crack and – if a client stands on it – it’s not a total throwaway and you’ve got that ability to restore it. Similarly, some
about whether we can use two screws instead of three, without affecting the integrity. Can the screws come from above instead of below where they would be more likely to fall out?”
While form and function are the cornerstones for his regular clientele, there are times when Coombs uses trickery to achieve a certain look. This is the case for film sets where he is commissioned to create eyewear that reflect a certain era or appear to degrade over time. It’s also not unusual to see a public demand surge for a certain frame immediately after a movie airs.
In the film Escape from Pretoria, filmed in Coombs’ hometown, he designed the eyewear worn by star actor Mr Daniel Radcliffe, best known for Harry Potter.
“It’s a beautiful frame, and the irony is that despite it being designed for a 1970s biopic, the frame is very ‘now’,” he says.
“Daniel’s Harry Potter character is synonymous with round frames, so it had to be as far from the circle as possible. The frames I make for people seeking eyewear featured in a film aren’t made identical because when you’re doing film work, there’s some smoke and mirrors.”
Interestingly, Coombs made three sets of the same frame for Radcliffe in the film.
“It was the same when I worked on the various Gallipoli films a few years ago. In one case, the main character had four or five frames to show before the Tobruk landing, after the landing, and several years later. How do you make it look really hammered, but at the same time, ensure it can hold together while filming? The frames in one film varied from those worn in the trenches, to a pristine gold pair worn by Winston Churchill’s character.”
Although Coombs is appreciative of the at-times public nature of his work, it’s the regular people with a passion for eyewear – those who buy one or two frames per year – that mean the most.
“Because you know it’s a big deal for them to spend a few thousand dollars on something that’s a wearable piece art. They have decided this is what I want, and this is how I’ll represent myself. Some of those people have been my clients since the 1990s.”
He will always appreciate how eyewear can transform a person’s look, and that he’s been able to carve a career out of it.
“It’s about the sort of shape we can overlay on a face to essentially create an optical illusion,” he says. “There’s tricks in the design that can make a face look larger, smaller or more normal sized, even to the point that you’re kind of giving them a face-lift.”
Inspiration for Peter Coombs’ work is found in everyday life and the people he meets.
Each frame is created in his South Australian workshop, involving hand tools, machines, drawings and test pieces
Peter Coombs forms various precious and refractive metals into luxury eyewear.
The evolution of intraocular lens technology and surgical technique has heightened patient expectations and spurred the era of refractive cataract surgery. Insight discusses the landscape with several seasoned ophthalmologists and the incremental gains that will transform the category for years to come.
Historically, the main candidates for cataract surgery were those with bad, dense cataracts. Surgeons had few options, but as technology has evolved, the candidate pool expanded to moderate cataracts. Today, those with mild cataracts – and presbyopes with a perfectly clear crystalline lens but who want a greater range of vision – are seeking out the services of surgeons.
As the most frequently performed elective surgery, with upwards of 250,000 procedures performed per year in Australia and 27 million globally, cataract surgery is a gateway to quality-of-life. And as technology, techniques and methods have advanced, optimising refractive outcomes have become a natural endpoint.
The pace at which the cataract category has developed – seeing ophthalmologists become “refractive cataract surgeons” – has been fulfilling for University of Melbourne academic and glaucoma and cataract subspecialist Associate Professor Simon Skalicky, as he can deliver better outcomes to patients.
“As we’ve gotten better at cataract surgery, the refractive outcomes have become more important. I don’t see refractive cataract surgeries as too distinct from cataract surgery these days,” he says.
Presbyopic patients seeking spectacle independence has been a major driver. But this isn’t possible without the refinement of intraocular lens (IOL) technology, especially the introduction of new generation extended depth of focus (EDOF) IOLs that are now offering a monofocal-like visual disturbance profile. Overcoming most of the symptoms of glare and haloes – still associated with multifocals – has been a major achievement for the industry.
Associate Professor Chameen Samarawickrama, from the Westmead Institute for Medical Research at Sydney University, says he recalls as a trainee
in the public system in 2010 when monofocals were all he could offer patients. Similarly, in the private space, he only had access to simple multifocals.
Now, since the refinement of multifocals and emergence of EDOFs, the nature of his IOL selection has shifted drastically.
“Before, about 20% of my patients were multifocal, and 80% were monofocal. Now, about 45% of my patients are EDOF, 35% multifocal, and the residual 20% are specialty lenses or monofocal,” he says.
“EDOFs have been a wonderful technological advance in just the last few years to allow some of that correction of presbyopia; not obviously as strong as the multifocal but without the significant post-operative side effects of glare and halo.
“I still feel the story’s not over because while EDOFs do a great job minimising the side effects, they don’t achieve spectacle independence, and so we’re not quite where we want to be yet.”
Image: Simon Skalicky.
“I still feel the story’s not over because while EDOFs do a great job minimising the side effects, they don’t achieve spectacle independence, and so we’re not quite where we want to be yet."
A/Prof Simon Skalicky
The University of Melbourne
TORIC TALK
Given the rate at which IOLs have progressed in recent years, A/Prof Skalicky hopes that a lens with the range of the multifocal IOL and the symptomatic profile of EDOFs will soon emerge.
PRE-OPERATIVE FOCUS
Meanwhile, Dr Mark Troski, a Melbourne-based cataract surgeon with more than 20 years’ experience in this space, says the surgical landscape progressed when incisions reduced in size, then with the introduction of phacoemulsification, followed by foldable lenses which reduced incision size even further.
However, for him – despite the research and technological advances – it has been the time spent consulting his patients prior to surgery that has been one of the largest transitions.
“Now, we spend less time actually performing the surgery and more time sitting with the patient discussing what their refractive wishes are and what we can realistically produce from the point of view of refractive outcomes – that’s now a huge part of our practices,” Dr Troski says.
Similarly, for A/Prof Skalicky’s practice, he is ensuring a comprehensive pre-operative consultation. For example, understanding the role of dry eye in cataract surgery outcomes has shaped his patients’ experiences for the better. While not part of his training, he says treating the ocular surface prior to surgery is important in maximising procedural precision.
“Dry eye can affect preoperative measurements and cause postoperative discomfort. One of the secrets cataract surgeons are learning and – me included – is how important it is to treat the ocular surface before cataract surgery for optimal outcomes,” he says.
A/Prof Skalicky says some patients don’t expect to have a conversation about dry eye preceding a cataract procedure, but it is a necessary conversation to get the most out of such a vital opportunity to remove the patients’ cataract and provide them vision they may not have experienced for many years.
He says in the two weeks leading up to surgery, he recommends patients use a combination of eyelid hygiene, such as applying warmth against the eyelids and then massaging with the fingers as well as preservative free lubricants.
“I’ve been doing that now for about five years and I noticed a significant improvement in patient satisfaction from dry eye symptoms as well as surgical outcomes,” A/Prof Skalicky says.
Outside of the operating room, Dr Troski says cataract surgery has seen as big an ideological shift as a technological one.
He was among the first in Australia to implant toric lenses for astigmatism. Not long after, he gave a lecture at an annual RANZCO meeting in Melbourne where he recommended toric lenses for all patients with astigmatism.
He says his audience was exasperated, as astigmatism correction was unheard of.
“About half the audience said, ‘Don’t do that – people like astigmatism’,” Dr Troski says.
In the years proceeding this, he witnessed a slow, discernible shift in the ideology as the industry embraced the technology. Dr Troski says now it is common practice and would be unthinkable to not use astigmatism correcting lenses. Today, Australia is one of the largest adopters of toric IOLs.
A/Prof Skalicky agrees and says toric lenses have been pivotal in shaping the procedure into what it is today.
“Before toric lenses, we weren’t getting anywhere near the refractive outcomes we wanted. There was no talk of spectacle independence, unless you happen to have no astigmatism,” he says.
“And so toric lenses shifted the goalposts for greater precision which was a really important milestone.”
PRECISION IS KING
When planning surgery, choosing the correct formula is one of the most important pieces in the puzzle.
A/Prof Skalicky says that the evolution of formulae for IOL power has advanced over the past 10-15 years, redefining surgical accuracy. “When I look back on the formula that we were using when I was in training, it’s very different from the formula that we’re using today,” he says.
A lot of that pioneering work came out of Australia, such as Professor Graham Barrett’s Barrett Universal II formula that uses a theoretical model eye in which anterior chamber depth (ACD) is elated to axial length (AL) and keratometry.
Previously, the SRK-II and Hoffer-Q formulas were the main formulae used by surgeons. So, when the Barrett Universal II formula emerged in the last decade, it offered a new level of accuracy for IOL selection.
“These formulae have led to greater precision and therefore stronger expectations from patients and clinicians for more precise outcomes,” A/Prof Skalicky says. “The formula combined with toric lenses, in my opinion, were pivotal for procedural outcomes.”
Dr Jack Kane, from Vision Eye Institute in Melbourne, is also among the pioneers shaping the surgical landscape, with the development of the Kane formula in 2017.
These formulae, coupled with the development of more advanced multifocal and EDOF IOLs, has had the greatest effect, according to Dr Kane.
“I’d done quite a bit of research into the accuracy of the different formulas –and I could see that there were points where they would all break down, and often at the extremes of the axial length,” Dr Kane says.
“And often, the patients that are getting the refractive cataract surgery have eyes that fall into these extremes of axial length. I aimed to make my formula accurate at the extremes of axial length.
“Currently, the formulas are extremely accurate, giving 90% of patients an outcome within 0.50 dioptres of target. Improving the accuracy of formulas beyond this will likely require a breakthrough in biometry, where a new measurement may allow us to improve our outcomes even more."
WHAT’S NEXT?
On the horizon, Dr Kane says cracking the code of accommodative IOLs and further refinement in this space would shift the surgical landscape again.
“The ultimate goal is to develop an IOL that can either accommodate or mimic accommodation. This is where you have the visual quality of a single
Image: Chameen Samarawickrama.
A/Prof Chameen Samarawickrama from the Westmead Institute for Medical Research.
focus lens, but the ability to focus up close, and there are lots of people thinking about ways to do that,” he says.
“Then, combining that with some adjustability so that in the future and after you do surgery for someone who’s 60, they can have 30 years of slight adjustments in their IOL to keep their vision perfect even as the cornea changes throughout their life.”
Dr Troski agrees, saying although accommodative IOLs are in stages of infancy, a lens that restores accommodation could define the future of refractive surgery. However, the technology is limited by the ability to develop an IOL that mimics the patient’s natural lens.
Dr Kane adds: “There are different methods to mimic what happens during accommodation, whether that’s due to changes in refractive index of the IOL material, multicomponent lenses that move fluid into different compartments in response to capsule bag contraction or direct movement of the lens as the ciliary muscle contracts. Research is focusing on all these different methods to try and get them to work.”
Dr Troski places Australia at the technological forefront of the refractive cataract surgery landscape – often having access to technology before the rest of the world.
“All the new lenses that I’ve seen in my career, we’ve had in Australia long before they’ve had them in America and often before Europe,” he says.
“Australia has been right at the cutting edge of most of the new technology lenses.”
Despite this, A/Prof Samarawickrama says for indiscriminate and greater health outcomes these advanced technologies should be made available in the public health system.
For example, at Westmead Hospital he conducted a trial where about 60 multifocal lenses and 60 EDOFs were allocated to senior registrars with appropriate training and support.
“We audited the outcomes and found that with appropriate training and support the senior registrar’s outcomes were comparable to the international literature and actually better than standard cataract procedures,” A/Prof Samarawickrama says.
“We created a multifocal pathway to help direct registrars in selecting the correct patient for surgery. This along with mentoring by a senior ophthalmologist seems to work. So, I think there is tremendous value in being able to adopt this training in the public system for the senior registrars.”
He is also a proponent of co-payment models. That way, public patients can opt for a premium lens if they’re willing to pay the difference between the lens costs.
“I think that shift would be advantageous because it means that we’re offering a comprehensive service to our public patients,” A/Prof Samarawickrama says.
To help navigate a complex technological landscape and match the right lens to patients’ eyes, A/Prof Samarawickrama says that emerging technology – such as the Hoya Vivinex Gemetric multifocal IOLs – is designed to shift the light distribution curve, to combine properties of multifocals and EDOFs.
“In one eye you can have distance and intermediate dominance but still have near vision and in the non-dominant eye you can have distance and near with mild intermediate vision,” he says.
Currently, premium lenses are only available to those who opt to have surgery privately. Meanwhile those who have surgery in the public system are typically offered monofocal lenses, or torics if they meet certain eligibility (usually above two dioptres of corneal astigmatism).
“I believe adopting a co-payment system to facilitate access of these
“The ultimate goal is to develop an IOL that can either accommodate or mimic accommodation. This is where you have the visual quality of a single focus lens, but the ability to focus up close, and there are lots of people thinking about ways to do that.”
Dr Jack Kane Vision Eye Institute
Although the lenses are still in clinical trial phase, he hopes to see it successfully implemented in practise.
Beyond the procedure itself and chasing better outcomes for patients, A/ Prof Skalicky says the community has a long way to go with sustainability. He wants to see the broader cataract community in Australia adopt the environmental ethics that their international counterparts have adopted.
“For example, there are some parts of the world such as cataract theatres in India, where the amount of plastic waste they produce from 100 cataract operations is the same as the amount of plastic waste that we might produce from one or two,” he says.
“Why is that? What are the forces in Australia that are making us use plastic? We need a case to move on to a more reusable and smaller carbon footprint way of doing things again.”
A/Prof Skalicky says the transition from cloth drapes to plastic drapes in the operating theatre, and replacement of reusable instruments to single use disposable instruments, was a step in the wrong direction, and is calling for the broader industry to revert back.
“To me, the great challenge now for cataract surgery is to somehow be part of the low carbon transition that is happening in a lot of industries,” he says.
Image: Mark Troski.
Dr Mark Troski, Melbourne-based cataract surgeon.
Image: Jack Kane.
charting new territory A history of
The industry is banding together to celebrate a major milestone since Sir Harold Ridley famously implanted the first IOL. With the lens manufactured by Rayner, CEO TIM CLOVER discusses honouring Ridley’s legacy and how the company continues to innovate alongside inventor surgeons.
Over the course of its 114-year history, intraocular lens (IOL) manufacturer Rayner has had a direct hand in sculpting modern-day cataract surgery. Today, it is celebrating the part it played in arguably one of modern medicine’s most important advancements – as this year marks the 75th anniversary of the first IOL implanted by Sir Harold Ridley.
The lens was manufactured by Rayner at its workshop in Brighton, East Sussex, UK, and implanted in a 45-year-old woman at St Thomas’ Hospital in London on 29 November 1949.
Mr Tim Clover, who took the reigns as Rayner’s CEO in 2014, says the IOL is one of the health industry’s most important inventions – with hundreds of millions of eyes treated since the mid 20th century.
“Giving someone their sight back has overwhelming emotional and economic benefits that are very hard to compare to other procedures,” he
says. “In my mind, it has been the most amazing advancement in medical science which continues to this day.”
The IOL story begins with Sir Ridley who was working at Moorfields Eye Hospital in London during World War II and treating air force casualties with shards of plastic from the Spitfire cockpit lodged in their eye. Curiously, he noticed they did not suffer any inflammation.
From there, he and Rayner’s optical engineer Mr John Pike designed the first IOL –manufactured by Rayner – in the back of Ridley’s Rolls Royce, parked around the corner from Moorfields.
This marked the first of many collaborations between Rayner and experts that would help define cataract surgery, as it is known today, including big names such as world-renowned Western Australian ophthalmologist Professor Graham Barrett.
Since its conception, Rayner’s research and development has been the heart of its operations. So, when Clover was appointed as CEO, he closed the business’ retail optometry business and established a state-of-the-art manufacturing centre on the UK’s south coast with significant investment in R&D.
“We did that with the intention to focus entirely on cataract surgery and to re-discover our entrepreneurial and innovative beginnings,” Clover says.
Images: Rayner.
Sir Harold Ridley designed and implanted the first IOL –manufactured by Rayner – in 1949.
The current market for IOLs is a behemoth, with more than 30 million IOLs implanted annually. As such, it is a vital market for new discoveries to challenge cataract surgeons and take patient care to new heights.
However, a market dominated by a handful of players can stifle innovation so – to not let potential advancements slip by – Rayner plays a unique role in fostering new ideas and providing a platform for critical research. The company is embedded in ophthalmology, helping to bridge the gap between the operating room and lab.
“We have become the partner of choice for inventor surgeons who have great ideas that should be brought to market. And often, we are the primary route to market for them,” Clover says.
Rayner has positioned itself this way, according to Clover, due to the organic R&D structure in place. Not only does it have a dedicated, internal R&D team, but the company’s differentiating factor is the magnitude of external collaborations with both individual surgeons and institutions.
Clover says with 14 product launches in the last seven years, this exemplifies the R&D roots of the company, and echoes the days of Ridley, where a company and surgeon work together to create something “revolutionary”. Among the most pivotal collaborations is helping establish the David J Apple Laboratory in Heidelberg, Germany.
“Dr Apple was partly responsible for designing the edge of the lens which we still use today. And that gives our product some very specific characteristics which makes it attractive to surgeons,” Clover says.
Other important collaborations include that with Professor Michael Amon, a Swiss surgeon, who designed an entirely new type of lens to be implanted in the sulcus, as opposed to the anterior chamber.
More recently, Prof Barrett and Rayner launched the RayOne EMV extending range of vision IOL. Harnessing positive spherical aberration, he spent many years working to bring his concept to market before finding a home in Rayner. In a recent interview with Insight, Prof Barrett had particularly high praise for Clover and the way in which the Rayner respected the essence of his design.
“Graham's EMV lens is our fastest growing and most important lens today,” Clover adds. “And that came homegrown from Australia.”
A NEW ERA
In January 2024, the acquisition of This Ag, the manufacturer of Sophi phaco emulsification machines, heralded a new era in Rayner’s global growth. Through the purchasing of adjacent technologies, Clover says this complements Rayner’s expanding cataract surgery portfolio.
Sophi is a completely cable-free system, with advanced features that provide mobility, simplicity, and safety within the operating theatre.
“It's a standout system. With its styling and technology, it was always the go to product, and an obvious link for Rayner,” Clover says.
Outside of acquisitions, Rayner is consolidating its global footprint by establishing direct commercial operations in countries around the world, including Australia in 2022. Operations have been set up in Sydney and led by country manager Ms Lisa Farquhar.
“This way, we’re able to have a closer, and better relationship with local surgeons,” Clover says.
As an important market with an accessible and high-quality regulatory affairs regime, having a direct presence in Australia for Rayner was an obvious decision. On-ground local knowledge of the Australian market dynamics enables the company to receive immediate feedback to surgeons, which Farquhar says has been at the forefront of Rayner growth within Australia.
“Australian ophthalmologists are early adopters of technologies and are among the most widely travelled and well respected in the world,” Farquhar says.
She says that a direct presence in Australia has enabled the company to focus on its relationship with surgeons and their staff to support the
“Giving
someone their sight back
has
overwhelming emotional and economic benefits that are very hard to compare to other procedures. In my mind, it has been the most amazing advancement in medical science which continues to this day.”
Tim Clover Rayner
rollout of bespoke new technologies for best patient outcomes.
“We are known to take on surgeon opinion which is increasing our recognition as an innovative brand and agile company in the marketplace,” Farquhar says.
Clover adds: “The premium technology is valued and embraced over there. Australian surgeons want to be at the forefront. So, they adopt that technology very readily, which is a good fit for us.”
PAST, PRESENT AND FUTURE
Just as it has had a hand in shaping the past and present of cataract surgery, Rayner hopes to have a hand in shaping its trajectory.
Clover says the company is driven by patient satisfaction – he wants to remove outliers and see near 100% patient satisfaction.
“The dissatisfaction comes from the complicated nature of the IOLs: they contain complicated diffractive structures that split light. This can come with a huge toll on productivity and time of surgery, among other things,” he says.
Hence, the company is exploring new territory. Armed with artificial intelligence, Rayner intends to develop novel optics that mitigate these issues and augment patient satisfaction.
Beyond technology, Rayner can be considered a pioneer in environmentalism with feats including a recycling plant for isopropyl alcohol.
It’s also reduced single-use plastic in products by 60% with updated packaging that eliminates traditional paper instructions and replaces the plastic tray and lid container with a flexible sterility pouch.
“This means you can put twice as many in the autoclave which means you need 30% less energy to sterilise them than you would normally,” Clover says.
This environmentalism played a major role in Rayner’s decision to acquire the Sophi system.
“Sophi has a cassette where all the bodily fluids go. And most companies expect surgeons to change those in between each patient. But the Sophi has a clever mechanism which is patented, which means it's clean and can be used for up to 10 patients at a time,” Clover says.
CELEBRATING RAYNER
The 75th anniversary of the first IOL implant is being appropriately commemorated later this year, with the industry banding together at the United Kingdom and Ireland Society of Cataract and Refractive Surgeons (UKISCRS) 48th Annual Congress in November 2024.
Organised by Rayner in conjunction with the Ridley Eye Foundation, the world’s leading cataract and refractive surgeons will congregate in the Tower of London to firstly commemorate the history of the IOL, and then discuss the technological horizon.
“It's such a nice story and it certainly deserves to be told through history. Hopefully, this is a little bit of a contribution to keeping the awareness going,” Clover says.
world, PanOptix® and Vivity®†*1,2 PanOptix
•>2.2 million implants worldwide**† Vivity
•>1 million implants worldwide†
• The first and only extended depth of focus IOL with X-WAVE Technology#3-8 Now available as a part of the Clareon Collection
†Based on worldwide sales of AcrySof and Clareon IOLs. *Based on worldwide IOL unit sales, 2022. **Based on global Clareon PanOptix and AcrySof PanOptix sales 2021-2022. #Based on in vitro examinations of glistenings, surface haze and SSNGs; as compared to Clareon CNA0T0, TECNIS ZCB00, TECNIS OptiBlue, Eternity W-60 and enVista MX60; n=30 per group; p<.001. 1. Alcon data on file, REF-22137, 2023. 2. Market Scope 2023 IOL Market Report. 3. Clareon Vivity IOL Directions for Use. 4. Alcon Data on File. US Patent 9968440 B2. 15 May 2018. 5. Alcon Data on File. TDOC-0055576. 09 Apr 2019. 6. Bala C, et al. Multi-country clinical outcomes of a new nondi ractive presbyopia-correcting intraocular lens. J Cataract Refract Surg. 2022;48(2):136-143. 7. Werner L, Thatthamla I, Ong M, et al. Evaluation of clarity characteristics in a new hydrophobic acrylic IOL in comparison to commercially available IOLs. J Cataract Refract Surg. 2019. 8. Alcon Data on File. A01970-REP-211731. 12 Jan 2022.
The hottest ticket in town
AUSCRS on Hamilton Island is the place to be in July 2024 if you’re an Australian ophthalmologist. Co-presidents PROF GERARD SUTTON and DR JACQUELINE BELTZ discuss becoming custodians of the conference and offer a glimpse into the 2024 agenda.
For Professor Gerard Sutton, one of the most telling signs about the health and popularity of the annual Australian Society of Cataract and Refractive Surgeons (AUSCRS) Conference is the willingness of international speakers to fly down under for the event.
These are some of global ophthalmology’s biggest names with major demands on their time, yet they can always find time for Australia’s biggest ophthalmology event, next to RANZCO. Among those returning this year include one of the US’s leading anterior segment surgeons Dr Audrey Rostov, India’s Dr Sheetal Brar and Germany’s Dr Florian Kretz who is flying his whole family into the event on Hamilton Island (24-27 July 2024) and will deliver the prestigious Barrett/Wolfe Gold Medal Lecture.
“Professor Graham Barrett and Dr Rick Wolfe – with the support of AUSCRS executive officer Jenny Boden – have created a very unique meeting which has developed such a strong reputation over the years that the international speakers, without exception, always want to come back to AUSCRS,” says Prof Sutton, adding this is the first year they’ve had to knock back abstracts.
“Jacqui and I are at conferences around the world, and ophthalmologists are always pleading with us to invite them along to AUSCRS, which I don’t think is the case for many other conferences. We are very ecumenical; we want to have best informed surgeons distilled down for our participants to come and savor.”
Prof Sutton – co-president of AUSCRS alongside Dr Jacqueline Beltz –says the speaker lineup is only one reason why AUSCRS is a highlight on the Australian ophthalmology calendar. For the general ophthalmologist performing cataract surgery, it provides a genuine update and review in the fields of cataract and refractive surgery, but in a special way. Keen to avoid the stuffiness of some conference formats, he describes the atmosphere as relaxed, but honest. The challenge is maintaining an environment everyone enjoys, while maintaining complete scientific rigor.
“We have the best of the best international speakers who are right on the cutting edge. They come and present their work, but the Australian cataract and refractive surgeons who turn up each year to AUSCRS do so because they get a chance to ask the hard questions of these
leaders in the field,” Prof Sutton says.
“Australia does bat above its weight when it comes to being early adopters in this field. The introduction of the EDOF IOLs is one example. The big companies, like Alcon with Vivity and now Johnson & Johnson with PureSee, come to Australia first so surgeons can test them and be part of the first few studies. Those Australian and New Zealand ophthalmologists using these lenses will stand up and present their data and they can expect to get a grilling, albeit a polite grilling, about what they’re presenting.”
Dr Beltz credits the AUSCRS conference as a foundational part of her career. It’s been an honour taking the reins from Prof Barrett and Dr Wolfe who have grown it into the event it is today.
“They developed AUSCRS over 25 years into a treasured and valuable meeting for many. Gerard and I are just in our second year as co-presidents, and our primary goal at this stage is to maintain the high standards they’ve set,” she says.
“This conference is where I learned to be a cataract surgeon, and I hope future generations can share that same privilege. I believe I can speak for Gerard when I say that our focus is on preserving the essence of AUSCRS – keeping people coming, giving everyone a voice, and fostering a collaborative environment where we can enjoy learning and innovating together.”
Prof Sutton and Dr Beltz agree that inclusivity is central to AUSCRS. Whether someone’s a registrar, in their first year of practice, or an experienced ophthalmologist with some burning questions, everybody is treated equally when they ask questions.
“This focus on dialogue has been carefully cultivated over many years by Prof Graham Barrett and Dr Rick Wolfe, who have worked tirelessly to create an environment that encourages open exchange of ideas,” Dr Beltz says.
By having presenters, including prominent professors, don playful and often humorous costumes – such as a fairy godmother or a T-Rex –AUSCRS aims to break down traditional barriers and hierarchies.
“This light-hearted approach helps to equalise the playing field, making
AUSCRS 2024 is being held on Hamilton Island from 24-27 July 2024.
attendees feel more comfortable to ask questions and challenge ideas, fostering a dynamic and engaging learning experience,” she says.
“The blend of serious academic discussion with a fun, relaxed environment is what makes AUSCRS a standout event on the Australian ophthalmology calendar. It’s a conference where not only cutting-edge scientific knowledge is shared, but also where the professional community can bond, leading to deeper collaboration and innovation in the field.”
EDOFs, SMILE AND MORE
Prof Sutton expects the rise of EDOF IOLs to be one of the hot topics of AUSCRS 2024. The Alcon Vivity caused a splash in this space when it launched locally in 2020/21, followed by Bausch + Lomb’s LuxSmart IOL and Rayner’s RayOne EMV developed with Prof Barrett. J&J Vision’s PureSee is coming to Australian shores, if not already.
“We intend to have an opportunity for the champions of those lenses to stand up and defend or to make a case for why it’s the best,” Prof Sutton says. “It then allows the ophthalmologist sitting in the audience to make a genuine assessment of whether they think that these lenses are right for them and their patients.”
He’s also excited to hear updates on small incision lenticule extraction (SMILE) refractive surgery, a category with plenty of activity in recent times.
“A number of new industry players have come up with different ways of doing SMILE on different platforms. And again, AUSCRS will be the place where refractive surgeons can compare them side-by-side in one session,” he says.
Dr Beltz adds: “I’m also excited about this session. This is the first time we’ve had a whole session focused on this technique, and I believe there will be a lot to learn from the presentations and discussions.
“AUSCRS is unique compared to other conferences in that almost everyone attends every session, so I anticipate that all sessions will be well attended.”
Personally, she has found the abstracts for the cornea session interesting and expects them to draw significant attention. The session on presbyopia correction at the time of cataract surgery is another drawcard, in addition to the complex cases and complications session.
Prof Sutton agrees the complications/complex case series is often a talking point.
“It’s always important to discuss how to deal with problems and in an honest way. I won’t spoil the surprise, but there will be a situation where ophthalmologists will be challenged by a complicated case in the video and there’ll be discussion and probably differences of opinions about how to handle it,” he says.
“These are valuable from an educational point of view, because there’s only one thing worse than being confronted by a complication in the operating theatre that you’ve never seen before – and that’s if you’ve never even thought about how to deal with it.”
ALSO AT AUSCRS
Something different at AUSCRS 2024 will be a wellbeing session led by a high-performance psychologist, alongside a panel of ophthalmologists and trainees from various career stages.
The session aims to explore the different strategies ophthalmologists use to thrive in their work lives. It’s hoped hearing from colleagues at different stages in their careers will provide diverse perspectives and insights and spark discussion.
“It’s an important topic, as maintaining wellbeing is crucial for sustained success and satisfaction in our demanding field,” Dr Beltz adds.
“This session reflects our commitment to supporting the holistic development of our attendees, ensuring they leave not only with enhanced clinical knowledge but also with practical tools to enhance their overall quality-of-life.”
Although the organisers want to keep some surprises for the opening ceremony and Gala Dinner on the final night, they can reveal the Advanced Trainee Program is the biggest yet with 26 sponsored to attend.
It will be the second year Dr Ben LaHood will lead the program after Dr Beltz stepped down from the role.
“This program is particularly meaningful to me because it’s how I got my start at AUSCRS – I’ve attended nearly every year since, and now I’m co-president, which shows how important I think it is,” Dr Beltz says.
“The Advanced Trainee Program covers topics that are not generally included in traditional training. This year, they’ll be focusing on the business side of ophthalmology – an area that isn’t often discussed during training but is crucial for a sustainable and successful career.
“The support staff program is also very well subscribed so far. We have Darren Percival from The Voice and Shih Shih Ta from Vision Eye Institute as keynote speakers. I’m sure their sessions will be a highlight, along with many other engaging and informative presentations tailored for support staff.”
While Hamilton Island provides an ideal backdrop for the conference, Dr Beltz says what she’s looking forward to the most is reconnecting with everyone.
“Whether it’s trainees, seasoned ophthalmologists, support staff, or industry partners, I’m eager to hear about what people are doing differently this year compared to last year,” she says.
“The sense of community and shared learning at AUSCRS is truly unparalleled.”
AUSCRS co-presidents Prof Gerard Sutton and Dr Jacqueline Beltz.
Images: AUSCRS.
With presenters wearing costumes, AUSCRS aims to break down traditional barriers and hierarchies.
AUSCRS 2024 invited international speakers
DR AUDREY ROSTOV, UNITED STATES
Dr Rostov is a cornea, cataract and refractive surgeon based in Seattle, Washington, and global health partner at HCP/ Cureblindness, an organisation eliminating blindness worldwide. She participated in the VISX clinical trials that granted US approval for PRK and LASIK and is the first surgeon in the Pacific Northwest to perform SMILE. Dr Rostov was also the first surgeon to perform and teach femtosecond laser keratoplasty in New Delhi, India. Among a host of awards and accolades – she is involved on the editorial board for several journals. Her current research includes clinical trials for IOLs and crosslinking for keratoconus, ZEDS study, SMILE, new technology IOLs and femtosecond laser keratoplasty techniques.
DR ELIZABETH YEU, UNITED STATES
Dr Yeu is the immediate past president of the American Society of Cataract and Refractive Surgeons (ASCRS) and is based in Virginia. She provides guidance and governance across several national medical boards and committees, including as an examiner for the American Board of Ophthalmology, current advisor of the ASCRS Young Eye Surgeons Clinical Committee, and as the chair of the Cataract Section of Ophthalmic News & Education Network for the American Academy of Ophthalmology. She is also editor-in-chief of U.S. Ophthalmic Review and previously served as the medical editor of Millennial Eye . She has been recognised with awards and featured on power lists.
DR FLORIAN KRETZ, GERMANY
Dr Kretz MD is an internationally renowned ophthalmologist, surgeon, speaker and researcher. As founder and CEO of PVK Precise Vision, and the Precise Vision Ophthalmologists Group, he practises across multiple locations, and as a traveling surgeon around the globe. He has established new treatment methods for cataract surgery and published more than 100 journal articles. He also runs the not-for-profit Augenärzte für die Welt gGmbh supporting the Khmer Sight Foundation in Cambodia.
DR FRANCESCO CARONES, ITALY
Dr Carones is chairman and founder of Advalia Vision in Milan. He has been involved in refractive surgery since 1989 when he started pioneering the use of excimer laser and participated in several clinical trials, including the first human study on hyperopia correction using erodible masks. He explored mitomycin C after laser surgery and was among the first to have access to the tracker-assisted flying-spot ablation technology and to propose LASEK. He was also the first to implant a toric multifocal IOL, as well as a low power add multifocal IOL. Among his many roles, he is associate editor of the Journal of Refractive Surgery and member of several editorial boards, involved with World College of Refractive Surgery and Visual Sciences, Refractive Surgery Alliance and American-European Congress of Ophthalmic Surgery. He has published 161 peer-reviewed papers, books and book chapters on refractive and cataract surgery and corneal topography.
PROF JOD MEHTA, SINGAPORE
Prof Mehta is executive director of the Singapore Eye Research Institute, a Distinguished Professor in Corneal & External Eye Disease and Refractive Department at Singapore National Eye Centre and vice-president of international relations for the American Corneal Society. He has won 70 awards for his clinical and research work, featured in several power lists and is regarded as one of the top corneal and refractive surgeons globally. His research work has generated 18 patents, five of which have been commercialised. He has pioneered Refractive Lenticule Extraction (ReLEx) and has patents on technique of lenticule cryopreservation, performing the first studies on animals. This has been licensed and he established the first approved lenticule bank in the world. He described the novel use of the femtosecond laser in ocular surface surgery (e.g. pterygium), which has the CE mark. Prof Mehta has published more than 520 peer-reviewed publications and 24 book chapters.
DR JOHN KANELLOPOULOS, GREECE
Keratoconus, refractive surgery with customisation and the microsurgery of complicated cataract, as well as cornea transplantation in complicated glaucoma procedures, are the areas of interest for Dr Kanellopoulos. His affiliation with the State University of New York dates back to 1996, and since 2010 he has been a Clinical Professor of Ophthalmology there. He has presented more than 1,000 original paper presentations and published over 130 peer-reviewed papers and dozens of book chapters. Since 2019, he has been the first surgeon to complete laser cataract procedure and IOL implantation through an incision under 1.6 mm. And he has trained dozens of international surgeons in the Athens Protocol CXL for keratoconus.
DR JOSEFINA BOTTA, ARGENTINA
Based in Buenos Aires, Dr Botta is a subspecialist in cornea, ocular surface and external eye through a Fellowship at the Hospital de Clínicas José de San Martín. She was secretary of the Argentine Council of Ophthalmology (CAO) during 2022-2023 and Vice President II of the Argentine Society of Cornea, Refractive and Cataract (SACRyC) between 2021-2022. She was also head of cornea, sclera and amniotic membrane transplantation at the Specialized Surgery Clinic of the City of Buenos Aires from 2014 to 2017.
DR LENA BECKERS, DENMARK
Dr Beckers practises at Precise Vision, Rheine, Germany, alongside Dr Florian Kretz in Rheine, and specialises in cataract, refractive surgery and lid surgery. She has previously worked as a young researcher at Breyer Kaymak Klabe research institute for international innovative Ophthalmic Surgery (I.I.O.), linked to the University of Heidelberg. She has published multiple papers and book chapters, presented at national and international congresses, is a reviewer for multiple peer reviewed journals, and a committee member of GERSO YO.
DR LUKE ANDERSON, UNITED KINGDOM
Dr Anderson was the glaucoma lead for the Cwm Taf University Trust before leaving in 2018 to work in Swansea Bay University Healthcare Trust. He has held several training positions within the Royal College of Ophthalmologists and is currently a founding member on the steering group for implementation of surgical simulation training into the curriculum. His research includes the digital assessment of vision, the use of data and neural networks in the diagnosis and prognosis of eye disease and glaucoma care pathways.
DR PAUL URSELL, UNITED KINGDOM
Dr Ursell has been a consultant at Epsom & St Helier University NHS Trust since 2001 and was recently appointed honorary senior lecturer at the Institute of Biomedical Education, St Georges Hospital Medical School. He combines NHS clinical commitments with undergraduate and postgraduate training, ongoing research projects and running a private practice in Wimbledon. He is the president of UKISCRS, ophthalmic advisor to the Royal Marsden Hospital Drug Development Unit, the Royal College of Ophthalmologists’ (RCOphth) dementia lead, UK representative to the EU (UEMS) and the European Board of Ophthalmology. He also sits on the International Committee of RCOphth and the Education Committee of ESCRS. He has more than 30 publications on cataract surgery and education in peer-reviewed literature.
DR POOJA KHAMAR, INDIA
Dr Khamar currently serves as a consultant in cataract, dry eye, and refractive services at Nethralaya Eye Institute. Beyond her clinical responsibilities, she is involved in translational research at her institute and affiliated organisations, including GROW and IBMS Lab. As one of the few surgeons globally with expertise in all refractive laser platforms, particularly lenticular extraction techniques, she as one of the first Indians to receive the Troutmann Award, the highest honor in refractive surgery.
DR RON YEOH, SINGAPORE
Dr Yeoh is an Associate Professor at Duke-NUS Graduate Medical School and Singapore National Eye Centre and is a founding partner of Eye & Retina Surgeons Singapore. For many years he has taught the finer points of phacoemulsification, FLACS, the use of intraoperative OCT and advanced technology lens implantation. He is a past-president of the Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS) and is scientific committee chairman for APACRS annual meetings. Plus, he is president-elect of the International Intraocular Implant Club (IIIC) and will assume the presidency in 2024.
DR SHEETAL BRAR, INDIA
Dr Brar is a senior consultant in the phacoemulsification and refractive surgery department and a research coordinator at Nethradhama Eye Hospital, Bangalore. She completed a fellowship in cornea at Aravind Eye Hospital, Madurai, and in phacoemulsification and refractive surgery at Nethradhama Eye Hospital. She has received awards at ophthalmology conferences globally, has 14 publications in peer-reviewed journals and is a reviewer for Corne a and BMC Ophthalmology
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treatment of ocular hypertension and glaucoma (LiGHT):
Alcon has now rolled out its Clareon material across its IOL range, becoming a defining feature that surgeons say is offering improved clarity and confidence.
Clareon IOLs and refining excellence
Alcon’s AcrySof Vivity was already addressing an unmet need for cataract surgeons across the country when it launched locally in 2021. Now, with the introduction of the Clareon Vivity, ophthalmologists have added confidence in terms of the long-term performance of an already “industry disrupting” lens.
For surgeons across the country, Alcon’s Vivity intraocular lens (IOL) represented a new dawn for the presbyopia-correcting category by offering excellent distance, intermediate and functional near vision along with a monofocal-like visual disturbance profile. The lens recently surpassed one million implants worldwide and has gone on to become the most implanted extended depth-of-focus (EDOF) IOL.
Now, it joins the suite of Alcon IOLs on the company’s most advanced material yet – the Clareon hydrophobic acrylic. The material was derived from the AcrySof hydrophobic polymer and retains many of the same mechanical properties, while enhancing material characteristics. This includes improved optical clarity and reduced glistenings by increasing equilibrium water content to 1.5%, improving milled edge profile, and a manufacturing process that reduces surface roughness and material inconsistencies.
Australian ophthalmologists Dr Uday Bhatt and Dr Tim Roberts were among the first to assess the material’s performance. In a study published in 2023, they found at three years, 100% of eyes implanted with the Clareon IOL presented with Grade 0 glistenings; and 92.9% of eyes (394/424) had either no posterior capsular opacification (PCO) or clinically non-significant PCO. Visual outcomes were excellent and stable over the three-year study period.
Clareon first became available to Australian ophthalmologists as a monofocal in 2018, followed by the toric version in 2020 and PanOptix in 2023. Within the monofocal range, Alcon has launched Clareon AutonoMe in an extended range of T2-T6 in 25.5 D – 30 D which is now available across Australia and New Zealand. With the addition of Clareon Vivity, Alcon’s IOLs have now completed the transition to the new material, offering an elevated level of confidence and clarity for surgeons and patients, respectively.
Retina and cataract surgeon Dr Angela Jennings from personalEYES in NSW is among early adopters of the Clareon Vivity and has been implanting the lens in patients since November 2023.
Although the AcrySof Vivity has been praised by surgeons and patients alike, Alcon uncovered an opportunity to advance the technology further, something Dr Jennings and her patients have welcomed.
As reported, Clareon has been designed to avoid a glistening effect that can occur when microvacuoles form within the IOL material, causing light to scatter and create a sparkling or shimmering effect. For AcrySof IOLs, this was a concern among some surgeons as, over time, glistenings may contribute to a degradation in quality of vision.
Dr Jennings says Clareon Vivity delivers the same, high-quality refractive
outcomes as its AcrySof predecessor, but with an added level of clarity and without concern over glistenings.
“It’s not prone to that photic phenomenon, glistenings within the material and surface haze. That’s the reason the Clareon is going to give you such a clear vision,” Dr Jennings says.
“In terms of what people can read on the distance chart, we wouldn’t notice an awful lot of difference between the two lenses. But in terms of what they feel about the clarity of the vision, there is certainly an advantage from what I’ve seen.”
Dr Jennings is no stranger to Alcon IOLs and the Clareon material, as they feature heavily within her armamentarium.
“If I’ve got a reason for wanting to put in a monofocal or monofocal toric lens in someone with a lot of macular pathology, for example, Clareon has been my go-to.”
Similarly, NSW cataract, corneal and refractive surgeon Dr Armand Borovik has found Clareon Vivity to be a go-to lens, providing an added layer of confidence that there’s unlikely to be any long-term and adverse effects.
“As a surgeon, it gives you more confidence to use it in younger patients. You’re more concerned about the longevity of the lens material because they have more years of vision left,” he says.
Dr Borovik says with Clareon he has no reservations about the suitability of the material.
Dr Jennings adds: “The Clareon reduces concerns, and you can be very confident with the clarity of the vision. Vision quality is not expected to degrade with time as the lens material is very stable.”
Dr Angela Jennings, personalEYES, NSW.
Image: Alcon.
In a 2023 study, Clareon visual outcomes were excellent and stable over a three-year period.
Image: Angela Jennings.
“Surgeons want the best possible outcomes for their patients, with excellent refractive results, clarity of vision, quality of life and long-term stability. This lens performs very predictably and to an excellent standard on all fronts.”
Dr Jennings says Clareon Vivity allows patients to perform daily activities, such as using a smartphone, without the need for glasses.
Particularly for patients with healthy eyes, it offers a level of independence from glasses that enhances their quality-of-life.
She also notes the benefits for the ageing population, as reducing dependence on multifocal glasses can lower the risk of falls and improve overall day-to-day visual function. Meanwhile, Dr Jennings is enthusiastic about the future of Clareon Vivity.
“Now that we’re going to have free access between them, I think it’s quite likely that I will shift to preferring the Clareon Vivity platform over the previous materials,” she says.
She believes the transition will be seamless for surgeons who have previously used AcrySof Vivity lenses, and that those who were hesitant due to concerns about the materials should consider the Clareon upgrade.
Dr Borovik describes the Clareon Vivity as his “workhorse lens”, and a reliable choice for the majority of his patients.
“I default to that lens and only move outside of Clareon Vivity if the patient is not suitable for an EDOF lens or if they specifically want a multifocal lens,” he says.
In some patients, Dr Borovik has implanted Clareon monofocal in one eye and AcrySof in the other. He says usually they prefer the clarity of the Clareon. The lens’ forgiving side effect profile and high patient satisfaction make it a staple in his practice. He believes that not offering PC-IOLs does a disservice to patients, as the vast majority are suitable candidates for these advanced IOLs.
“My explant rate remains zero,” Dr Borovik says.
He notes that anecdotally, patients may achieve slightly better intermediate or near vision with Clareon, though he acknowledges that this observation requires further study. Despite this, he confidently defaults to Clareon for all suitable patients.
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Dr Armand Borovik describes the Clareon Vivity as his "workhorse lens".
Image: Armand Borovik.
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2 Alvarez-Falcón et al. (2024). Performance of VisuALL virtual reality visual field testing in healthy children. J AAPOS : t 28(1), 103802.
When patients
demand extended range of vision
The optical principle behind the Bausch + Lomb LuxSmart IOL – in addition to monofocal-like halo and glare among his patients – is a major reason why Melbourne cataract surgeon DR MICHAEL SHIU is adopting the lens in more of his patients.
Melbourne cataract and refractive surgeon Dr Michael Shiu is agnostic when it comes to the intraocular lenses (IOLs) he uses. Trifocal, extended depth of focus (EDOF) and monofocol designs – from various manufacturers – are all at his disposal, but ultimately it comes down to the physiology and lifestyle of the patient sitting before him.
Today, around 30% of his surgeries involve an IOL offering vision at varying distances – and the newest design he’s adopted is the LuxSmart Preloaded, a premium hydrophobic IOL from Bausch + Lomb (B+L). Offering an extended range of vision with a monofocal-like visual disturbance profile, he’s found the lens has performed especially well in patients transitioning into retirement.
And with the lens recently released in its toric form (August 2022), its post-operative rotational stability has also been a feature, thanks to B+L’s four-point haptic design.
“For a while I had been using Bausch + Lomb’s monofocal platform, enVista, and have been achieving good results,” Dr Shiu, a cataract and refractive surgeon who works across multiple sites in Victoria, explains.
“I started to build some trust with their product and after reading articles and talking to my rep, I introduced LuxSmart by carefully selecting the patients who I knew would have a strong probability of good results to begin with. I’ve found the lens to be particularly useful in those in the 60-70 age range as they transition out of the working age group. They may be more lifestyle-focused; for example, playing golf or using the computer where there is a demand on their intermediate vision.”
LuxSmart has been available to Australian surgeons since May 2022.
According to B+L, it offers a range of vision required to cover the major needs of cataract patients in their daily activities. The lens has been reported to provide distance and intermediate continuous vision with some spectacle dependence for near tasks. One of the lens’ key attributes is a potentially similar visual disturbance profile to a monofocal IOL.
In Clinical Ophthalmology in 2021, Campos et al. reported the LuxSmart IOL achieved higher performance for intermediate and near vision compared with a conventional monofocal IOL, without increasing the risk of dysphotopsias. They concluded the lens “may be an attractive and safe option for patients who desire spectacle independence for distance and intermediate vision”.
As an adopter of EDOF and multifocal IOLs from various manufacturers, Dr Shiu is particularly fond of the optics in LuxSmart. The lens is based only on refractive profiles (Pure Refractive Optics Technology – PRO Technology), meaning there are no diffractive areas. The optics comprise a refractive aspheric surface at the periphery, a patented transition zone and a 2 mm elongated focus centre with combination of 4th and 6th orders of spherical aberration of opposite signs.
“In some designs, what we know about the technology isn’t entirely clear, whereas with LuxSmart it’s quite clear about how the optics work, utilising spherical aberration to manipulate the light and offer patients and extended range of vision, it’s easy for us to understand,” he says.
For Dr Shiu, a key feature of LuxSmart is the lack of halo or glare reported among his patients. This could be as high as 5% in other EDOFs he uses, and 10-12% in trifocals, according to the literature.
“With LuxSmart, I’m seeing less visual disturbance risk, in fact in my experience I’ve had no reports of this among my patients so far. It is something that quietly surprised me and the lens stands out for that reason,” he says.
In Dr Shiu’s experience, it may take three to four weeks before the patient realises the final outcome. For patients with a larger pupil size, he is more inclined to choose LuxSmart, in addition to those who prioritise distance visual acuity over their intermediate vision.
“Most of my patients achieved 6/6 to 6/7.5 unaided for distance, N8-N6 intermediate and N8 near too with good lighting,” he adds.
With any premium IOL offering an extended range of vision, he says it is vital to manage patient expectations. The lighting conditions, pre-existing dry eye disease, contrast sensitivity and other visual requirements all play a role.
“These technologies rely on a so-called blur circle, so that means there will be blur at some distance," he says.
"Therefore, as a clinician, we have to explain to the patient they may achieve 95% distance vision or 90% intermediate with these lenses, depending on the patient. But I think LuxSmart does perform very well in both eyes, especially for distance – they usually see towards 20/20 for binocular visual acuity."
Bausch + Lomb’s LuxSmart IOL became available to Australian surgeons in 2022.
Image: Bausch + Lomb.
TORIC EXPERIENCE
Since B+L launched the toric version of LuxSmart, Dr Shiu has also moved to implant the IOL in his astigmatic patients too. The LuxSmart toric comes in 0.75, 1.00 and 1.50 D and higher cylinder powers. The additional low power toric (0.75D) allows improved accuracy for the majority of toric patients, who would have otherwise received a 1.00 D lens.
T he IOL’s four-point fixation is a key feature. According to B+L, lenses with this haptic design have shown to have good centration,1 and similar postoperative performances in terms of corrected distance visual acuity, inflammation and primary capsule opacification (PCO) compared with the C-loop design.1
Additionally, around 90% of lenses with four-point fixation rotate less than five degrees at six months,2 and are stable in the eye.3
While Dr Shiu says the lens can tend to rotate peri-operatively in his experience – meaning the surgeon needs to wait until the lens sits properly while avoiding over-inflation of the capsule – post-operatively it demonstrates excellent stability and is a more forgiving lens.
“For EDOF and multifocal toric lenses, this is vital, because if there’s any residual astigmatism, even up to -0.50 D cylinder, this will already degrade the quality of vision because you’re adding another aberration on top. And if you reach -0.75 D cylinder, you will not achieve great outcomes,” he explains.
“But it also means you need to have a strategy in place to correct residual astigmatism, whether that be laser refinement or going back in to re-rotate the lens. I tell my patients there’s a 5% chance of refinement due to astigmatic correction.
"But ultimately, it’s vital for any surgeon implanting these types of lenses to ensure the calculation all the way through to post-op care are performed with precision to avoid issues later down the track.”
LuxSmart also features B+L’s 360-degree continuous square edge on the posterior surface. Nixon and Woodcock4 demonstrated this design element had significantly less posterior capsule opacification (PCO) than a square edge that was interrupted at the optic–haptic junction.
In terms of the learning curve, Dr Shiu says he has taken time to adapt to the LuxSmart lens material that can unfold slower than some other IOLs he uses, and he has been methodical in learning how to use the injector system.
For other surgeons considering adopting the LuxSmart, he says first it is important to understand the technology and physical properties of the lens.
“The second piece of advice is that with a lens of this nature, you’ve got to ensure the patient is easy-going and actually requires that particular range of vision to begin with,” he says.
“The third thing is to always talk to a representative to learn how to use the lens and perform the calculations. Sometimes, you’ve got to trust the platform and be patient with the post-op result. You can’t become too disheartened after the first week when they’re not achieving 20/20 like
“But in my experience, the patient doesn’t usually complain with the LuxSmart compared with some other lenses immediately after surgery, especially with glare and halo. So they have more leniency to wait for it
At the end of the day, Dr Shiu says lens selection is determined by the patient in front of him, taking into account the physiology of their eye,
LuxSmart is providing yet another important tool in an ever-improving suite of IOLs designed to meet the growing demands patients seeking greater freedom from their spectacles. As an example, research cited by B+L shows the use of digital devices by Australian seniors in the near and intermediate visual range has increased in recent years, with senior internet use also increasing from 68% to 93% from 2017 to 2020.5
“The new generation of EDOF lenses is giving additional choice for the patient that wants distance and intermediate vision, with some near vision, while also minimising the potential of glare and haloes,” Dr Shiu says.
“I’m individualised in my approach. Ophthalmologists using these lenses need to take the time to carefully understand the benefits and limitations so they can go through an appropriate patient consent process. By having a go-to lens approach as opposed to tailoring the lens selection, sometimes you run the risk of increasing dissatisfaction, halo and glare because of the aberration factor with these lenses. We’re fortunate to have access to this technology, however all presbyopia-correcting lenses whether multifocal or EDOF require the same
NOTE: References are available in the online version of this article or upon request.
A simple diagram of the optical principles at play within the LuxSmart IOL.
Melbourne ophthalmologist
Dr Michael Shiu.
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Uveitis guide for optometrists
Uveitis is a complex eye condition characterised by inflammation that can lead to serious complications if not managed promptly. HANNAH PELTZER delves into the essentials of the condition, equipping optometrists with the knowledge to recognise its signs, conduct effective examinations and collaborate with specialists.
Uveitis is a potentially sight-threatening condition characterised by inflammation of the uveal tract and classified by its anatomical location1 which includes the iris (anterior), ciliary body (intermediate) and choroid (posterior). When all areas are affected, it’s called ‘panuveitis’.
Uveitis can be acute or chronic and, as primary eyecare providers, optometrists play a crucial role in the early recognition, diagnosis and management. This article aims to provide optometrists in Australia with a comprehensive guide to understanding uveitis, recognising its signs, conducting a thorough uveitis eye exam, providing tailored management, educating patients about the condition and fostering quality collaboration with ophthalmologists.
PREVALENCE AND CONTEXT
Uveitis is an umbrella term for a group of conditions that cause inflammation in the eye (the word ‘uveitis’ comes from the Latin word ‘uva’, meaning grape, and the suffix ‘-itis,’ which indicates inflammation). In Australia, it is most often caused by an autoimmune response, but it can occasionally be due to infections. In the case of autoimmune conditions, the immune system is attacking perfectly healthy tissues.
There is a reported uveitis incidence of 20 in 100,000 people in Australia per year. Across the world, however, uveitis is the third leading cause of irreversible blindness.2 Although it is still relatively uncommon, uveitis needs to be diagnosed and treated quickly and correctly. Anterior uveitis, or inflammation of the iris, is the most common form, and represents 70-90% of all cases.
RECOGNISING THE SIGNS
LEARNING OBJECTIVES:
At the completion of this article, the reader should…
• Know the various signs and symptoms of uveitis in clinical presentation
• Review the essential components of a comprehensive uveitis eye exam
• Review a list of patient questions to ask to ascertain potential underlying causes and associated symptoms of uveitis
• Review recommended dosage guidelines of topical steroid eye drops
Acute uveitis appears suddenly, shows symptoms and typically resolves completely within three months with treatment. In contrast, chronic uveitis tends to develop slowly, may have no symptoms or mild symptoms and can last for several months or longer. Since acute anterior uveitis is the most
common type that optometrists encounter, this article will mainly discuss this form.
Uveitis presents with various signs and symptoms that optometrists should be vigilant in identifying during routine eye examinations. These may include:
• Redness and pain: Patients with uveitis often experience redness, discomfort, or pain in the affected eye. The severity of pain can vary from mild discomfort to severe, debilitating pain.
• Photophobia: Sensitivity to light is another common symptom of uveitis. Patients may report increased discomfort in bright environments or when exposed to light.
• Blurred vision: Blurred vision may occur due to inflammation-induced changes in the structures of the eye, such as the cornea or vitreous.
• Decreased visual acuity: Uveitis can lead to a decrease in visual acuity, which may be mild to severe depending on the extent of inflammation and involvement of ocular structures.
ESSENTIALS FOR A COMPREHENSIVE UVEITIS EYE EXAM
A comprehensive examination of uveitis is crucial for accurate diagnosis and effective management. It involves several key components; each plays a vital role in evaluating the extent and severity of uveitis and guiding appropriate treatment strategies.
B.Optom, therapeutically endorsed Professional services manager & optometrist The Optical Company Images: Hannah Peltzer.
Figure 1: Posterior synechiae with ring of deposits on lens show where the iris was previously attached.6
Table 1. Grading of AC flare and AC cells.
EDUCATING PATIENTS ABOUT THE NEXT STEPS
Effective communication and education are essential when discussing uveitis with patients. Here are some key points to address:
• E xplanation of uveitis: Provide a clear and concise explanation of uveitis, including its causes, potential complications, and treatment options. Explain the need for further systemic testing if required.
• Tr ea tment plan: Discuss the recommended treatment plan, including possible side effects such as IOP response from corticosteroids, dilated pupil, blur and light sensitivity from cycloplegia. Advise the patient to keep any corticosteroids prescribed refrigerated and to shake the bottle vigorously before instilling.
• I mportance of compliance: Emphasise the importance of adherence to treatment and follow-up appointments to ensure optimal outcomes and minimise the risk of recurrence or complications. A handy tip is to put an alarm in their phone reminding them when to use each eye drop throughout the day.
• M onitoring and symptom recognition: Educate patients about the signs and symptoms of uveitis recurrence or worsening, such as increased pain, redness, or vision changes, and instruct them to seek prompt medical attention if these occur.
• S upport and resources: Provide reassurance and provide written instructions on drops and frequency as well as a follow up appointment. Provide them a copy of an anterior uveitis patient brochure if possible.
• Recurr ence advice: Smoking is proven to increase chance of relapse and severity. Advise your patients to cease smoking. There is also a suggestion that there could be a link between vitamin D and recurrence.7 Although more research is needed to confirm this, testing vitamin D levels and treatment is simple so it may be worth advising patients to make sure theirs is in a healthy range with the help of their GP.
• History taking: obtain a detailed medical and ocular history, including the onset and duration of symptoms, past ocular conditions, systemic health, medications and any recent infections or injuries.
• Visual acuity assessment: evaluate visual acuity and document any changes compared to previous visits.
• Pupil assessment: check for pupil size differences; uveitis often gives a miotic pupil
• Slit lamp examination: Use a slit lamp to examine the anterior segment of the eye, including the conjunctiva, cornea, anterior chamber, iris and lens.
• Intraocular pressure measurement: Measure intraocular pressure (IOP) to rule out elevated IOP from blockage of the trabecular meshwork with cells or steroid use. Or low IOP from ciliary body shutdown.
• Dilated fundus examination: perform a dilated fundus examination to assess the posterior segment, including the vitreous, retina and optic nerve head. Look for signs of posterior uveitis such as vitreous cells, retinal vasculitis and optic disc swelling.
SLIT LAMP
Slit lamp examination is invaluable for detecting acute anterior uveitis due to its ability to provide detailed magnification and illumination of the structures in the front of the eye. The typical acute anterior uveitis signs that are often seen on slit lamp examination are:
• Anterior chamber reaction – cells and flare
• Circumlimbal flush due to the ciliary body
being inflamed
• Corneal oedema
• Keratic precipitates – if they’re small, it’s likely acute. Large, waxy ‘mutton fat’ precipitates are an indicator that the uveitis is more likely chronic
• Posterior synechiae (Figure 1)
• Hypopyon, which is suggestive of an infective cause
GRADING CELLS AND FLARE
Grading cells and flare is crucial for tailoring appropriate management and monitoring treatment effectiveness. The best way to do this is to count the number of cells in a 1x1mm beam. Due to the convection currents in the anterior chamber, the cells at the front of the eye, closer to the cornea will be moving up and the ones at the back, closer to the iris, will be moving down. I count all of the cells moving up and then double this to get the total.
Recognising these systemic signs and symptoms can help optometrists identify the underlying systemic condition and guide appropriate management, which is crucial for preventing recurrences of uveitis and managing the overall health of the patient.
QUESTIONS TO ASK ANY PATIENT WITH UVEITIS
It’s important for an optometrist to ask specific questions of their uveitis patients to understand the potential underlying causes and associated symptoms.
• Lungs/chest: do you ever have difficulty breathing, a chronic cough or recent fever?
• Back/joints: Do you have any joint pain, if so, which joints and how many? Do you have any arthritis diagnoses? Do you have back pain or stiffness, especially in the morning or limited motion of your hips?
• Tummy/bowl: Do you experience recurrent diarrhoea, abdominal cramps or pain?
• Groin/mouth: Do you get ulcers or painful lesions in your mouth or on your groin?
• Skin: Do you have any psoriasis or other skin lesions?
MANAGING UVEITIS
The management for acute anterior uveitis is different depending on the severity and presentation. It’s vital to treat the inflammation as well as prevent posterior synechiae and manage ocular pain.
Inflammation
• Corticosteroids
Optometrists need to consider the location that they are trying to reach if using topical steroid eye drops. In acute anterior uveitis, the drop needs
“WHEN PRESENTED WITH A PATIENT WITH UVEITIS ALWAYS ASK YOURSELF: ‘WHY DOES THIS PATIENT HAVE UVEITIS?'”
to reach the anterior chamber/ciliary body and so good penetration is required. The strength and dose used is based on the severity of the inflammation.
UNDERLYING CONDITIONS ASSOCIATED WITH ANTERIOR
UVEITIS
Optometrists should also be aware of systemic signs and symptoms, such as joint pain, fatigue, or skin rashes, which may indicate an underlying systemic condition associated with uveitis.
In the eye, prednisolone acetate 1% is approximately equal to dexamethasone 0.1% in its inflammatory response, however dexamethosone has a higher risk of IOP response. The goal is rapid control of the inflammation and there are some patients that respond better to one than the other.
Dosage Guidelines
• Grade 3-4+ inflammation: one drop every hour. Depending on severity this may include overnight or a loading dose of one drop every five minutes over 15 minutes (four drops total)
before bed and upon waking.
• Grade 2 inflammation: one drop every two hours during waking hours
• Grade 1 inflammation: one drop every four hours
Once the inflammation has recovered to grade 1 or less, a taper of the drops is necessary to both avoid rebound as well as help stop recurrence. A guide for a taper is four times a day for one week, three times a day for one week, twice a day for one week and finally once a day for one week. Once the patient has finished their drops completely, it is important to review the patient’s condition five to seven days later to ensure there is no return of inflammation and that their IOP is normal.
Pupil dilation
In uveitis, there is an increase in Substance-P, an inflammatory cytokin, which induces sphincter contraction (the miotic pupil) as well as fibrin making the aqueous ‘sticky’. Both of these contribute to posterior synechiae development increasing the risk of pupil block.
By dilating the pupil, we lessen the chance of this as well as helping to control the pain from spasm of the ciliary muscle and iris sphincter. Cycloplegic such as atropine 1% two to three times a day while there is active inflammation should
REFERENCES
1. H arthan JS, Opitz DL, Fromstein SR, Morettin CE. Diagnosis and treatment of anterior uveitis: optometric management. Clin Optom (Auckl). 2016 Mar 31;8:23-35. doi: 10.2147/OPTO.S72079. PMID: 30214346; PMCID: PMC6095364.
3. J abs DA, Nussenblatt RB, Rosenbaum JT; Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol. 2005 Sep;140(3):509-16. doi: 10.1016/j.ajo.2005.03.057. PMID: 16196117; PMCID: PMC8935739.
4. Agrawal RV, Murthy S, Sangwan V, Biswas J. Current approach in diagnosis and management of anterior uveitis. Indian J
be prescribed. If there is posterior synechiae, an attempt to break it in the consulting room can be done with Tropicamide 1%, one drop every five minutes for three drops.5
CONCLUSION
When presented with a patient with uveitis always ask yourself: ‘Why does this patient have uveitis?’. Treat the underlying cause if identifiable. Remember, not all uveitis is the same, be sure to tailor your treatment to the individual case and always check IOP at each visit to monitor for any steroid response.
Uveitis is a sight-threatening condition that requires prompt recognition, thorough evaluation and appropriate management to prevent vision loss and complications. Optometrists in Australia play a crucial role in the early detection and management of uveitis by recognising its signs, conducting comprehensive eye exams, educating patients about the condition and collaborating effectively with ophthalmologists.
By staying informed, communicating effectively, and working collaboratively, optometrists can make a significant difference in the lives of patients with uveitis, ensuring they receive the best possible care and outcomes.
5. RVEEH CLINICAL PRACTICE GUIDELINE: Emergency Department Anterior Uveitis (AU)
6. H erbort CP. Appraisal, work-up and diagnosis of anterior uveitis: a practical approach. Middle East Afr J Ophthalmol. 2009 Oct;16(4):159-67. doi: 10.4103/0974-9233.58416. PMID: 20404984; PMCID: PMC2855658.
7. C ERA. Is there a link between vitamin D deficiency and uveitis? 2019 Sept 24
8. O ptometry Australia Clinical Practice Guide for the Diagnosis, Treatment and Management of Anterior Eye Conditions April 2018
ENSURING QUALITY COLLABORATION WITH OPHTHALMOLOGISTS
When should you refer?
Same day/within 24 hours:
• Se vere cases, bilateral, posterior segment involvement, recent surgery, presence of drainage bleb, IOP >30mmHg, monocular patients, very young or very old patients if first presentation.
Within 72 hours:
• Cas es that do not respond to initial treatment. Refer to medical practitioners (GP, ophthalmologist) following second episode 8 or if answered yes to any of the health questions
Collaboration with ophthalmologists is essential for the comprehensive management of uveitis. Optometrists should strive to establish and maintain effective communication and collaboration with ophthalmology colleagues by:
• Re ferral guidelines: Familiarise yourself with referral guidelines for uveitis, including indications for urgent versus non-urgent referral, and ensure timely communication with ophthalmology colleagues regarding patient referrals.
• S hared care protocols: In cases of chronic or recurrent uveitis, consider implementing shared care protocols in collaboration with ophthalmologists to facilitate ongoing management and monitoring while optimising patient convenience and access to care.
• C ase discussions: Engage in regular case discussions with ophthalmology colleagues to exchange knowledge, discuss challenging cases, and ensure coordinated care for patients with complex uveitic conditions.
• Con tinuing education: Stay informed about advances in uveitis management through continuing education opportunities, conferences, articles like this in Insight magazine and literature reviews, and apply this knowledge to enhance patient care and collaboration with ophthalmology colleagues.
• Pa tien t advocacy: Advocate for your patients by ensuring they receive timely and appropriate care from ophthalmologists and supporting them throughout their uveitis journey.
NOTE: Insight readers can scan the QR code or visit insightnews.com.au/cpd/ to access a link to this article to include in their own CPD log book.
Figure 2: High magnification slit-beam photograph 3×1 mm in size in dark room showing presence of cells and flare.4
ABOUT THE AUTHOR:
Ménière's disease: a primer for optometrists
While Ménière's disease primarily affects the inner ear and is typically managed by ENT specialists, vigilant optometrists can play a role in its early detection if they are aware of the condition’s potential ocular manifestations, write PROF WILLIAM GIBSON and DR CELENE MCNEILL.
Ménière’s disease affects about 40,000 Australians. The onset of the condition is usually between 40-50 years of age. The disease can prevent regular work at a time when the sufferer has to support their family. Despite the severity of the disease for the sufferers, curative treatment is still unavailable. Early diagnosis helps to allay fears and provide some simple treatments.
Optometrists are trained to evaluate visual symptoms and ocular health, which can sometimes reveal underlying systemic conditions. In the case of Ménière's disease, certain visual symptoms or findings during an eye examination may raise suspicion and prompt further evaluation and referral.
DEFINING MÉNIÈRE'S DISEASE
Dizziness is the major symptom of Ménière's disease during its early stages. Characteristically, there is a sensation of rotation, which is called vertigo.
The vertigo is usually associated with nausea and vomiting. The vertigo can be disabling and occur without warning.
Each attack occurs for least 20 minutes and may last for several hours. The vertigo usually occurs in clusters of several attacks with in between periods of remission.
DETECTION AND REFERRAL
CLINICAL CPD HOURS This activity meets the OBA registration standards for CPD
LEARNING OBJECTIVES:
At the completion of this article, the reader should…
• Know the four stages of Ménière’s Disease
• Be familiar with the ocular symptoms related to Ménière’s Disease
• Be familiar with the anatomy and physiology of the inner ear
• Be able to discuss Ménière’s Disease with their patients, allying fears and explaining available treatment options
Diagnosis in the early stage is difficult, but may be suspected if symptoms are present. A hallmark of vertigo is nystagmus. During the sensation of rotation, the eyes deviate quickly in one direction and then more slowly return. For a few days after each attack, the nystagmus may still be detected if ocular fixation is removed.
The optometrist may notice that the retina is moving in a jerky fashion if one eye is occluded and a bright light in the other eye prevents ocular fixation.
Questioning your patient about the presence of tinnitus and a sensation of aural fullness can also help to confirm the diagnosis. The patient should be referred to their family doctor who can prescribe medications. Referral to an audiologist who may be able to demonstrate a fluctuating low frequency hearing loss is very important to reach the correct diagnosis.
INFORMED REFERRAL
A typical referral letter received by the audiologists at the Healthy Hearing & Balance Care clinic from optometrists requests an audiogram. It usually includes reference to the patient’s history of vertigo and the fact that an eye examination prompted suspicion of nystagmus and Ménière's disease. It’s also important to include the name and contact details of the patient’s GP.
EAR ANATOMY AND PHYSIOLOGY
The inner ear (Figure 1) has three main components. The pars superior is the cochlea (yellow) which contains the haircells which respond to the sound vibrations entering via the tympanic membrane and ossicles. The haircells transduce the vibrations into electrical energy to activate the auditory nerve and provide hearing.
The pars inferior consists of three semi-circular canals (blue) which measure head movements in all directions and keep the eyes on target. Loss of bilateral semicircular canal function results in opisthotonos, an illusion that the surroundings are bobbing up and down. The lateral semicircular canal is dominant in humans and alterations in its output results in horizontal nystagmus.
The semicircular canals arise from the utricle (green) which contains the otolith organ which provides the sensation of sideways and back and forth movements. Pieces of this organ called otoliths can displace into the semicircular canals, most often the posterior semicircular, which can cause benign paroxysmal positional vertigo (BPPV). BPPV gives a sensation of spinning which lasts a few seconds on certain head movements. There is also another organ within the otolith ‘the saccule’ (green) in the pars inferior which provides the feeling of vertical movements.
The pars superior and the pars inferior are
Emeritus Professor of Surgery, The University of Sydney Image: William Gibson.
BSc (Sp & Hg) MA(Aud) PHD audiologist Healthy Hearing and Balance Care, Bondi Junction, NSW Image: Celene McNeill.
Figure 1: The three components of the inner ear. Image: William Gibson/Celene McNeill.
joined by the ductus reuniens which connects to the saccule. The saccular duct leads to the endolymphatic sinus which also connects via the utricular duct to the utricle. There are two types of fluid within the inner ear: the endolymph and the perilymph. The membranous labyrinth contains endolymph which bathes the haircells in the cochlea and fills the pars inferior. Excess endolymph is called endolymphatic hydrops and is a feature of Ménière’s disease. There is a mechanism called longitudinal drainage which can take the excess endolymph to the endolymphatic sac (red) for removal. For example, when there is an infection within the inner ear, excess endolymph is produced and then drained to the endolymphatic sac removing noxious agents away from the haircells which cannot regenerate.
THE PATHOPHYSIOLOGY OF MÉNIÈRE'S DISEASE
The original description of the disease was by Prosper Ménière in 18611 who recognised that the symptoms were due to an inner ear disorder. It was in 1938 that Hallpike and Cairns,2 and independently Kamakawa,3 described endolymphatic hydrops histologically. It is likely that endolymphatic hydrops relates to the loss of hearing, tinnitus and sensation of aural fullness. An increase in endolymphatic hydrops is probably the cause of the attacks of vertigo.
In ears affected by Ménière’s disease, the passage of endolymph down endolymphatic duct is restricted. This can be due to narrowing of the surrounding bony vestibular aqueduct, but other causes are possible.
There are two main theories of the cause of the attacks of vertigo. Schuknecht4 proposed that ruptures of the delicate Reissner’s membrane within the cochlea caused a mixing of perilymph and endolymph reducing the afferent neural impulses from the semicircular canals until the rupture was repaired.
An alternative theory5 is that when the endolymph drains from the cochlea it cannot pass freely towards the endolymphatic sac and some cochlea endolymph passes into the utricle stretching the haircells within the cristae of the semicircular canals.
DIAGNOSIS
The diagnosis depends on the clinical history of the patient and supportive tests.
The American Academy of Otolaryngology and Head and Neck Surgery (AAOO-HNS) provided the following two categories of the diagnosis of Menière’s disease in 2020.
• Definite MD: Two or more spontaneous attacks of vertigo, each lasting 20 minutes to 12 hours.
Audiometrically documented fluctuating low to midfrequency sensorineural hearing loss (SNHL) in the affected ear on at least one occasion
MÉNIÈRE'S DISEASE OCCURS IN FOUR MAIN STAGES
Stage 1
Hearing aids can help with hearing loss or tinnitus in Ménière's disease. These need to be adjustable as hearing can frequently vary, especially in Stage 2 of the disease.
Ménière's disease at the onset is dominated by attacks of vertigo. There may be a fluctuating hearing loss, tinnitus and fullness in the affected ear.
Stage 2
At this stage, Ménière's disease still causes distressing vertigo attacks, but the hearing loss, tinnitus and feeling of aural fullness can exacerbate the distress. The patient may never recover completely.
Stage 3
At this stage, the attacks of vertigo subside, but the hearing loss is severe, the tinnitus and aural fullness are often persistently upsetting.
Stage 4
The patient experiences a total loss of vestibular function in the affected ear and hearing loss is so distorted that a hearing aid can no longer help.
NOTE: The time between each stage is variable and can take several years. Not every patient reaches Stage 4. The disease is usually unilateral but can become bilateral in 40% of sufferers.
before, during, or after one of the episodes of vertigo. Fluctuating aural symptoms (hearing loss, tinnitus, or fullness) in the affected ear. Other causes excluded by other tests.
• Probable MD: At least two episodes of vertigo or dizziness lasting 20 minutes to 24 hours Fluctuating aural symptoms (hearing loss, tinnitus, or fullness) in the affected ear. Other causes excluded by other tests.
MRI is now the test which excludes other causes.
SUPPORTIVE TESTS
Pure tone audiometry can indicate the stage of the disease. Initially, in Stage 1, the audiogram can fluctuate back to normal levels. A low and mid frequency sensory loss is typical in Stage 2 and in Stage 3, the hearing loss is severe, affecting all frequencies.
• Vestibular tests can show a loss of function in the affected ear. Vestibular function loss may not be evident until Stage 2 and 3. Classically, the caloric test when warm and cool water is poured into the ears and the affected side gives a lesser
response. More recently other tests can be undertaken. The video head thrust (vHIT) tests show the function of each of the semicircular canals. The ocular and cervical myogenic tests can show abnormalities of the utricular and saccular otolith organs.
• Nystagmus during Ménière's attacks is usually horizontal with the fast phase beating to the contra-lateral ear during the attacks and to the affected side during the recovery period. More recently, the advance of portable video technology use in mobile phones has allowed eyecare providers, and patients, to record evidence of nystagmus showing different axis and directions during vertigo attacks.
The following tests are available at major public hospitals and also in specialist audiology centres such as Healthy Hearing & Balance Care clinic.
• Electrocochleography is the recording of the electrical responses in the cochlea to sound. The potentials can be distorted in the presence of endolymphatic hydrops. Electrocochleography is most accurately obtained by a needle electrode
OPTOMETRY, NYSTAGMUS AND MÉNIÈRE'S DISEASE
The presence of nystagmus, particularly during a vertigo attack, can be a clinical sign suggesting Ménière's disease. A clinical presentation of nystagmus offers the vigilant optometrist a potential role in its observation and documentation, particularly with advancements in portable video technology.
• Observation: optometrists may observe nystagmus during an eye examination, especially if they perform tests involving changes in head position.
• Documen tation: with the advent of portable video technology, nystagmus can be recorded during vertigo attacks. This documentation can provide a valuable visual record of the characteristics of the condition, such as axis and direction, which can aid in the diagnosis and management of M énière’s disease.
• Clinic al Insights: the characteristics of nystagmus in Ménière's disease, such as the direction and axis, can also provide clinical insights into the condition’s progression and response to treatment. Optometrists can use this information to collaborate with other healthcare professionals, such as the specialists at Healthy Hearing & Balance Care clinic, in providing comprehensive management for patients with Ménière's disease.
placed through the tympanic membrane (transtympanic). As this is an invasive test, it is likely to be replaced by the Magnetic Resonance Imaging (MRI).
• MRI is likely to become the test for showing the presence of endolymphatic hydrops. The contrast agent Gadolinium (Gd) remains in perilymph and only slowly enters the endolymph compartment. There are serious complications to administrating too high a dose of Gd intravenously, so often it was administered by a transtympanic injection so that the Gd infuses into the perilymph from the middle ear. Because of the advances in MRI imaging and with the use of head coils, the Gd can now be given at reasonably safe levels intravenously. The MRI in a normal cochlea shows the endolymph compartment as a black area where there is little Gd but when there is endolymphatic hydrops, the size of this black area is increased.
PATIENT EDUCATION
While Ménière's disease can be challenging to manage, optometrists can explain to their patients that there are effective treatment options available to help improve sufferer’s quality-of-life. Above all, correct diagnosis and reassurance that
Ménière's disease is not a brain disorder and not life threatening is vital.
During acute vertigo episodes, Zofran (ondansetron) 4-8mg helps control vomiting and a vestibular sedative can be combined. Severe episodes may need paramedical assistance and a vestibular sedative can be administered intramuscularly as oral medication would be vomited. If there are clusters of frequent attacks, steroids given orally or injected into the ear may be needed. For ongoing support between attacks, reduction of salt and increased water intake, and sometimes diuretics to reduce fluid in the inner ear, help. Long term use of prochlorperazine (Stemetil) or similar medications are discouraged because of side effects.
If the attacks of vertigo are frequent and severe, treatment to reduce the strength of the vestibular function are available. A series of gentamicin injections injected into the middle ear can be effective. Surgical treatments include endolymphatic sac surgery. Vestibular nerve section destroys all the balance function in the ear which certainly stops the attacks but has some long-term balance side effects.
“IN THE CASE OF MÉNIÈRE’S DISEASE, CERTAIN VISUAL SYMPTOMS OR FINDINGS DURING AN EYE EXAMINATION MAY RAISE SUSPICION AND PROMPT FURTHER EVALUATION AND REFERRAL.”
TREATMENT OF HEARING LOSS AND TINNITUS
There is no medication to improve hearing loss or tinnitus. However, help is available using properly-fitted hearing aids. The hearing aid needs to be adjustable as the hearing can frequently vary, especially in Stage 2. Tinnitus is due to circuits in the mid brain becoming altered. Tinnitus in Ménière's disease is usually appeased by an alternative sound reaching the brain. Hearing aids can be very successful to reduce tinnitus perception and improve overall hearing.
If the sufferer reaches Stage 4, hearing aids can no longer help. Fortunately, a cochlear implant is often very effective for both hearing improvement and tinnitus reduction.
A HYPOTHETICAL CASE HISTORY AND REFERRAL
John is 45 years old with a young family. One day, he suddenly becomes very dizzy and is vomiting. His wife calls an ambulance fearing the worst. He is taken to hospital, given medication and then allowed home with a suggestion he goes to his family doctor.
Unfortunately, the attacks continue every few weeks and his vision seems disturbed. He goes to
his optometrist who reassures him that his eyesight has not changed but has noticed that he has some nystagmus as his retina moves jerkily when his optic fixation is removed.
The optometrist has some knowledge of Ménière's disease and asks if he has any hearing loss, tinnitus or sensation of ear fullness. The optometrist suggests he has some testing by an audiologist. The results are then given to the general practitioner who has arranged an MRI to exclude the presence of a brain tumour.
The diagnosis has been established, but the clusters of attacks continue. John has had to relinquish his job as he cannot reliably attend work. The general practitioner may refer John to an ENT specialist who deals with Ménière's disease. Audiological and vestibular testing is required to determine best management options.
After appropriate treatment, the vertigo becomes manageable but there is still the worry of declining hearing, and the tinnitus can be very frustrating. The audiologist can provide ongoing support even if a cochlear implant is eventually required.
SUMMARY
The diagnosis of Ménière's disease in the early stages is not easy. Often the first attacks lead to trips to hospital where medication is given to ease the vertigo. The sufferer may be terrified that a brain tumour has caused the vertigo. Early diagnosis of Ménière's disease provides reassurance and can lead to useful treatments.
Optometrists can also provide support and guidance to patients by referring them to audiologists and ENT specialists for further evaluation and treatment. And finally, by educating patients about their condition and the available treatment options, optometrists can empower them to take an active role in managing their health and improving their quality-of-life despite the challenges posed by Ménière’s disease.
REFERENCES
1. M énière P. M Mémoire sur des lésions de l’orielle interne donnant lieu à des symptômes de congestion cérébrale appoplectiforme. Gaz Méd Paris 1861; 16 :597-601.
2. H allpikeC, Cairns H. Observations on the pathology of Menière’s Disease. JLaryngol Otol 1938; 53:624-54.
3. Yamakawa Y. Über die pathologische Veränderung bei einem Meniere- Kranken J. Otorhinolaryngol Soc Jpn 1938; 884:2310-12.
4. S chuknecht H: Correlation of pathology with symptoms of Menière’s disease. Otolaryngol Clin North Am 1968; 1: 433–38
5. G ibson WP: Hypothetical mechanism for vertigo in Menière’s disease. Otolaryngol Clin North Am 2010; 43: 1019– 27.
NOTE: Insight readers can scan the QR code or visit insightnews.com.au/cpd/ to access a link to this article to include in their own CPD log book.
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lenses and service Tailored
PHOYA has developed a suite of progressive lenses catering for any patient that walks through the door, regardless of budget or their visual demands. This, backed with cutting-edge consulting technology, is paving the way for its independent customers to offer a standout service.
rogressive lenses are a staple in any independent optometrist’s product offering. Beyond servicing a growing and ageing patient cohort, the high value lens technology helps create financial stability for the business and, if executed well, build patient loyalty.
Therefore, it's important for independents to make state-of-the-art progressives a centrepiece of their lens offering, says Mr Ulli Hentschel, training and development management at HOYA Lens Australia.
“There's more at stake with a progressive lens dispense. A lot more patient data and information is built into this lens category, and there are greater visual demands from the patient so it’s vital for the independent to deliver on that,” he says.
Hentschel says progressive lenses are also the most important product sold in terms of a practice’s profitability. They yield higher margins, plus the nature of presbyopic patients means customers tend to return regularly for updates. And a satisfied progressive lens patient can generate compounding business for the practice.
“When patients are happy with their progressive lenses, they are more likely to remain loyal to the practice and recommend it to others. With HOYA’s suite of progressive lenses, you can take into account all individual parameters; you're individually tailoring the lens to the patient's face and taking that service to that next level.”
Today, HOYA’s progressive range is spearheaded by the Hoyalux iD MySelf, alongside the MySelf Profile, which have been curated to build on predecessors such as Hoyalux MyStyle V+. The company has placed a major focus on improving adaptability, reducing swim effect and personalisation in these designs.
Hoyalux iD MySelf and MySelf Profile lenses are said to overcome the shortcomings of standard progressive lenses by allowing wearers’ vision to seamlessly transition from near to far and back.
H entschel says feedback from customers using the MySelf progressive has been overwhelmingly positive, which has bred greater certainty among optical practice staff when communicating the benefits of this premium offering.
“This was a significant step up, giving optometrists and optical dispensers greater confidence in recommending the product. Given that progressive lenses are often a high-ticket item, the positive feedback reassured them that patients would love it.”
CRYSTAL CLEAR
Creating the ‘wow factor’ for patients doesn’t happen by accident. Progressive lenses are harder to adapt to than single vision lenses, so the lens design is crucial – something HOYA has achieved by integrating AdaptEase and 3D binocular vision technologies into the product.
AdaptEase gives users a wider visual field without compromising between near and far. Meanwhile, Hoyalux iD MySelf 3D binocular vision is said to reduce distortion and swaying effect along all dimensions. According to the company, binocular harmonisation technology improves depth perception and enhances clarity of vision even in cases of prescription differences between right and left eye.
“The previous flagship product had a few restrictions that made it harder to use and implement into the practice. We resolved those issues and introduced technologies in the new product which reduce peripheral prismatic effects in the near zone,” Hentschel says.
This means patients experience less movement sensation, peripheral distortions or ‘swim effect’.
Higher-end progressive lenses, such as Hoyalux iD MySelf, Myself Profile and iD LifeStyle 4, also work to significantly reduce many adaptation issues to ensure long-term success and comfort. Patient satisfaction was at the
Images:
HOYA.
HOYA’s progressive lens range is spearheaded by the Hoyalux iD MySelf.
core of the design process, according to Hentschel, generating long-term success for patients and, ultimately, for the practice.
EMPOWERED DECISION-MAKING
To ensure patients leave the practice feeling invested, empowered and impressed with their lens selection, HOYA has released a range of digital consulting tools. In addition to high tech centration technology, the company has created an app that front-of-house staff use to walk the patient through the lens consultation. There’s been a major effort to pull apart the various parameters and preferences that go into a lens design, and present these to the patient in a digestible format – all on an iPad Pro. Hentschel encourages independents to go with a lens-first dispensing approach, noting that this will suggest the ideal frame-type, so both components can work in tandem for an excellent vision outcome.
After the patient finishes the optometrist consultation, they are greeted in the retail area by front-of-house staff who take them through the lens consultation on the HOYA Consulting Centre (HCC) 360 app. The platform can be adapted to include the practice’s own logo and even their lens language, helping to elevate and professionalise the service. HOYA describes this as an “all-in-one solution” for the dispensing consultation, and includes advanced customisation software that recommends lens design based on a lifestyle questionnaire and previous lens satisfaction. This ensures that patients receive the best lens design tailored to their needs, for best adaptation and satisfaction.
“Using the HCC 360 consultation app, the optical dispenser sits down with the patient and discusses everything they need to know about the lens technology including coatings, colour change, progressive lenses, occupational lenses. Everything is within the one space,” Hentschel says.
“The HCC 360 app facilitates comprehensive consultations, making the process more engaging for patients. This lens-first approach not only differentiates the practice but also builds loyalty and encourages patients to invest in high-quality lenses. When consumers are engaged in the process and realise they are receiving a truly tailored product, the price-point becomes less of a concern.
“We’ve seen more practices move away from a good, better, best structure, into offering a more customised solution for patients and it’s paying off.”
The consultation app also allows patients to see how various progressive
“There's more at stake with a progressive lens dispense. A lot more patient data and information is built into this lens category, and there are greater visual demands from the patient so it’s vital for the independent to deliver on that.”
Ulli Hentschel HOYA Lens Australia
options would look in the real world. But a key feature HOYA has built into the app is an ability to account for the previous progressive lens that patients have worn. Regardless of manufacturer and model, HOYA has a profile on a significant range of lenses and – whether the patient is satisfied or not – can factor this into the final design of the HOYA lens.
“We've mapped the majority of different lens designs – including brands other than HOYA. We can then select what corridor length they had previously and scale their satisfaction. The algorithm will then merge a similar design, suitable to the patient’s lifestyle and what they've been wearing before.”
Hentschel adds that, as a result, HOYA can significantly reduce any adaptation problems even if patients have been wearing a different manufacturers’ product.
The lens consultation – undertaken on the HCC 360 app – also links with HOYA’s digital fitting and centration systems. Today, there are two options: the HOYA Digital Fitting app and the visuReal AI wall mounted system.
The digital fitting app uses LiDAR scanning technology in iPad Pros and provides a portable and accurate method for obtaining all necessary measurements. It uses a single photo for fitting measurements and one for reading distance and position.
“Digital fitting offers convenient and accurate individual parameters. You can get all those parameters in a convenient, portable version. If you don't have the room to have a wall mounted device, for example, this is an accessible option,” Hentschel says.
Meanwhile, the visuReal system has undergone a recent upgrade to incorporate AI software offering automatic measurement capabilities that simplify the fitting process. According to HOYA, the AI-powered algorithm has been trained to reduce manual adjustments, resulting in a simpler, more efficient and accurate as well as a less user-dependent process.
Equipped with six specially designed cameras and resembling a “high-tech mirror”, it automatically optimises the images it captures of customers wearing their frames.
“VisuReal has taken the existing device – which is already accurate – and taken it to new heights. The patients engage with a mirror with LED lights and cameras going up and down. With the incorporation of this AI software, it has been taken to another level where automatic measurements are incredibly fast,” Hentschel says.
“As soon as the photos taken, there's virtually nothing that you need to do with it. Just click ‘Save’ and then ‘Next’.”
Together, HOYA’s progressive lens technology – coupled with a seamless retail experience powered by new digital consulting tools – is helping practices execute a memorable service. It’s a key differentiating factor for independents who are increasingly focusing on quality and service over price, to remain competitive.
“If consumers have had all this involvement in building a product tailor made for themselves, they can relay their experience to others, and start to build that following and loyalty with the practice,” he says.
“At the end of the day, there's so much technology that goes into a lens that’s often invisible to the consumer. But if you get them involved in the process and demonstrate the value they are receiving, it will completely transform their perception of the product.”
Featuring the five most popular customised designs (from left: adventure, detail, expert, modern and stable) based on visual needs for today's lifestyle, HOYA says its Hoyalux iD MySelf Profile progressives offer wearers easy focusing across all distances and comfortable vision – and also while using digital devices.
O-SHOW24 and the return of ODMA Fair
As the Optical Distributors and Manufacturers Association dropped the curtain on O-SHOW24 in Sydney, it announced plans to bring back ODMA Fair in 2025.
One of the Australian optical industry’s signature events O-SHOW24 concluded with close to 1,000 visitors turning out over two days, and a strong showing from independents from NSW and beyond.
The boutique trade fair, which took place at Sydney’s Hordern Pavilion over 17-18 May 2024, has been hailed as a success with several adjustments made to this year’s program to improve the attendee experience.
With O-SHOW having a strong commercial focus, the biennial event was also timed to coincide with Optometry NSW/ACT (ONSW/ACT)’s Super Sunday CPD event so optometrists could engage in trade and education across the same weekend.
Optical Distributors and Manufacturers Association (ODMA) CEO Ms Amanda Trotman hoped for a 1,000+ event, and that was exceeded with more than 1,300 total industry professionals coming together for the event including suppliers, media, students and other industry representatives.
“This is the first time we’ve opened late on the second day until 7pm, the intention was to allow those that had a busy day in practice on Saturday to still come and see the show. Whilst some people have made the effort to come down the Saturday evening did not end up as busy as the Friday night and likely Sydney’s polar blast weather on the Saturday worked against us,” she said.
“We’ve asked attendees whether they are a single independent practice, have multiple practices or are part of a chain, and the numbers show there was at least 800 visitors from independents in attendance; that’s a significant representation and the key market for our exhibitors.
“This is unashamedly ODMA’s commercial show, and it’s all about the
quality of people that come here with the intention to buy products and services – and I think we have delivered on that.”
Of the 1,000 attendees, approximately 30% were classified as owner/ director, 30% optometrist, 30% optical dispenser and 10% miscellaneous.
“We’re happy with the mix. It’s clear businesses see the value of sending multiple people from their practice. We’ve also had 100 people from Queensland and 100 from Victoria registered, as well as some international too. That indicates people will travel for this sort of event even without the clinical component.”
In addition to later opening hours (10am-7pm both days), this year’s event included a Frames Central zone in the centre of the trade floor. While exhibitors didn’t hero one of their brands as anticipated, Trotman said it still served its purpose.
Images: ODMA.
O-SHOW24 took place in Sydney’s Hordern Pavilion over two days in May 2024.
Equipment demonstrations were a major component of O-SHOW24.
Image: ODMA.
“These more affordable booths have allowed smaller suppliers to exhibit and be part of the show. We’ve had great feedback about the breakout areas where people could sit and network over a free cup of tea. It made for a nice casual atmosphere where people enjoyed mulling around, so I would like to put more of those areas in the next show.”
The short educational sessions, held in a small upstairs room overlooking the trade floor, were a small, yet important, aspect of the show.
Highlights included the joined session by Eyecare Plus’s Mr Philip Rose and ProVision’s Mr Mark Corduff who delivered some important truths about buying and selling independent practices, getting deep into the financials that lead to a successful transaction for both parties (more can be found on page 59).
Meanwhile, Ms Fatin Tobia, from Eye2eye Marketing 360, offered key insights into the art of patient recalls, promoting a switch back to the traditional method of personalised phone calls as one of the best methods to ensure patient retention.
Apart from the education sessions, Trotman said the equipment demonstrations were another highlight of the show.
“For those who would prefer not to have the one-on-one demo, it’s a nice way to get a general feel for the instrument, and maybe book a more comprehensive appointment later. It’s been a nice approach that we will take forward,” she said.
“This year we’ve also collaborated with Optical Dispensers Australia for the eyewear making workshops with Chris Savage, which a handful of people have taken part in. At the end of the day, that’s what it’s all about: collaboration and ensuring there is something for everyone in the optical industry all under one roof.”
As for the future of O-SHOW, Trotman hinted that while the essence of the show would remain in the future, ODMA is considering a change in location. More details are expected to be announced soon.
ODMA FAIR RETURNING IN 2025
Shortly after O-SHOW24, ODMA revealed the renowned Australian optical industry event ODMA Fair is returning in 2025 and is heading to the International Convention Centre (ICC) in Sydney over three days from 27-29 June.
The event is set to showcase the latest eyewear, equipment, lenses and optical related offerings within the Darling Harbour precinct providing a stunning setting for suppliers and industry professionals in attendance.
O=MEGA, an event jointly owned by ODMA and Optometry Victoria South Australia (OVSA) that was cancelled in 2021 due to COVID and last ran in 2023, will not run in 2025. ODMA and OVSA will continue to explore potential future collaborative event opportunities that work for both parties. Trotman said ODMA Fair in 2025 would allow the organisation to expand on the O-SHOW offering that has been popular in recent years.
“At O-SHOW, we must limit exhibitors to no more than four booth spaces and whilst we love the format and boutique feel, it will be great to enable
those wanting more space to expand their presence and to allow for a broader range of exhibitors to be invited to participate,” she said.
“All those with services to offer the optical industry will be invited to exhibit – frames, lenses, sunglasses, accessories, equipment, devices, buying groups and business services.”
ODMA will be expanding the event speaker line-up and seeking out both optical and business presenters to address key areas of interest for attendees to address their business challenges.
A key feature of the speaker program will be consideration of the amount of time required to cover specific topic, rather fitting sessions into hourly timeslots.
“We feel this approach to presentation content which compliments and runs in harmony with a major products and services trade fair, will set this event apart, especially given there is already a broad range of CPD focused events on offer for optometry professionals, whether that be live local events or virtually,” Trotman said.
“An event taking place at the end of financial year should also assist those wanting to invest in larger orders, as it provides for making purchases within the current or following financial year. The event will be one that welcomes
ODMA 2024 FRAME AWARDS
Four eyewear pieces were recognised as part of ODMA’s frames awards program at O-SHOW24. They were:
• Avanti PRIDE (Modstyle) – 2024 Outstanding Frame – RRP under AU$300
• K ahiko Maui Jim (Maui Jim) – 2024 Outstanding Sunglasses –RRP under AU$300
• Ne fertari – Camilla (Sunshades Eyewear) – 2024 Outstanding Frame – RRP AU$300 and over
• R ocket Man Cutler & Gros (Noo Eyewear) – 2024 Outstanding Sunglasses – RRP AU$300 and over.
Image: Prime Creative Media.
The winning frames (from left) Kahiko Maui Jim, Rocket Man Cutler & Gros, Avanti PRIDE and Camilla’s Nefertari.
A panoramic shot of the O-SHOW24 trade exhibition.
GEOGRAPHIC ATROPHY
WE CAN’T WAITAND SEE
People living with geographic atrophy (GA) have reduced independence and quality of life due to vision impairment.1-3
At Apellis, our goal is to bring to market a treatment for this debilitating disease.
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Vision impairment due to geographic atrophy may vary.
References: 1. Singh RP, et al. Am J Ophthalmic Clin Trials 2019;(1):1-6.doi:10.25259/ajoct-9-2018. 2 . Sivaprasad S, et al. Ophthalmol Ther. 2019;8(1):115-124. 3. Patel PJ, et al. Clin Ophthalmol. 2020;14:15-28.
Apellis Australia Pty Ltd, L3, 141 Camberwell Rd. Hawthorn East, VIC, 3123, ABN 87 600 316 612 April 2024 | AU-GA-2400032
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Many patients believe one pair of spectacles will do the job for every task, but this may change over time. That's why practitioners need to prepare for this scenario, including conversations around a second pair, writes NICOLA PEAPER.
T"WHEN CONSIDERING AN OCCUPATIONAL LENS, CHOOSE ONE THAT IS SUITABLE FOR THE VISUAL TASK THAT WILL DELIVER THE CORRECT POWER AT PUPIL HEIGHT."
he frequent question that lens sales reps and customer service operatives are asked is: “Which of your multifocal lens designs will work best for a patient who wants to drive and use a desktop computer?” The reply is, unless the patient still has a level of accommodation, none. To have an ergonomically correct position for a desktop screen the patient needs to be able to see around 80 cm with their head in a straight-ahead position. This means that the power at pupil height, made up of accommodation and lens power, needs to be +1.25 D. If it is less than that the patient will have to lift their chin, potentially exposing them to computer back/neck syndrome.
Consider a first time presbyope with a +1.25 D addition. They have at least 1.25 D of accommodation left which is sufficient to see a screen at arm’s length. Looking through a point at the fitting cross, any progressive lens design will work to give them clarity for screen use. As the presbyopia goes up the patient will probably start to lift their chin to access some of the add but, as the add is low the subsequent corridor width is high, they will probably have enough width for a couple of screens.
When the addition goes up to +2.00 D and there is only +0.50 D of residual accommodation, they will now need at least +0.75 D of power from the corridor of the multifocal. To access this power they will need to lift their chin. If the corridor is 16 mm long and we assume the power comes in at a rate of 0.13D/mm (2.00D/16mm), to achieve at least +0.75 D, the patient must use a point 5.8 mm below the fitting cross. This will probably be in the narrowest part of the corridor.
One regular response is to shorten the corridor and ‘push’ power up the lens. With a 14 mm corridor, the power rate is 0.14D/mm. Now the point at which 0.75 D is achieved is 5.4 mm down. This 0 .4 mm gain is not going to be noticed by the patient. However, the subsequent reduction in corridor width and increase in head movement to see the full screen width will be.
The solution is to have an occupational
lens for computer use, and the patient needs to be warned that this may happen at every point of their presbyopic journey. Patients can be very tolerant and so to warn that problems may occur and, if they do, there is a solution will set both practitioner and patient up for a second pair conversation.
When considering an occupational lens, choose one that is suitable for the visual task that will deliver the correct power at pupil height.
Digressive lenses were developed for close visual tasks and there are many different ‘PC’ type lenses on the market. These designs tend to have long corridors of 24 mm or more and the pupil sits about a third of the way down They will always deliver the correct amount of power so that, depending on the level of residual accommodation, the patient will be in a comfortable posture for looking at screens. As the digression carries on above pupil, they also give depth of clear vision beyond the screen. These lenses are ordered with distance script and add as the digression will differ depending on accommodation available.
Because digressives have a corridor, as the addition increases the available width for screen use goes down. By the time the addition is over 2.00 D there probably will not be enough width for multiple screen use. In these cases, one option is to use a single vision lens with a boost of power, so called anti-fatigue lenses. Ordered with an intermediate script for screen use and a boost sufficient for working at 40 cm, this can be a good solution. The drawback is that the patient has less depth of vision and will not be able to see clearly beyond their screen.
The fact remains that many patients think that one pair of spectacles will always suffice for every task, and with low additions this maybe the case. However, good practice dictates that practitioners should warn that this may change and then be familiar with suitable second solutions.
ABOUT THE AUTHOR: Nicola Peaper is the national professional services manager for Rodenstock Australia. She spent 20 years working as an optometrist in the UK, and for the past 17 years she has worked within the lens manufacturing industry.
NICOLA PEAPER
ABOVE: Occupational lenses for computer use hold the key to overcoming potential back and neck issues for progressive lens wearers.
Images: Rodenstock.
Insight Dry Eye Directory is back in 2024
The October 2024 issue will feature the Insight Dry Eye Directory, Australia’s most comprehensive source for dry eye care.
Back by popular demand, this all-in-one resource is a valuable purchasing guide for practices, showcasing available Therapies and Diagnostics in Australia. It will also feature a comprehensive list of dedicated Dry Eye Clinics.
It’s FREE and EASY for you to list your products or services.
If you operate a dry eye clinic, or are a supplier of dry eye products, scan the QR code to organise you listing, or visit www.surveymonkey.com/r/INSIGHTDryEyeShowcase2024
To amplify your product via advertising, contact
Insight Brand Manager Luke Ronca: 0402 718 081 or luke.ronca@primecreative.com.au
Scan HERE to arrange your listing.
ORTHOPTICS AUSTRALIA 2024-25 FEDERAL BUDGET REFLECTIONS
Orthoptics Australia president AMANDA FRENCH reviews the 2024-25 Federal Budget and what it means to the allied health sector.
"FUNDING FOR STUDENT PLACEMENTS SHOWS AN UNDERSTANDING OF THE PRESSURE ON HEALTH STUDENTS. OA WILL WATCH THE IMPLEMENTATION OF THIS INITIATIVE AND LOOKS FORWARD TO A POSSIBLE FUTURE EXPANSION OF THE SCHEME TO ORTHOPTICS."
Orthoptics Australia (OA) welcomes the Budget announcements for the eye health sector including new and amended Medicare Benefits Schedule (MBS) listings, such as:
• From 1 July 2025 the implementation of the majority of recommendations for changes to MBS items from the MBS Review Taskforce Ophthalmology report, along with other minor changes to MBS items that relate to the eye and associated anatomy.
• From 1 March 2025, the implementation of the majority of recommendations from the MBS Review Taskforce Optometry Report.
• Additionally, there is the inclusion on the PBS for tebentafusp (Kimmtrak) for the treatment of advanced melanoma of the middle layer of the eye.
OA is also happy to see the Federal Government providing $23.1 million over two years from 2024-25 to extend the MBS Continuous Review program that ensures the MBS remains clinically appropriate. OA understands that the review will begin in 2024 and will include allied health Items.
Looking across the broader allied health sector, there were additional announcements welcomed by OA.
The commitment to funding for student placements shows an understanding of the pressure on health students in Australia. OA will watch the implementation of this initiative and looks forward to a possible future expansion of the scheme to orthoptics. Supporting orthoptic students through a similar measure would be a positive move to attract and maintain students in fields with high demand for workforce such as orthoptics.
OA supports the government’s intention to explore the introduction of a psychology assistant role. OA agrees that clarity of the role of the growing assistant workforce will underpin the quality and safety of healthcare.
The allied health sector is a vital part of healthcare provision in Australia. Allied health professionals provide a broad range of diagnostic, technical, therapeutic and direct health services to improve the health and wellbeing of the consumers they support.
It would have been wonderful to see more recognition of the allied health sector
in the 2024 – 25 Budget.
OA has been keenly watching and participating in the ‘Unleashing the Capacity of our Health Workforce’ scope of practice review. This independent review, led by Professor Mark Cormack, is looking at the available evidence about health professionals’ ability to deliver on their full scope of practice in primary care. The review was a recommendation from the Australian Government’s ‘Strengthening Medicare Taskforce Report’.
We hope to see the outcomes of the review informing future direction of primary healthcare in Australia and the 2025 -26 Budget.
ABOUT THE AUTHOR: Associate Professor Amanda French is the president of Orthoptics Australia. She graduated as an orthoptist from the University of Sydney in 2007 and completed her PhD in 2013.
and equity in eye health care. Visit: orthoptics.org.au
Image: Orthoptics Australia.
ORTHOPTICS AUSTRALIA is the national peak body representing orthoptists in Australia. OA’s Vision is to support orthoptists to provide excellence
Image:
Robyn
Mackenzie/Shutterstock.com.
FINDING CLARITY IN CORPORATE CONTRACTS
With increasing pressures on practitioners running independent practices, more are seeking the security of a corporate network. KAREN CROUCH breaks down the key components when negotiating your future.
“INDEPENDENCE
IN EXERCISING ONE’S DECISION MAKING IN SUCH CLINICAL MATTERS IS ESSENTIAL
TO THE PRACTITIONER AND HEALTH OF THEIR PATIENTS."
The ophthalmic industry is no stranger to corporate networks, and medical practitioners need to make informed decisions when considering joining one. An essential, preliminary step is to assess basic alterations to one’s lifestyle and changes from totally independent business management to an environment which may be quite different; not to say it will be challenging but will certainly require adjustments.
Legally binding contracts and service agreements provide the glue for business management and operating infrastructure. One of the larger GP corporates attracted unwanted press some time ago for suing its doctors for breach of restraint of trade and for failing to work contracted hours, highlighting the need for upfront, thorough assessment of requirements of such agreements and likely impacts on a practitioner’s ongoing working life.
The essence of ‘corporatisation’ is acquisition of a medical practice by a large corporation serviced by several practitioners, commonly supported by a service agreement for (newly joining) principals behind the practice to continue providing their services.
providing services, can be fraught if they do not obtain legal and tax advice on both sale of their existing practice and their continuing obligations in the new corporate environment. There are many considerations when deciding whether to corporatise. These may include sacrificing the benefits and independence of ownership including development of a practice culture that is consistent with the owner’s personal principles and vision.
TERMINATION
BELOW: Owners should be wary of fixed term contracts that provide no opportunity to opt out should they become dissatisfied, says Karen Crouch.
Of key concern to the principals –previously the owner – is what they will receive in exchange for parting with ownership of their medical practice and how financial proceeds will be treated for taxation and personal wealth creation purposes.
The decision to sell an owner’s medical practice, and thereafter contract with the corporate to continue
Generally, contracts will provide for termination at any time by mutual agreement. However, most contracts to enter a corporate practice are set for fixed periods of time, usually a significant number of years. This is a huge commitment by newly joining principals to ensure longer term stability, longevity and profitability. Owners should be wary of entering fixed term corporate contracts that provide no opportunity to opt out should they become dissatisfied with working or patient management conditions. It is essential that owners fully and thoroughly explore the practice, facilities, prevailing corporate culture and legal obligations to ensure they will be able to work to their satisfaction (and expectations of the new principal) in the facility. A friendly discussion with a currently practising, previous practice owner, is suggested.
RESTRAINT OF TRADE
It is customary for service agreements to include reasonable restrictions that the practitioner must not provide medical services in a specified area and for a specified period after, or while, the agreement is in force. There is no hard and fast rule about geography of the operating areas or what time period is reasonable. Each situation must be judged according to individual circumstances and appropriate legal advice obtained.
In Idameneo Pty Ltd v Dr Teresa Angel-Honnibal [2002] NSWSC 1214, Justice Palmer stated:
“A factor to which the court has regard is whether the parties have, as a result of negotiation on equal terms, freely made a bargain in which the particular restraint has been sought by one and given by the other… the party seeking to enforce the restraint still bears the onus of showing, by sufficiently persuasive evidence, that the protection of the covenant is no greater than is reasonably necessary between the parties.”
INDEPENDENCE
The service agreement should contain a clause that the practitioner has “sole and unfettered right to make decisions about the treatment of patients” and will not be subject to any direction from the corporate concerning the way in which the practitioner provides services to their patients. Independence in exercising one’s decision making in such clinical matters is essential to the practitioner and health of their patients. It is advisable to envisage, to the greatest extent possible, the future when a practitioner may no longer wish to practise under the guise of the corporate but resume independent practice. You may find yourself having to start from scratch, having to leave your (corporate) practice, patients, records and staff behind as you move on to re-establish your name, reputation and clientele in a different environment, with which you were hitherto familiar.
Consider your options and future carefully before deciding to join a corporatised practice. These caveats are not intended to discourage interested practitioners but to bring attention to potential challenges of a new working environment which is influenced by another parties. Many large corporates operate successfully and to the personal satisfaction of their private practice owners.
ABOUT THE AUTHOR: Karen Crouch is the managing director of Health Practice Creations Group, a company that assists with practice set ups and the administrative, legal and financial management of a practice. Contact her via email kcrouch@hpcnsw.com.au or visit www.hpcgroup.com.au.
Image: Lee Charlie/Shutterstock.com.
Image: Karen Crouch.
SOAPBOX
BUYING AND SELLING INDEPENDENT PRACTICES
BY PHILLIP ROSE & MARK CORDUFF
Australian optometry market. The future is bright, and for the right practitioner, it is rewarding on multiple levels whether it’s being in control of your career and decision making, through to commercial advantages such as tax benefits, uncapped earning potential and the reward of one day selling your business.
Nevertheless, navigating the transaction of independent optometry practices can be daunting, especially for buyers. Recently, we have seen a growing number of younger aspirational optometrists seeking independent ownership. There’s also been considerable interest in greenfield practices, and while admirable, we encourage buyers to acquire an existing practice with an established patient base, goodwill, and often a fit out and equipment. Financiers will also view this more favourably.
After facilitating many transactions over the years, we have identified some key metrics and models that ensure the best result for both parties. Example: for a practice turning over $820,000 from retail sales and consulting income, $220,000 could be spent on cost of goods, leaving a potential $600,000 gross profit. From there, we minus some average expenses such as marketing ($20,000), financial costs ($25,000),
wages ($360,000), rent and outgoings ($80,000), utilities ($20,000), leaving $505,000 in expenses. The adjusted net profit is $95,000. A common issue is the owner excluding their salary in the practice wages, inflating the net profit. Be aware, this will be adjusted when the accountants audit the financials for sale.
Buyers and sellers can expect the practice to be worth 2.8-3.5 times the net profit. In the example, that’s around $285,000. This excludes recently purchased equipment or inventory that, depending on negotiations, can be added to the value. If selling, you want to show the buyer the maximum theoretical available cashflow by washing out the tax minimisation strategies, extra super contributions etc. Also, a practice management software report won’t suffice, it needs to be an audited profit and loss (from the past three years) that clears the accountants and ultimately the buyer’s bank.
Rent is also important. This can be as low as 5% of turnover in regional areas, while in metro areas or shopping centres, it will ideally be between 10-15%. This is an advantage of going regional, in addition to more staff stability and many owners benefit from lower housing costs and a brilliant lifestyle.
Buyers can be found in many places, but it’s important for sellers to start under their nose. Often, we ask if the employed optometrist would be interested, or maybe a nearby practice wants to expand? The
more successful transactions often involve the selling/retiring optometrist phasing out. With a longer succession strategy, you transfer goodwill to the new owner and therefore drive up the practice’s value, protect the legacy and create a larger pool of potential buyers. You also become the practice’s locum post-sale, if you wish.
We’re often asked to value a practice to the cent, but it’s not a science. Often, the available market dictates this. Sometimes, the owner has several offers, but the preferred candidate isn’t the strongest bidder (because they are a better fit for the practice).
Owners should consider they may work alongside the buyer for two to three years, and should be happy for them to look after their patients long-term.
And if you’re selling, remember the buyer is coming in unemotionally, and may talk the price down. To achieve what your practice is truly worth, you need clear explanations and documentation to support your valuation to provide buyers confidence and understanding they can achieve a return on their investment.
The nature of your practice will determine the buyer pool. Not everyone is seeking a contact lens or behavioural practice. It’s also important to manage expectations around the time it will take to execute the sale. Marrying the seller with potential buyers can take time.
Sometimes they fall through so having a contingency plan is important While not without its challenges, independent ownership can be one of the most rewarding journeys for an ambitious optometrist – and you don’t have to do it alone. Whether it’s joining formal groups like Eyecare Plus or ProVision, or informal chats with others who have been there before, the independent community is collaborative and supportive.
ABOUT THE AUTHORS:
Name: Philip Rose; Mark Corduff
Affiliations: Eyecare Plus, general manager; ProVision, business services manager
Locations: Sydney; Melbourne
Years in industry: 15; 5
YOU NEED CLEAR EXPLANATIONS AND DOCUMENTATION TO SUPPORT YOUR VALUATION TO PROVIDE BUYERS CONFIDENCE AND UNDERSTANDING THEY CAN ACHIEVE A RETURN ON THEIR INVESTMENT.
Eyecare Plus' Philip Rose (left) and ProVision's Mark Corduff presenting at O-SHOW24.
Image: Prime Creative Media.
EVENTS CALENDAR
JULY 2024
To list an event in our calendar email: myles.hume@primecreative.com.au
Ophthalmology Updates! will be held 24 -25 August 2024 at the Fullerton Hotel in Sydney, with RANZCO-approved 12 CPD points on offer.
SPECSAVERS CLINICAL CONFERENCE (SCC) 2024
Gold Coast, Australia 14 – 15 September specsaversclinicalconference.com.au
NORTH QUEENSLAND VISION CONFERENCE 2024
Cairns, Australia
6 – 7 July optometryqldnt.org.au/nqv
NATIONAL ACBO CONFERENCE
Gold Coast, Australia 6 – 7 July acbo.org.au
AUSCRS 2024
Hamilton Island, Australia 24 – 27 July auscrs.org.au
AUGUST 2024
EUROSCOLE AUSTRALIA
Melbourne, Australia
3 – 4 August euroscole.com
TASMANIA’S LIFESTYLE CONGRESS
Tasmania, Australia 17 – 18 August taslifestylecongress.com.au/
OPHTHALMOLOGY UPDATES!
Sydney, Australia
24 – 25 August ophthalmologyupdates.com
PROVISION NATIONAL CONFERENCE
Perth, Australia 30 August – 1 September icmsmeetings.eventsair.com/provision-2024
SEPTEMBER 2024
ESCRS 2024
Barcelona, Spain
6 – 10 September escrs.org
BLUE SKY
Adelaide, Australia 13 – 14 September bluesky.optometry.org.au
OCTOBER 2024
EYECARE PLUS NATIONAL CONFERENCE & AGM
Sydney, Australia 18 – 19 October eyecareplus.com.au/conference/
NOVEMBER 2024
RANZCO CONGRESS 2024
Adelaide, Australia 1 – 4 November ranzco2024.com
Tasmanian Lifestyle Congress provides optometrists a unique educational experience in Hobart.
Image: AngryBirdProductions/Shutterstock.com.
Image: Ophthalmology Updates!
Image: RANZCO.
The RANZCO Congress is returning to Adelaide in November 2024.
CHANGING LIVES THROUGH
SPECSAVERS STORIES: TINA NGAN
WHY DID YOU PURSUE AN OPTOMETRY CAREER?
I spent a lot of my later childhood years immersed in the world of healthcare, serving as a translator for my mother’s medical appointments. I witnessed the meaningful work that health professionals do for their patients every day and felt inspired to pursue a career within healthcare. However, it wasn’t until an encounter with an exceptional optometrist during my final year of high school that my path became clear. That day I went home and rearranged my course preferences to have optometry as my top choice. I was beyond stoked to have received an offer into the optometry course that summer.
HOW DID YOU COME TO WORK AT SPECSAVERS?
Like many other final year optometry students, the idea of working for Specsavers came to light when the graduate team hosted an information session. I found myself interested in the vision and mission that Specsavers had and wanted to be part of their initiatives. I also knew I wanted to kickstart my early career by practising full-scope optometry, seeing patients from all backgrounds at all different ages. Specsavers offered all this and more and following my job interview with my inspiring future store partners, there was no hesitation.
WHAT GROWTH
OPPORTUNITIES
HAVE PRESENTED THEMSELVES?
Growth opportunities have always presented themselves to me throughout my time in this profession and I have never shied away from them. The opportunity to mentor a graduate, as well as completing the Pathway Program during my third
Specsavers
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 opportunities enquiries: Carly Parkinson on +61 (0) 478 201 057 or carly.parkinson@specsavers.com
Australia Optometrist employment enquiries: Marie Stewart – Recruitment Consultant marie.stewart@specsavers.com or 0408 084 134
Locum employment enquiries: Matthew Cooney matthew.cooney@specsavers.com or 0447 276 483
New Zealand employment enquiries: Chris Rickard –Recruitment Consultant chris.rickard@specsavers.com or 0275 795 499
year of practising, began my journey to seek continual professional development. The biggest growth opportunity has been stepping into the corporate space at Specsavers Support Office. My time as a regional training manager allowed me to grow my communication, organisation and influencing skills. Now in my current role as an optometry development consultant, I’m can apply those skills and enhance my ability to think critically and strategically for the business.
CAN YOU OUTLINE YOUR TOP CAREER HIGHLIGHTS SINCE JOINING SPECSAVERS?
There are many but those that sit at the top would be my time travelling on the road to visit all the Specsavers stores in my portfolio in West Victoria. I was able to see firsthand – and support – the work of our store partners. This is in addition to facilitating and presenting in classrooms, workshops and graduate inductions –speaking in front of a large group had been a completely foreign concept prior to joining support office. The best is always yet to come, and I am excited to add ‘Hosting the Specsavers Clinical Conference 2024’ as a future career highlight.
WHAT EXCITES YOU MOST ABOUT TURNING UP FOR WORK EACH DAY?
The people that I get to work and interact with every day. From my team and colleagues across other departments, to ophthalmologists and optometrists in store, my role allows me to tap into my passion for connecting with people. I also get the opportunity to plan CPD events, travel to different regions across the country and hear other people’s unique stories – no two days are ever the same which makes coming to work exciting.
$50k sign-on bonus – Designate Partnership in Emerald, QLD Specsavers Emerald has an exciting opportunity for an experienced Optometrist to join the store on a 2-year Designate Partner program - No upfront cost and opportunity to try partnership before committing long term. Specsavers Emerald is 3 test room store with a varied patient demographic and an extremely welcoming, supportive and social team. You will be supported with a relocation package tailored to your needs, be partnered with an experienced Specsavers Retail Partner and have access to our Pathway and Partnership development program for duration of time in role.
Attention ambitious optometrists seeking career progression! Specsavers Belconnen welcomes applications for a full-time Senior Optometrist role, emphasising leadership, mentorship, and enhancing clinical efficiencies. Help lead our practice, nurturing and guiding our graduates, while streamlining clinical operations. Part-time candidates are encouraged to apply. Benefit from a competitive remuneration package of $150,000 + super! —a rare find in any other capital city. This position offers a clear pathway to partnership, as evidenced by numerous successful transitions within the Belconnen team. Elevate your career and apply today!
Seeking a talented optometrist to join our extraordinary team at Specsavers Queenstown. We offer cutting-edge technology, a friendly environment, and a commitment to professional growth. Work in one of NZ’s most picturesque locations. Explore stunning mountain views and enjoy a fantastic outdoor lifestyle. Don’t miss this incredible opportunity to be part of Specsavers Queenstown.
Graduate Opportunities
Still deciding on where to start your optometry career? Specsavers have a number of exciting opportunities throughout regional Australia and New Zealand. With over 150 current first and second year graduates working in regional locations across ANZ, you will have a network of optometrists to help support you during your Graduate Program.
Regional Locum Opportunities
Specsavers are seeking experienced optometrists to locum across regional stores in Australia, allowing you to choose your own days and locations. This is an opportunity to combine work and travel. We have a variety of locum across Australia, starting now and going throughout 2024. Whether you’re locally based and looking to fill up your diary with that regular one day a week or to escape the cold and work in the sun for a few weeks, Specsavers has you covered with all travel and accommodation provided and booked for you.
People on the move
Dr Justin Sherwin has recently joined the Australian
Wolfe who was sole director for more than 35 years. His clinical interests are cataract surgery, lens-based
Cambridge, UK, and currently lectures in cataract and refractive surgery. He also practises at Bayside Eye Specialists, Brighton East and Vista Eyes Laser Centre, Elsternwick.
2024. With a wealth of professional experience in optical sales and key account management, the company says his expertise aligned with its goals and vision. “Joining us with the aim of enhancing our sales department and contributing to the continued growth and success of HOYA Lens Australia, Chris brings unique skills and fresh insights that will greatly benefit both our team and our clients. He is looking forward to utilising his vast optical expertise in supporting and growing business for his NSW customers,” HOYA said.
health optometrist with experience in project roles in Indigenous Eye Health, The Fred Hollows Foundation, Rotary Australia and the Brien Holden Foundation.
skill-based professionals who volunteer their expertise to provide strategic and governance oversight,” ACO said. This was announced at a recent AGM. Returning council members Ms Sophie Koh, ACO president, and Mr Darrell Baker were reappointed for a further two-year term.
vision, clinical research, ophthalmic practice, and practice management. She is also a former Associate Lecturer at the University of Sydney in Orthoptics and a mentor for clinical orthoptic students.
A perfect fit1 for your patient’s ablation profile
Just like the most refined haute couture, each wavelight plus procedure is fully tailored.1
InnovEyes™ Sightmap measures the unique optical system using biometry, tomography and wavefront.2
Innovative ray tracing methods create a personalised 3D model of the eye,1 used to plan a truly unique treatment with excellent visual outcomes.*3
