Insight September 2020

INSIGHT SEPT

2020

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

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STATE POLICIES CREATE 'HIDDEN' WAITING LIST

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*Based on AcrySof ® IQ Vivity ®’s monofocal visual disturbance profile.References: 1. AcrySof ® IQ Vivity ® Extended Vision IOL Directions For Use. 2. Alcon Data on File 2019: Optical Evaluations of Alcon AcrySof ® IQ Vivity ® vs. two diffractive IOLs. © Alcon Inc. 2019. Alcon Laboratories (Australia) Pty Ltd ABN 88 00 740 830. Ph: 1800 224 153. NZ: c/- PharmaCo. Auckland NZ. Ph: 0800 101 106. ALC1108 11/19 ANZ-VIV-1900015.

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INSIGHT SEPT

2020

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

PUBLIC HOSPITAL POLICIES LEAVE PATIENTS ON ‘HIDDEN’ ELECTIVE SURGERY WAITING LIST

Queensland eyecare professionals have voiced concerns over “unnecessary” changes to referral requirements, with patients being bounced between specialists and allied health professionals and contributing to what’s being described as a hidden waiting list.

Ophthalmologists and optometrists from the state have told Insight that since the COVID-19 outbreak, public hospitals have been rejecting some referrals and stating that they must now be resubmitted by either an optometrist or GP – or both in some cases.

It’s also been revealed that some Category 3 patients are being discharged back into the care of optometrists and removed from

surgery waiting lists entirely. This is despite deterioration of their eye health and the fact they need an ophthalmologist to diagnose and treat their condition.

hospitals during the COVID-19 period had been deemed null and void, with the patient needing to be re-referred by an optometrist and/or GP.

Like other state health systems, the Queensland Government is working to address an elective surgery backlog. This was caused by a suspension on non-urgent cases at the height of the pandemic to ensure health systems were prepared for an onslaught of COVID-19 patients.

“It’s frustrating for the optometrist, the GP and the patient – and it’s completely unnecessary,” he said. “But it’s the way [public hospitals] can control demand, they are constrained by budgets and therefore can only perform a certain number of cases per year, and the way to reduce demand is by sending people around in circles.”

Although this never eventuated, the public system has been placed under further strain after thousands of people dropped their private hospital insurance cover earlier this year amid the economic uncertainty.

The necessity of new patient referral requirements is being questioned.

Australian Society of Ophthalmologists deputy director Dr Bill Glasson, who performs eye surgery in both private and public settings, said there were around 52,000 Queenslanders on waiting lists. There was also approximately 7,000 more people awaiting ophthalmic surgery than what would normally be the case.

He said many referrals to public

Glasson said because those patients never got to see a specialist as medically required, this was forming “a hidden continued page 6

HEALTH FUNDS SAY THEY AREN'T HIDING POT OF GOLD The private health insurance sector has repeated its claim that health funds are not profiting from a reduction of eyecare and other health services enforced during the initial peak of the COVID-19 pandemic.

Dr Rachel David, CEO of peak industry body Private Healthcare Australia (PHA), says the sector is “not hiding a pot of gold”, following reports that insurers initially saved $515 million on extras services such as optical and $500 million on cancelled elective surgery during the six-week lockdown between March and May. David said so far more than half a billion dollars of pandemicrelated savings have already been

returned to customers, but the sector still needed to account for catch-up elective procedures and rising health costs.

Health funds, she said, are governed by strict regulatory and capital requirements and the Australian Prudential Regulation Authority (APRA) has made it clear the sector must retain enough capital to fund an elective surgery backlog and additional private healthcare.

“Health funds made some savings over the six-week period in which elective surgeries were cancelled and some allied health providers were closed,” David said.

“Health funds have repeatedly and publicly said they will not profit

from the COVID-19 restrictions.

Elective surgeries were not cancelled, they were postponed.

Members who needed joint replacements, cataracts and endometriosis surgery still do postCOVID. Dental and allied health appointments have now returned to normal levels.”

In July, Insight reported that thousands of people dropped their private health cover in the first quarter of 2020 as they were unable to access services they were paying for. PHA says optical services resumed back to normal levels by the end of June.

According to David, the $500 million returned to members continued page 6

MAKING YOUR EYEWEAR KNOWN IN THE DIGITAL AGE Insight explores how optometrists and eyewear retailers are using costeffective and creative marketing techniques to attract patients in today’s ultra-competitive market landscape. page page 30 7

Open to opportunity Our mission to transform eye health in Australia and New Zealand has never been more important, guiding and motivating us as we work our way through a significant patient backlog.

Our stores have opened their appointment books for routine eyecare, while recalling existing patients and prioritising care in our communities to those who need it most.

This has led to a greater need for optical professionals across our store network. From new roles in WA to partnership in QLD, opportunities are emerging across the country.

If you’re looking for your next step, with a stable business that has a strong strategy for the future, look no further.

To find out more about what’s on offer at Specsavers go to spectrum-anz.com

UPFRONT Just as Insight went to print, the SPECSAVERS stores in Ipswich and Queenstown were awarded the annual Doug Perkins Medal in Australia and New Zealand, respectively. The award, introduced in 2018, recognises practices that deliver exceptional patient outcomes, with a strong focus on education and training and collaboration with medicine. Patient feedback and a commitment to accessible eye health also formed part of the judging criteria. Specsavers Ipswich partners

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WEIRD

Mr Paul Jewitt, Ms Emma Woolner and Mr Victor Scrooby were announced winners at the SCC Online Series event on 26 August alongside the Queenstown partners. IN OTHER NEWS, Zeiss announced the Australasian release of the v1.5.2 software update for the Humphrey Field Analyzer 3, with improvements to reliability, upgradability and the 24-2C testing strategy. The new 24-2C strategy is designed to better detect macular defects by testing 10 additional points within the central 10 degrees that align with known nerve fibre loss most commonly flagged with central vision defects. “Based on the commonly adopted SITA Faster strategy

that has brought a 30-50% improvement in testing time, 24-2C will add another level of clinical confidence for central field defects in glaucoma," the company stated.

FINALLY, Australia’s Ambassador to the US and former NSW senator Mr Arthur Sinodinos became The Fred Hollows Foundation’s inaugural patron in America.

“The foundation is an iconic charity and wonderful example of Australian innovation, with a growing presence in the US," he said. "[It] is tackling the world’s largest unaddressed health issues – poor vision – with large-scale, transformative interventions designed to restore sight to millions.”

STAT

n

WACKY

A US breakfast TV host who tore her retina after her 2-year-old son mishandled his toy train isn’t out of the woods yet. Today anchor Ms Savannah Guthrie sought surgery to repair the retinal injury, but then required cataract surgery to fully restore her vision a few months later. “I feel like it’s Christmas morning because if they remove this cataract I’ll be able to see,” she said.

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Budapest hosted a concert in the dark to promote awareness about blindness and visual impairment, while raising money for audiobooks.

As part of the performance, a blind pianist accompanied three singers. The audience was asked to focus on the sense of hearing to understand how blind people perceive the world.

Published by:

Publisher Christine Clancy

Federal officers in the US city of Portland suffered 113 eye injuries while guarding a courthouse from activists armed with high-powered lasers. The revelation came during a Senate subcommittee hearing focused on violence during protests against the killing of George Floyd by Minnesota police. n

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OCT AND BEYOND

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It is estimated that there are 30 million OCT imaging procedures performed worldwide every year, with the market approaching $1 billion per year. Full report page 34.

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WHAT’S ON

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The 20th Congress of Ophthalmology and Optometry China is still going ahead in Shanghai.

The event is Asia’s leading optical trade fair held in the fashion-conscious Japanese market.

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INSIGHT September 2020 5

NEWS

ELIGIBLE PATIENTS ERASED FROM WAITING LIST continued from page 3

waiting list”. Instead, they were often being seen by non-medical and allied health professionals.

“And then it’s being said that the patient has been ‘seen’ by a doctor – and this isn’t the case. A doctor is the only person who can book them for surgery,” he said.

Gribbin said some other patients discharged back into his care without seeing an ophthalmologist were glaucoma suspects. He found this was not an isolated case, with many optometrists also reporting similar experiences in the state.

“We need to get a handle on those people who are waiting to be seen to be assessed by a doctor.”

“With COVID-19 I understand raising the criteria for surgery to a certain extent, but removing from the list entirely – that’s the bit that has got me annoyed.”

REMOVED FROM WAITING LIST

Additional changes introduced during COVID-19 that now require patients to have a referral by both the optometrist and GP were also causing logistical headaches, with cases being rejected if the referrals aren’t sent simultaneously.

Meanwhile, Mr Justin Gribbin, whose practice Eye Envy Optometrist is based in Morayfield north of Brisbane, said approximately 11 of his Category 3 patients had received letters stating they had been removed from ophthalmology waiting lists and returned to his care.

In the worst case, he had a cataract patient who had been on the waiting list since October 2018. He’s a commercial driver but no longer reached the licensing requirements due to his vision.

“The letter said if you feel the condition deteriorates don’t hesitate to provide us with a new referral. In this gentleman’s case, there had been a significant change in his vision; he was initially 6/19, but this had dropped down to 6/30. So we sent another referral saying that he’s a commercial driver, he needs

within appropriate timeframes.

his vision and they rejected him a second time.”

According to Queensland Health, that funding has already seen the number of patients waiting longer than clinically recommended drop to 2,774 from a projected peak of 7,000.

"IT’S FRUSTRATING FOR THE OPTOMETRIST, THE GP AND THE PATIENT – AND IT’S COMPLETELY UNNECESSARY" BILL GLASSON, AUSTRALIAN SOCIETY OF OPHTHALMOLOGISTS

“If there’s a lag between my referral and the GP’s referral, its rubber stamp rejected,” Gribbin said.

While public hospitals continued to deliver 11,723 urgent lifesaving surgeries during the restriction period, a spokesperson said approaches would differ for Category 3 patients depending on whether they are waiting for elective surgery or specialist care.

“Individual Hospital and Health Services across the state continue to monitor their own wait lists, and are continuing to put actions in place to reduce the time for patients waiting longer than clinically recommended,” the spokesperson said.

Queensland Health Minister Mr Steven Miles acknowledged to the ABC that Queensland Health could do better managing patients who were "bounced around" between specialists and allied health professionals.

In one letter seen by Insight, the public hospital said the measure was introduced for non-urgent referrals to “allow a more holistic understanding of the patients’ requirements”.

"We need to improve those pathways so that does not happen, but it is important to realise that is a very small number," he said.

‘A VERY SMALL NUMBER’ Glasson was hopeful the Queensland Government’s $250 million allocation for a backlog surgery ‘blitz’ – announced in June – would help address waiting list issues and ensure patients are treated

In response to questions from Insight, he said elective surgery services are now routinely at their pre COVID-19 levels in many hospitals. n

CALLS TO CANCEL OCTOBER PREMIUM INCREASE continued from page 3

came in the form of postponing the April 1 premium increase for six months; financial hardship provisions for people who were unemployed or underemployed due to COVID-19; and funding of telehealth services for psychology, physiotherapy and more.

“Some funds have also provided members with cash backs, rollover of services to the next calendar year and cancelled the October 1 premium increase. If the independent regulator’s claims data, due to be released in a few months’ time, shows more savings need to be returned to members, health

6

INSIGHT September 2020

funds will do so,” David said.

campaigner Mr Dean Price said.

She added that the COVID-19 situation had not stopped health inflation rising at levels above general inflation and although health funds did not want to increase premiums, it would be necessary to ensure they remain financially viable and meet statutory prudential requirements.

He said there was only one insurer who has “done the right thing” by giving their customers 12 months’ relief from premium increases during the crisis.

SCRAP THE PRICE HIKE Australian consumer group CHOICE says all private health funds should cancel their upcoming October price rises.

“Reports that private health funds have made mega profits out of COVID-19 show they must provide some relief to Australians,” CHOICE health

Rachel David, Private Healthcare Australia.

“Funds are charging full price while not delivering the full range of healthcare services. They can’t get away with doing the bare minimum while raking in these profits. The October price rises must be scrapped for the good of the community.”

“All health funds need to join HBF in deferring the 2020 premium increase for the full year. To increase people’s premiums on 1 October, as most funds plan to do, would be cruel in light of these abnormal profits.” n

NEWS

QUEENSLAND SURGEON PERFORMS NEW CATARACT TECHNIQUE

IN BRIEF

Gold Coast ophthalmologist Dr Nick Andrew has completed Australia’s first procedure with the Zeiss miLOOP lens fragmentation device, which he believes may offer a superior surgical risk profile over conventional techniques in advanced cataract cases.

Andrew, a cataract and glaucoma specialist who completed one of his fellowships under renowned Canadian ophthalmologist Dr Ike Ahmed, recently performed the new nucleus disassembly technique in Southport.

“The goal for Zeiss was a complicationfree product launch, and I’m pleased that we were able to achieve this. miLOOP is actually very simple to use and the learning curve is not particularly steep," Andrew, who practises at the Eye and Laser Centre Gold Coast and Gold Coast University Hospital, said.

He believes miLOOP could significantly improve cataract surgery safety, efficiency, and post-operative recovery of vision, particularly in cases of brunescent cataracts.

“It enables us, as eye surgeons, to improve the control, consistency and efficiency of one of the most critical steps of cataract surgery,” he said.

“This device allows the cataract to be divided without ultrasound or laser energy, without fluid irrigation and without sharp instruments inside the eye. Basically, the technology helps to level the playing field for dense cataracts, and it can offer patients faster post-operative recovery of vision by reducing corneal oedema.” miLoop is designed to bisect the cataract with minimal zonular stress by using a retractable Nitinol loop to deliver an inward-directed (centripetal) cutting force. This is in contrast to most conventional techniques that fracture the lens with outward-directed (centrifugal) forces and adjunctive phacoemulsification energy.

While ultrasound energy is still required to extract the lens fragments, Andrew said miLOOP has been reported to reduce the total amount of ultrasound energy and fluid irrigation required to remove the cataract.

“The advantages will be greatest for dense cataracts and for surgeons whose conventional cataract technique involves sculpting a trench in the lens.

"IT ENABLES US, AS EYE SURGEONS, TO IMPROVE THE CONTROL, CONSISTENCY AND EFFICIENCY OF ONE OF THE MOST CRITICAL STEPS OF CATARACT SURGERY"

Zeiss's miLOOP works to reduce zonular stress.

NICK ANDREW, OPHTHALMOLOGIST

I expect that some surgeons will switch to using miLOOP for most cases to help them achieve greater consistency, efficiency, safety, and a reduction in post-op corneal oedema.”

Andrew said his standard cataract technique is direct vertical chop, which requires very low levels of ultrasound energy. However, perfecting this technique requires many hundreds of cases and a skilled teacher.

“In contrast, you could do 50 miLOOP cases and very quickly be quartering lenses within a minute with no phaco energy,” he said.

“From an efficiency point of view, a surgeon could turn their brunescent cataract cases from a 40 minute procedure that they are sweating over because they are putting a lot of energy into the eye, to potentially another 10 to 15 minute case with only modest amounts of energy. So it has potential for many surgeons.”

According to Zeiss, in a 2019 surgeon survey, the majority of trained Zeiss miLOOP surgeons reported a perceived reduction in overall procedure time.

miLOOP was developed by US ophthalmologist Dr Sean Ianchulev and commercialised internationally by IanTECH in 2018.

Zeiss acquired IanTECH in 2018 and is now distributing the device in Australia. n

VICTORIAN SURGERY

Despite an elective surgery slowdown, the Victorian Government reported patients received surgery quicker in the second quarter (April to June) compared with the same period last year. The average time to treat patients was 20.5 days which was 7.5 days fewer than the same quarter in 2019 and 12.5 days fewer than the first quarter. This is also reported to be considerably better than the 2018-19 national average of 41 days.

With a pause on all non-urgent surgery announced in July, the government plans to recommence an elective surgery blitz to clear a growing backlog as soon as it is safe to do so.

n

EYE HEALTH SPINOFF

Bausch Health Companies announced last month that it intends to spin off its eye health business into an independent publicly traded entity called Bausch + Lomb – NewCo. The spinoff will establish two separate companies that comprise a pure play eye health company and a pharmaceutical company with positions in gastroenterology, aesthetics/ dermatology, neurology and international pharmaceuticals. According to the company, the benefits of separating the businesses include an improved strategic focus and greater financial transparency.

The timing of the anticipated spinoff will be tied to conditions and approvals, including the reorganisation of the reporting segments, which it expects to begin in the first quarter of 2021.

n

It also reported that a 2018 randomised controlled study in the British Journal of Ophthalmology showed using miLOOP in hard grade 3-4+ nuclear cataracts reduced phaco energy by up to 53% and lowered the surgical irrigation fluid volume used per case by over 20%.

Andrew said he had no financial interests in miLOOP or Zeiss to declare.

n

KIDS AND CONTACTS

Children first fit with soft contact lenses between the ages of 8 and 12 experienced similar rates of microbial keratitis compared with adults. To analyse soft contact lens safety in children and young teens, US clinical trial consultant Dr Robin Chalmers performed a retrospective chart review of 963 children. “The study was designed to be of sufficient size to estimate the microbial keratitis rate in soft contact lens wearers aged between 8 to 17 years and fit between 8 and 12 years,” Chalmers said. “The [7.4 per 10,000] rate is comparable to established rates in adults wearing soft contact lenses daily, and the rate of other inflammatory adverse events was similarly low.”

INSIGHT September 2020 7

NEWS

MELBOURNE PRACTICES REDUCED TO URGENT CARE

Optometrists are being advised to only provide urgent and necessary care to prevent deterioration of an established condition.

Broken spectacle replacements, essential OrthoK reviews, foreign bodies and intravitreal injections feature among the most necessary services Melbourne eyecare professionals are providing during hardened lockdown restrictions.

cases, whilst ensuring that their practices are strictly adhering to a COVID-Safe plan,” he said at the time of writing.

The Stage 4 measures, which came into effect from 6 August and will remain in place until at least 17 September, have reduced optometry and ophthalmology service levels, with the overall aim of limiting people-movements across the city to reign in the spread of COVID-19.

Specsavers Australia said with optometry being defined as an essential publicly funded health service, the vast majority of its Victorian stores will remain open to assist patients and customers with their “urgent and essential” eyecare needs. A continual review of DHHS and AHPRA guidelines may alter this position, it stated.

Optometry Australia (OA) received advice from government officials that optometrists and other AHPRAregistered health workers can continue to “provide services that prevent a significant change/deterioration in functional independence necessitating escalation of care”.

“We believe this means that optometrists can provide urgent care and care that is necessary at this time to prevent deterioration of an established condition,” OA stated.

Mr Steven Johnston, CEO of independent optometry network ProVision, said extremely positive June and July results have given most of its members cause for renewed optimism, even though “Stage 4 has set a significant section of its Victorian practices back on their haunches”.

“The majority of our Melbourne based optometrists are making themselves available for urgent and emergency

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INSIGHT September 2020

“A few of our practices have chosen to close to eliminate all potential risk to all stakeholders.”

Meanwhile, Mr Willy Gunawan, of Collins Street Optometrists, said the Melbourne CBD where his practice is located is like a ghost town, with patient numbers well down and their staffing reduced to 50%.

In line with directions from the Victorian Chief Allied Health Officer, the practice is only providing services that “prevent a significant change or deterioration in functional independence necessitating escalation of care”. These include “true emergencies” such as infections and sudden changes in vision, and circumstances where patients are no longer able to function, for example the loss or breakage of glasses that a patient is dependent on.

He said the Department of Health guidelines also mean the practice is prohibited from providing routine eye examinations and services that are not

"THE REGULAR MONITORING OF CHRONIC EYE DISEASES SUCH AS CATARACT OR GLAUCOMA CAN USUALLY ALSO BE DEFERRED FOR THE SCHEDULED SIXWEEK PERIOD"

essential and can safely be delayed.

WILLY GUNAWAN, COLLINS ST OPTOMETRISTS

Elsewhere, Dr Philip Cheng, of Eyecare Concepts in Kew East, was attending to corneal foreign body removals, which have risen with an increase in DIY work, referrals from GPs and patients who have lost or broken their glasses.

“The regular monitoring of chronic eye diseases such as cataract or glaucoma can usually also be deferred for the scheduled six-week period. But in the longer term once the Stage 4 restrictions have expired, we reiterate recent government advice that people with chronic health conditions should not avoid clinically necessary reviews,” Gunawan said.

He is also continuing to see children who recently commenced myopia control treatments like orthokeratology, which require multiple reviews at the start of the treatment program.

Bailey Nelson announced its stores are conducting eye exams for patients with essential eye health needs, while Bupa Optical has closed seven Melbourne stories until 13 September, and has kept its Camberwell and Bourke St City locations open for urgent care.

OPHTHALMIC CONSULTING Meanwhile, under Stage 4 restrictions, all non-urgent elective surgery has been suspended, with public and private medical specialists able to provide urgent consultations.

Dr Heather Mack, the RANZCO president and senior associate at Eye Surgery Associates in Melbourne, said with most elective surgery postponed, ophthalmologists would mainly continue to see emergency cases, perform intravitreal injections and patients who self-select.

Ms Lara Helen, practice manager at multi-disciplinary ophthalmology clinic Bayside Eye Specialists in Melbourne’s Brighton East, requested all 10 ophthalmologists to triage their patients for the six-week period. More than 1,000 appointments needed to be reviewed.

“We will continue providing essential and acute ophthalmic care including glaucoma, medical retina, infections, foreign bodies, squamous cell carcinomas. New referrals will be accepted for any acute cases, such as anything that is potentially sight threatening,” she said. n

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NEWS

TOPCON SOFTWARE HARMONISES IMAGING DEVICES Multinational ophthalmic device company Topcon has expanded its footprint in Australia with the introduction of a business segment overseeing the roll out of a new software platform that connects all ophthalmic imaging devices regardless of the manufacturer.

Topcon Healthcare Solutions (THS) Australia & New Zealand is the newest addition to the Topcon business, which will now feature alongside the company’s agriculture and positioning branches in Australia.

Based in Melbourne, THS launched in late 2019 with company director and experienced IT professional Mr Chris Mather, alongside engineers Mr Anton Pretorius and Mr Walter Palomino, and orthoptist Ms Vicki Paras leading the clinical sales division.

“Our aim is to provide and deliver the next generation in technology along with exceptional service to all new and existing Topcon customers,” Mather said.

The technology is available from this month.

The Therapeutic Goods Administrationapproved technology is a web-based data management application that connects all ophthalmic imaging devices regardless of the manufacturer.

"ONE OF HARMONY’S MOST UNIQUE FEATURES IS ITS ABILITY TO INTEGRATE IMAGES FROM ALL MAKES AND MODELS OF DIAGNOSTIC EQUIPMENT" VICKI PARAS, TOPCON HEALTHCARE SOLUTIONS

“Our main focus is to create clinicoriented software solutions,” Paras said.

“One of Harmony’s most unique features is its ability to integrate images from all makes and models of diagnostic equipment, which helps to create significant workflow benefits.”

“We are very pleased to be working alongside our longstanding distributer of hardware, Device Technologies, who will continue to provide exceptional device sales and servicing of Topcon equipment.”

Traditionally, eyecare professionals may have been required to open multiple viewing platforms to assess various scans for a single patient. Ultimately, Harmony removes the need to examine images on device-specific software.

With the establishment of THS, Australian eyecare professionals will now have access to Topcon’s Harmony Ophthalmology PACS platform from this month.

“Because it’s web-based it offers secure, cloud hosting and storage, so you can access patient information anytime, anywhere,” Paras said.

Harmony syncs with all common electronic medical record systems to transfer patient information, helping minimise potential errors. It incorporates an inbuilt referral system which improves the referral process with its functionality and ease of use.

Additionally, the system can integrate with the latest in artificial intelligence for the screening of age-related macular degeneration and diabetic retinopathy.

Topcon is offering a range of Harmony package options to suit single practitioner clinic or multi-practice organisations such as ophthalmic and optical chains as well as hospitals, where it is designed to improve internal and inter-practice communications.

The software is already available in the US and European markets, with Australian optometrists and ophthalmologists getting their first glimpse during a demonstration at the RANZCO Congress in November last year.

Despite only launching this month, Paras said the company has been heartened by the local interest already.

“It’s nice to know that the tiny glimpse of Harmony is already generating attention and excitement. We are looking forward to sharing our technology with eyecare professionals and creating a space for improved clinical assessment and a more efficient workflow.” n

NEW SAFILO PROTECTIVE EYEWEAR IS BEGINNING TO CATCH ON IN AUSTRALIAN CORONAVIRUS HOTSPOTS Optometry practices in Victoria are behind increasing demand for newly released COVID-19 protective eyewear from Italian eyewear manufacturer Safilo.

The company recently announced that it has broadened its Polaroid product range to include a Therapeutic Goods Administration (TGA)-approved face shield and a sunglass visor after redirecting its production efforts in response to the pandemic.

Safilo Australia senior marketing expert Mr Andrea Rolando said the company had already received significant orders for both products, which contain anti-fog properties.

“Practices in Victoria have started

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INSIGHT September 2020

ordering both the face shield and the visor. The sunglasses visors are designed more for patients, while the face shield is for both patients and practitioners. Some practices have ordered one for each of their staff members plus they are holding stock for patients as well,” he said.

Rolando said the company’s proximity to the coronavirus outbreak in Italy prompted its decision to diversify its range of optical frames and sunglasses.

“During the initial stages of the pandemic, our research and development, industrialisation and manufacturing teams switched our production efforts of the Italian plants to produce eyewear and safety products to

support the doctors, nurses and health professionals of Italy.”

Polaroid face shield was developed for health professionals.

The Polaroid face shield was developed for medical professionals during this period and remains manufactured in Italy.

It is certified and tested under European standards for eye protection, to ensure optical clarity and impact resistance, and was registered with the TGA on 22 May. “We hope that the face shield may help practitioners to continue to interact with their patients in this difficult time, while still maintaining a sense of connection by allowing patients to see them, without fogging up while wearing a face mask,” Rolando said, adding that it is also available in a smaller version for children.

n

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NEWS

STRENGTHENING EVIDENCE LEADS TO NEW MASK ADVICE "WHEN FACETO-FACE CONSULTATIONS ARE REQUIRED, BOTH OPHTHALMOLOGISTS AND ASYMPTOMATIC PATIENTS ARE ADVISED TO WEAR A SURGICAL MASK"

Peak industry bodies representing ophthalmologists and optometrists are now recommending Australian eyecare professionals and their asymptomatic patients wear surgical masks during faceto-face consultations in various scenarios, in response to the emergence of evidence.

Until recently, the use of personal protective equipment (PPE) by eyecare professionals seeing symptom-free patients has remained contentious and conflicting, with the Australian Department of Health only recommending its use for healthcare professionals and their patients in the event of suspected or confirmed cases.

RANZCO has previously advised that ophthalmologists use their own judgement for PPE use in asymptomatic, routine patients. But on 20 July, it stepped up its advice to recommend all Australian ophthalmologists wear masks during all routine care and procedures after further review of the literature.

“When face-to-face consultations are required, both ophthalmologists and asymptomatic patients are advised to wear a surgical mask,” the college stated.

“Ophthalmologists should avoid touching patients directly, and if they need to, should wear disposable gloves or at the very least, practice hand washing after each contact.

Eye protection is preferable.”

However, it noted the recommendations

Mask use should consider local supplies of PPE.

RANZCO

implementation of universal masking for healthcare workers and patients.

Meanwhile, on 30 July Optometry NSW/ ACT recommended practice staff and optometrists working in identified hotspot areas wear a face mask when engaged in a close-quarters clinical setting with patients.

Up until that point, NSW health professionals were operating under a tighter recommendation advising all health workers wear surgical masks if they are within 1.5m of a patient. However, these measures were not legally enforceable for private practices.

On 4 August, the Victorian Department of Health and Human Services upgraded its advice to state healthcare workers must wear a Tier/Level 1 disposable surgical mask and eye protection.

should take into account the local prevalence of disease, local policies and importance of preserving supplies of PPE in Australia and New Zealand. If supplies are limited in a public health setting, ophthalmologists should be permitted to wear their own PPE, if they feel this is clinically justified.

Masks and eye protection can be worn up to a maximum of four hours, unless damp/ soiled or completing aerosol generating procedures. Gloves must be changed between every patient.

Sydney retinal surgeon Associate Professor Adrian Fung, who is on the RANZCO COVID-19 Taskforce and vice chair of the Clinical Standards Committee, told Insight the sector was now guided by stronger evidence. He highlighted a review of healthcare workers from Mass General Bingham, the largest healthcare system within Massachusetts with more than 75,000 employees. It demonstrated a linear reduction in SARS-CoV-2 positivity rates from 14.65% to 11.46% after the

Optometry Victoria South Australia said non-clinical staff such as receptionists and practice managers must wear a Tier/Level 1 disposable surgical mask while at work. Cloth masks are not deemed appropriate. n Turn to page 37 for an in-depth look at mask use and COVID-19 transmission in eyecare settings.

KEEPSIGHT DIABETES REGISTRATIONS EXCEED 80,000 Registrations with eye check reminder program KeepSight have surpassed 80,000, with enrolment rates now on the rise after dropping during the initial peak of the COVID-19 outbreak.

Diabetes Australia confirmed to Insight that as of 20 July 81,900 people were registered with the scheme, which was officially unveiled by Federal Health Minister Mr Greg Hunt in October 2018 and formally launched to the public in March 2019.

There are also 4,000 eyecare professionals now registered with the program, which has been described as a once-in-a-generation opportunity to capture the 630,000 people with diabetes who skip regular eye checks each year. Overall, 1.8 million

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INSIGHT September 2020

Australians have diabetes. A Diabetes Australia spokesperson said KeepSight registrations are rising every week, particularly as COVID-19 restrictions lift in most states and people start to return to their normal routines.

“Importantly, this means people with diabetes are resuming their regular health checks including eye checks,” the spokesperson said. “There was a dip in KeepSight registrations from March to June as many eyecare providers were only able to provide urgent care.

Registration numbers are now back on track with earlier projections.”

KeepSight sends regular reminders to people with diabetes when they are due to have their eyes checked, and acts as a national register to identify those who are

having regular examinations, as well as the people who aren’t.

This enables Diabetes Australia to target its messaging accordingly.

1.8 million Aussies have diabetes.

“The reality is that a regular diabetes eye check is the best way to ensure problems are identified early so they can be treated early,” Ms Taryn Black, national policy and program director at Diabetes Australia, said.

“People with diabetes have many regular health checks they need and often diabetes eye checks are put off, or forgotten about, because there are more pressing health issues to address.”

KeepSight has previously been labelled the missing link in Australia’s diabetes health system. n

www.sunglasscollective.com.au (03) 8202-4300 @sunglasscollective

NEWS

NOVA EYE BUYS NEW ZEALAND GLAUCOMA BUSINESS Newly renamed Australian ophthalmic device manufacturer Nova Eye Medical has immediately delivered on a plan to expand its glaucoma portfolio, with the AU$921,000 acquisition of a New Zealanddeveloped drainage device platform.

Nova Eye, formerly Ellex Medical Lasers until the sale of its core business earlier this year, announced a new deal to purchase the Molteno3 glaucoma drainage device (GDD) range from Molteno Ophthalmic, a privately-owned Dunedin-based business.

For the purchase, the ASX-listed firm has used some of the AU$97.4 million proceeds it received from the sale of Ellex's laser and ultrasound business to French multinational Lumibird Group.

Nova Eye executives have been keen to begin building a comprehensive suite of glaucoma therapies that support its iTrack minimally invasive glaucoma surgery (MIGS) device.

Commenting on the NZ$985,000 (AU$921 million) acquisition, Nova Eye chairman Mr Victor Previn said it supports the company’s focus on glaucoma therapies. The Molteno business currently has a presence in approximately 30 countries.

“Having pioneered the world’s first

The Molteno3 glaucoma drainage device.

glaucoma drainage device in the 1960s, Professor Anthony Molteno and the team at Molteno have built a worldclass platform of glaucoma implant technologies,” he said.

"DESIGNED TO TREAT SEVERE OR COMPLEX GLAUCOMA, THE MOLTENO3 PLATFORM SERVES AS A PERFECT COMPLEMENT TO OUR ITRACK MIGS PORTFOLIO" VICTOR PREVIN, NOVA EYE MEDICAL

“Molteno has the longest and most comprehensive history of any of the GDDs available on the market. Professor Anthony Molteno is responsible for many industry firsts. His research has contributed to a comprehensive understanding of GDD surgery that has informed each evolution in Molteno and has culminated in the advanced Molteno3 S-Series.”

reduction in intraocular pressure in cases of severe or complex glaucoma.

It has also been shown to offer the benefit of improved practice efficiency via a shorter surgical time.

“With the acquisition of the Molteno3, we will be able to offer our ophthalmologist customers a portfolio of reimbursed, surgical consumable devices that cover all stages of the glaucoma disease process,” Previn added.

“Designed to treat severe or complex glaucoma, the Molteno3 platform serves as a perfect complement to our iTrack MIGS portfolio, which aims to treat mildmoderate cases of glaucoma.”

Despite its design and capabilities, Nova Eye believes the Molteno3 GDDs are underpenetrated in key markets, including the US. It will leverage its existing glaucoma sales and marketing infrastructure to drive the Molteno3 platform further into those markets.

Nova Eye has also acquired the lease on Molteno’s current manufacturing facility in Dunedin. The facility is certified in accordance with the ISO13485 standard.

According to Nova Eye, the Molteno3 platform is supported by more than 50 years of scientific and clinical research and has been implanted in thousands of patients worldwide. It has been clinically validated to deliver consistent, long-term

Additionally, the company has entered into a consulting agreement with Molteno CEO Dr Nina Molteno for three-months to assist with the transition. n

TOPCON ACQUIRES HENSON PERIMETER RANGE BOC Ophthalmic instruments will remain as the Australian distributor of Henson perimetry devices after they were sold to Japanese ophthalmic device company Topcon.

perimeters locally for a number of years. However, Topcon has a hardware distribution deal with a different Australian company, leaving questions over who may distribute the devices locally in future.

On 15 July, Topcon announced it had acquired the Henson line of perimetry products, including the Henson 9000 and 7000, from Elektron Eye Technology (EET), which is based in Cambridge, UK.

BOC national sales executive Mr Robin Lanesman said EET had informed him that BOC would continue to be the Australian distributer for the product line.

The acquisition includes the transfer of a number of EET staff to Topcon, with manufacturing to continue in the UK. Topcon will also continue to work with academic, researcher and inventor Professor David Henson, whose expertise has driven the evolution of Henson instruments since 1986.

Sydney-based BOC has held a licensing agreement to distribute Henson

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INSIGHT September 2020

“We have been selling Henson perimeters for many years. The latest Henson 9000 is an excellent product,” he said.

According to Topcon, Henson perimeters are regarded in the eyecare sector for their accuracy, speed and ease of use.

The Henson 9000 is the ideal perimeter for the early detection of glaucoma and the ongoing monitoring of established loss.

Meanwhile, the Henson 7000 is an

affordable, lightweight, mobile model designed to perform suprathreshold glaucoma screening in the central field.

Henson 9000.

Commenting on the acquisition, Topcon Healthcare global vice president of marketing and product design Mr John Trefethen said the acquisition will provide an opportunity to strategically develop this area of the company’s product portfolio.

"With Topcon’s growing emphasis on screening and early disease detection, the Henson product range perfectly complements our global strategy," he said.

“We look forward to working with Professor Henson and the talented team from EET to further develop this innovative product line, bringing critical glaucoma screening, monitoring and early disease detection tools to the global eyecare community.” n

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INDICATION FOR USE. The iStent inject ® W Trabecular Micro-Bypass System (Model G2-W) is intended to reduce intraocular pressure in adult patients diagnosed with mild to moderate primary open-angle glaucoma (POAG) currently treated with ocular hypotensive medication. The device can be implanted with or without cataract surgery. CONTRAINDICATIONS. The device is contraindicated for use in eyes with primary angle closure glaucoma, or secondary angle-closure glaucoma, including neovascular glaucoma, because the device would not be expected to work in such situations, and in patients with retrobulbar tumor, thyroid eye disease, Sturge-Weber Syndrome or any other type of condition that may cause elevated episcleral venous pressure. WARNINGS. This device has not been studied in patients with uveitic glaucoma.

Patients should be informed that placement of the stents, without concomitant cataract surgery in phakic patients, can enhance the formation or progression of cataract. The surgeon should monitor the patient postoperatively for proper maintenance of intraocular pressure. iStent inject ® is MR-Conditional, meaning that the device is safe for use in a specified MRI environment under specified conditions; please see labelling for details. Physician training is required prior to use and consists of 3 parts: webinar, Didactic session with Glaukos surgical representative and observation of surgical cases by Glaukos representative until implantation proficiency is demonstrated. Do not reuse the stent(s) or inject or. ADVERSE EVENTS. Postoperative adverse events include but are not limited to: corneal complications including edema, opacification and decompensation, cataract formation (in phakic patients), posterior capsule opacification, stent obstruction, intraocular inflammation (non-preexisting), BCVA loss and IOP increase requiring management with oral or intravenous medications or surgical intervention. Please refer to Directions for Use for additional adverse event information. CAUTION: Please reference the Directions For Use labelling for a complete list of contraindications, warnings and adverse events. © 2020 Glaukos Corporation. Glaukos and iStent inject ® are registered trademarks of Glaukos Corporation.

Australian Sponsor – RQSolutions Pty Ltd / New Zealand Sponsor: Toomac. PM-AU-0106.

NEWS

SYDNEY RESEARCHERS EXPLORE NEW SYNTHETIC GEL THAT COULD HEAL CORNEAL INJURIES "LIQD CORNEA COULD BE APPLIED OUTSIDE THE OPERATING ROOM SETTING, MEANING THERE IS IMMENSE POTENTIAL TO REDUCE HEALTHCARE COSTS"

Australian researchers are part of an international team pioneering a synthetic gel treatment that could repair corneas damaged by injury or infection, removing the need for transplant surgery.

Associate Professor Chameen Samarawickrama, from the University of Sydney’s Faculty of Medicine and Health and The Westmead Institute for Medical Research, has helped develop and perform preclinical testing of LiQD Cornea, an adhesive liquid that is designed to mend damaged corneas.

The study he co-authored – recently published Science Advances – states that transplantation with donor corneas has been the mainstay for treating corneal blindness, but a global shortage has highlighted the need for other treatment options.

At present, corneal perforation from infection or inflammation is sealed with cyanoacrylate glue. However, the resulting cytotoxicity means that without follow-up corneal transplantation, sight could be lost.

LiQD Cornea is an alternative to conventional corneal transplantation and sealants. It is a cell-free, liquid hydrogel matrix for corneal regeneration. It is said

to comprise short collagen-like peptides conjugated with polyethylene glycol and mixed with fibrinogen to promote adhesion within tissue defects.

The process of gelation occurs spontaneously at body temperature within five minutes, potentially allowing for clinical application in outpatient clinics, instead of operating theatres, and therefore minimising healthcare costs.

CHAMEEN SAMARAWICKRAMA, UNIVERSITY OF SYDNEY

About 4,300 Australian’s sustain corneal injuries each year, but the figures are much higher in developing countries where agricultural accidents are a common cause. Samarawickrama has collaborated with colleagues at the University of Montreal in Canada and Linkoping University in Sweden on the conception and manufacturing of LiQD Cornea. He and post-doctoral researcher

Mr Damien Hunter carried out a trial with rabbits, one of the two pre-clinical trials detailed in the paper, finding LiQD Cornea worked effectively on smaller injuries.

“It acts very much like a dental filling,” Samarawickrama said.

“It comes out as a liquid and sets in a gel form, stays on the eye comfortably, doesn’t scar and remains see-through or translucent, countering many of the limitations of the tissue glue currently used. Our early studies also suggest it allows the eye to continue to regenerate.”

Due to the synthetic nature of the material, risks associated with immune rejection and disease transmission are also reduced in comparison to natural products. While further pre-clinical studies are needed to ensure safety and efficacy before progressing to human trials, Samarawickrama said the results are encouraging noting that the cornea is avascular in all mammals, increasing the likelihood of similar outcomes in humans.

“If successful, LiQD Cornea could be applied outside the operating room setting, meaning there is immense potential to reduce healthcare costs and increase patient access,” he said. n

EYE-RELATED INJURIES LEFT OUT OF 10-YEAR PLAN Vision 2020 has highlighted the omission of eye injuries in a Federal Government strategy to prevent injuries, a major cause of preventable disability in Australia.

In its submission to the draft National Injury Prevention Strategy 2020-2030, which is out for consultation, the organisation points out that preventing avoidable vision loss can also contribute to injury prevention by reducing rates of falls and other major causes of injury in certain cohorts.

To support its call for eye injuries to be included in the Department of Health’s 10-year strategy, Vision 2020 cites statistics demonstrating that eye injuries lead to a high number of emergency department presentations (more than 86,000 between 2013-15) and

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INSIGHT September 2020

hospitalisations (more than 51,000).

organisations work to promote awareness of eye injury prevention and have dedicated initiatives which align with the aims of the National Injury Prevention Strategy.

“Safe Work Australia statistics between 2000-2015 show around 5,950 serious claims were due to eye injuries received at work,” the Vision 2020 submission said.

“Given the total estimated cost of injuries in the same period was $61.8 billion, eye injuries contribute to the significant burden on society and workers, caused by injuries.”

The Department of Health recognises that injuries are the leading cause of death of all people up to the age of 44. Although success has been demonstrated in some areas, such as reducing road trauma, there is a need for nationally focused action on injury.

Vision 2020’s submission notes that many of its almost 50 member

Hospitals saw over 135,000 eye injuries between 2000-2015.

It cites the RANZCO national eye health awareness month, JulEye, which this year is focusing on preventing common household injuries.

Both Optometry Australia’s occupational and safety eyewear guide, The 2020 Occupational Optometry Guide, and the Lions Eye Institute proposal for sports eye protection to be accepted for review by Standards Australia, also lent weight to Vision 2020’s submission.

The Department of Health has engaged The George Institute for Global Health to lead the project. n

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NEWS

MDFA BRINGS FORWARD RESEARCH GRANT APPLICATIONS DATE The next round of Macular Disease Foundation Australia (MDFA) Research Grants has been brought forward, with the applications period opening in October this year.

Applications for the program, which launched nine years ago, typically commence in March every other year, meaning researchers would have expected to begin applying for grants in March 2021.

However, MDFA has altered the timeline to now begin on Thursday 8 October – World Sight Day. The successful applicants will be revealed in May 2021, during MDFA’s Macula Month awareness campaign.

Since 2011, the MDFA Research Grants Program has committed $4.1 million to support 18 world leading Australian researchers across 21 research projects.

Professor Robyn Guymer, head of macular research and deputy director of the Centre for Eye Research Australia, Professor Mark Gillies, director of research at the Save Sight Institute at the University of Sydney, Professor Paul Mitchell AO, director of the Centre For Vision Research at The Westmead Institute for Medical Research, and Dr Fred Chen from the Lions Eye Institute are among notable past recipients.

In the last round of funding in October 2019, MDFA awarded $600,000 to advance research into Indigenous diabetic vision loss through Professor Alex Brown’s DREAM project, sub-retinal fibrosis through Dr Audra Shadforth and novel macular disease detection methods through Dr Zhichao Wu. The program aims to fulfil MDFA’s objective to support research to reduce the incidence and impact of macular disease and ultimately find cures.

MDFA grants are considered significant contributions to Australian medical, social, low vision and nutritional research into macular disease.

They are awarded following rigorous evaluation, based largely on the National Health and Medical Research Council (NHMRC) process, along with peer review, to ensure that the successful applicants meet high standards. n

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INSIGHT September 2020

COOPERVISION INTRODUCES NEW LENS PARAMETERS AND DESIGNS "OPTOMETRISTS NOW HAVE AN EASY-TO-FIT LENS, USING FAMILIAR LENS DESIGN TECHNOLOGIES AND THE PROVEN BIOFINITY SILICONE HYDROGEL MATERIAL" JOE TANNER, COOPERVISION ANZ

Australian eyecare professionals now have access to an expanded range of parameters for the CooperVision clariti toric contact lens, allowing optometrists to fit a broader range of astigmatic patients.

It comes after the contact lens manufacturer also recently unveiled its new Biofinity toric multifocal contact lens to the Australasian market to provide 200,000 prescription options for patients who are both astigmatic and presbyopic.

The clarity toric silicone hydrogel 1-day contact lens is now available in aroundthe-clock axes to increase parameter options by almost 50%.

“This latest range extension illustrates our commitment to providing a wide range of stable, comfortable silicone hydrogel 1-day toric options, allowing as many astigmatic patients as possible to be fitted,” Dr Gary Orsborn, CooperVision’s vice president of global professional and clinical affairs, said.

“From sphere to toric to multifocal, and in every modality, CooperVision continues to offer the broadest range of soft contact lenses in the industry to enable today’s optometrists to meet the unique vision correction needs of virtually any patient.”

According to CooperVision, the clariti 1-day toric features a high-precision

Biofinity is now available as a toric multifocal.

design that delivers “exceptional optical performance and consistent correction of astigmatism”.

Meanwhile, the company’s Australian and New Zealand professional services manager Mr Joe Tanner said the Biofinity toric multifocal contact lens is the latest addition to the product portfolio. It combines the performance and design of CooperVision’s existing Biofinity toric and Biofinity multifocal offerings.

“Optometrists now have an easyto-fit lens, using familiar lens design technologies and the proven Biofinity silicone hydrogel material,” Tanner said.

“Being able to reliably correct astigmatism means there is no need to compromise visual acuity and we encourage practitioners to use this lens whenever 0.75D or more of astigmatism is present. n

NEW RANGE OF BREATH SHIELDS DEVELOPED FOR ZEISS INSTRUMENTS Zeiss has expanded its breath shield offering to cover additional devices and support eyecare professionals in their efforts to achieve social distancing in clinical environments.

Following its popular slit lamp breath shield program, in which thousands of Australian and New Zealand practices were given free protective coverings, the ophthalmic equipment company has now released a range of shields for the Humphrey Field Analyzer, Clarus ultra-widefield retinal camera, IOLMaster optical biometer and the Cirrus family of OCTs. Although they are not free-of charge as per the slit lamp offer, the new protective covers can be installed by the user and ordered for a nominal price from the Zeiss Online Shop, which can be accessed

Breath shields are now available for Cirrus OCTs.

via the Zeiss Support Now website.

Installation instruction videos for each instrument have also been produced.

According to Zeiss, the free slit lamp breath shield program has ended, but clinicians can continue to order them via the same website for a modest price.

Further breath shields for other devices are expected to be released. n

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NEWS

BREAKTHROUGH VITAMIN B3 GLAUCOMA TRIAL SET TO EXPAND

TRANSITIONS UNVEILS VIRTUAL TRY ON TOOL Transitions Optical has launched a new customisable digital tool that allows patients to see themselves in its latest lens offering before entering the practice.

Australian patients can now access the Transitions Virtual Try On Tool on their desktop, mobile or tablet devices, minimising the need for physical contact during COVID-19.

The new immersive augmented reality experience allows patients to choose from a selection of frame styles and then experiment with Transitions Signature GEN 8’s different lens colours.

Transitions Optical Asia Pacific general manager Mr Stuart Cannon said patients can experiment with different looks and explore which best suits their style before heading in-store.

“In a COVID safe world, it’s more important than ever before to enhance patients’ digital journey through customisation and convenience,” he said.

The technology is designed to give users a realistic, interactive experience wearing Transitions lenses in auto-sized frames in real time. It also enables them to control the photochromic activation across all lens colours and to capture downloadable photos in all stages of tint.

“We encourage practices to promote the tool to patients before coming into the practice via communications such as recalls, newsletters and social media,” Cannon said.

“The tool can also be used by eyecare professionals in-store to help the patient choose the best Transitions lens colour for their frame style.”

The Transitions Virtual Try On tool is currently available online. Eyecare professionals can also direct their patients online to experience the tool.

The company is also launching new imagery from its ‘Transitions for All’ campaign, enabling practices to refresh their point-of-sale.

Available for free, practices can order posters, counter cards and dispensing mats. Social media content is also available. n

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INSIGHT September 2020

"A LARGER STUDY WILL HELP US DETERMINE WHETHER VITAMIN B3 SHOULD BE TAKEN ON AN ONGOING BASIS

BY GLAUCOMA PATIENTS" JONATHAN CROWSTON, CERA

Daily doses of vitamin B3 (nicotinamide) can lead to significant improvements in glaucoma patients who are also receiving regular treatments to lower eye pressure, new results of a world-first study have revealed.

Research led by Professor Jonathan Crowston and Dr Flora Hui at the Centre for Eye Research Australia (CERA) has shown significant improvement in the visual function of glaucoma patients who received a daily high dose of three grams of nicotinamide for 12 weeks in addition to their regular treatment to reduce eye pressure.

Earlier pre-clinical research in the US has shown that vitamin B3 could prevent optic nerve degeneration but this is the first time similar results have been witnessed in a human trial.

“For the first time, we have shown that daily high doses of vitamin B3 can lead to early and significant improvements in patients who are also receiving traditional treatments to lower eye pressure,’’ Hui said.

“As a safe therapy that is well tolerated by patients, vitamin B3 has potential as a clinical supplement to support patients who are receiving glaucoma treatment.’’

Dr Flora Hui, CERA.

CERA’s trial involved 57 glaucoma patients from private ophthalmic clinics in Melbourne and the Royal Victorian Eye and Ear Hospital. All received both placebo and vitamin B3 over the course of the study. A larger trial is now being planned to assess whether these improvements can help reduce disease progression over a longer period.

“We now need a longer-term study to know conclusively whether nicotinamide delays glaucoma progression more than simply using eye pressure lowering medications alone,’’ Crowston said.

“A larger study will help us determine whether vitamin B3 should be taken on an ongoing basis by glaucoma patients.”

The study was published in Clinical and Experimental Ophthalmology. n

AUSSIE PROFESSOR RECOGNISED HOME AND ABROAD FOR RESEARCH Australian Professor Mark Willcox has been recognised for his research focusing on infection prevention and medical devices, receiving two awards from leading organisations.

Willcox, a medical microbiologist and director of research at the UNSW School of Optometry and Vision Science, has been awarded the 2020 Donald R. Korb Award from the American Optometric Association (AOA) for research excellence, as well as the NHMRC Marshall and Warren Ideas Grant Award for the highest scoring Ideas Grant for 2019.

Like Dr Korb who translated much of his research and clinical knowledge into new products, Willcox hopes to emulate that with his research into antimicrobial surfaces and tear film biomarkers for

Professor Mark Willcox, UNSW.

ocular diseases such as dry eye.

His NHMRC grant will evaluate whether new antimicrobials that his team has patented can be bound to the surfaces of medical devices such as catheters and contact lenses and reduce the ability of microbes to adhere to them. This could tackle the major issue of hospital acquired infections. n

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ESSILORLUXOTTICA-GRANDVISION DEAL HITS STUMBLING BLOCK

FDA CLEARS AI SYSTEM FOR DIABETIC RETINOPATHY Medical technology company Eyenuk has secured US Food & Drug Administration (FDA) clearance to market its EyeArt autonomous AI system for diabetic retinopathy.

EyeArt is now indicated for use by healthcare providers to automatically detect more than mild diabetic retinopathy (mtmDR) and visionthreatening diabetic retinopathy (vtDR) in eyes of adults diagnosed with diabetes who have not been previously diagnosed with more than mild diabetic retinopathy.

The approval sees EyeArt become the first FDA cleared autonomous AI technology that can detect both mtmDR and vtDR in one test in primary care and eyecare settings. It’s also the first US-approved autonomous artificial intelligence technology that has diagnostic outputs for each eye of a patient.

According to the company, convenient and reliable screening without overburdening eyecare professionals has become a top priority of governments and health systems worldwide.

The EyeArt FDA 510(k) clearance is based on a pre-registered, prospective, multi-centre clinical trial where it demonstrated 96% sensitivity and 88% specificity for detecting mtmDR and 92% sensitivity and 94% specificity for detecting vtDR. All eyes with early treatment of diabetic retinopathy study (ETDRS) level 43 or higher were correctly identified as mtmDR positive.

“The study also showed that novice operators can be trained to obtain medical grade retinal images,” the company said.

“Even at primary care centres where most operators did not have prior ophthalmic imaging experience, EyeArt had an imageability of 97%. Moreover, a vast majority of participant eyes (90%) received disease detection results without needing dilation.”

The EyeArt system is indicated for use with two models of fundus camera in the US; the Canon CR-2 AF and Canon CR-2 Plus AF. The company plans to expand the list of EyeArt-compatible imaging devices, by leveraging its expertise in device validation, clinical research, and regulatory process in markets around the world. n

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INSIGHT September 2020

"THIS IS TO ASSESS THE WAY GRANDVISION HAS MANAGED THE COURSE OF ITS BUSINESS DURING THE COVID-19 CRISIS" ESSILORLUXOTTICA

EssilorLuxottica has launched legal action against global optician group GrandVision as it seeks information on how the firm has been managed during the COVID-19 pandemic.

In response, GrandVision has initiated arbitration proceedings to confirm it had not breached the agreement, a move EssilorLuxottica regards as a method to detract from the issue.

For the past year, EssilorLuxottica has been seeking to acquire a majority stake in the Dutch-based multinational for up to €7.2 billion (AU$11.8 b) in order to control its more than 7,200 stores across 40 countries and vastly expand its retail presence.

However, the Franco-Italian eyewear giant initiated proceedings against GrandVision in a District Court in Rotterdam, the Netherlands, on 18 July.

“This is to assess the way GrandVision has managed the course of its business during the COVID-19 crisis, as well as the extent to which GrandVision has breached its obligations under the support agreement,” EssilorLuxottica said in a statement.

“Despite repeated requests, GrandVision has not provided this

GrandVision operates in more than 40 countries.

information on a voluntary basis, leaving EssilorLuxottica with no other option but to resort to legal proceedings.”

In response, GrandVision stated it strongly disagreed with EssilorLuxottica’s demands and has full confidence the claims will be rejected in court.

Later, on 30 July, GrandVision commenced arbitration proceedings to obtain confirmation that it was not in material breach of the agreement.

EssilorLuxottica acknowledged the arbitration, although it said it “regards these … as a surprising and obvious attempt by HAL and GrandVision to detract from GrandVision’s breaches under the support agreement and its failure to provide EssilorLuxottica with required information”. n

SAFILO ANNOUNCES FIRST HALF FINANCIAL PERFORMANCE Italian eyewear company Safilo generated first half 2020 sales of €335 million (AU$552 m), with the Asia-Pacific region accounting for approximately 7% of total revenue.

The company-wide figure represents a 32% revenue decline when compared with the same period last year, as it rebounds from the impact of the COVID-19 pandemic.

In Asia-Pacific, 2020 first half net sales equalled €23 million (AU$37 m), declining 45.4% at current exchange rates, with second quarter sales totalling €8 million (AU$13 m), down 65.7%.

“As we had anticipated to the market in May, our second quarter sales and economic results were heavily impacted by the massive shutdown of commercial activities across the world in April, and the very gradual and patchy reopening

The company is rebounding from the initial effects of the COVID-19 pandemic.

of stores for prescription frames and sunglasses starting to occur in May. In these two months, this business context resulted in a sales drop of approximately 75%,” Mr Angelo Trocchia, Safilo CEO, said.

“In June, store traffic and conversion rates started to clearly rebound in markets like Italy, France and Germany.” n

INTERNATIONAL

AOA GALVANISES TO FIGHT NEW CONTACT LENS RULE THAT WILL DISADVANTAGE OPTOMETRISTS Opposition in the US is gathering against a new ruling which allows patients to comparison shop for contact lenses with a copy of their prescription in hand.

Under the regulations, contact lens prescribers are now required to automatically provide a copy of a patient’s prescription and verify or provide prescriptions to third-party sellers.

Advocates believe the measure will costs optometrists thousands of dollars in compliance costs.

The Federal Trade Commission (FTC) announced final amendments to its Contact Lens Rule on 23 June, prompting the American Optometric Association (AOA) to mobilise its members and the wider eyecare sector to challenge it.

The AOA is objecting to changes that require contact lens prescribers to obtain signed acknowledgement forms indicating patients’ receipt of contact lens

prescriptions, and to keep record of that patient confirmation for at least three years.

A growing chorus of leading industry voices are protesting against the ruling directly to FTC officials, including CooperVision, VSP Global and the Health Care Alliance for Patient Safety.

The AOA said the FTC ignored its concerns as well as those of doctors of optometry, ophthalmologists, patient health and consumer advocates, since the plan was first proposed in 2016.

rules that will needlessly saddle thousands of already struggling, small health care practices with tens of millions of dollars in new compliance costs,” Reynolds said.

Optometrists could pay thousands in compliance costs.

AOA president Dr William Reynolds said the AOA is mobilising to ensure all its doctors can speak out, educate and engage government officials in challenging the new ruling.

“This is an attack on law-abiding, frontline optometry practices made even more outrageous by the fact that the FTC has chosen this moment – amid a pandemic and economic meltdown – to finalise new

According to the AOA, independent health economists estimate that the new mandate will cost the industry tens of millions annually, at least US$18,000 (AU$25,000) per doctor, per year.

The AOA and state affiliates brought their concerns to the highest level of government in a 2 July letter to President Donald Trump, urging the administration to take action “to stop the FTC from enacting this dangerous rule change and harming thousands of essential small-business healthcare practices”.

The AOA has asked the FTC to defer the rule’s enforcement until 1 January 2021, but without action, the new changes may go into effect this month. n

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INTERNATIONAL

COVID-19 FORCES CANCELLATION OF MAJOR OPTICAL TRADE SHOWS, NEW 2021 DATES FOR SILMO PARIS "WHILE CERTAINLY DISAPPOINTING, THE DECISION TO CANCEL VISION EXPO WEST 2020 IS PRUDENT AND NECESSARY"

The 2020 international optical events calendar has suffered a double blow after the cancellation of some of the last remaining major trade shows.

Due to ongoing uncertainty surrounding the COVID-19 pandemic, Silmo Paris and Vision Expo organisers have scraped their respective shows, with Silmo unveiling new dates for 2021.

The European show, among the world’s major optical fairs, was scheduled to take place from 2 to 5 October at Paris Nord Villepinte after it was required to postpone the original July date.

“However, at this juncture where the registered exhibitors were about to make additional expenditures to finalise their participation in the trade fair, and where visitors were about to begin making travel plans, there were still uncertainties as to whether the trade fair would be able to take place as planned,” Ms Amélie Morel, chairwoman of the Silmo Association, said.

“In the absence of immediate visibility, the Silmo executive board met with its partner Comexposium, and took the unfortunate decision to cancel the Silmo 2020 Paris event.”

Prior to the cancellation, there were

Prior to cancellation, Silmo Paris had 688 exhibitors registered for 2020.

FRAN PENNELLA, REED EXHIBITIONS

688 registered exhibitors. Last year there were 1000 exhibitors form 42 countries.

the show organisers’ primary concern, Vision Expo, along with the Venetian Resort, developed a multi-layered, in-depth plan to ensure the safety of everyone planning on attending,” according to a Vision Expo statement.

“Despite these efforts and a strong interest from the industry to participate, the decision has been made to cancel as a result of Nevada Governor Steve Sisolak’s announcement on Monday, June 26 sharing that Nevada ‘will remain in Phase 2 of reopening plans through the end of July due to current trends of the coronavirus infection’.’”

Last year, Vision Expo West attracted 760 exhibitors form 68 countries, along with 15,000 eyecare professionals, buyers and influences.

Morel said Silmo 2021 will now take place at the same venue from 24 to 27 September.

Ms Fran Pennella, event vice president, at Reed Exhibitions, added: “While certainly disappointing, the decision to cancel Vision Expo West 2020 is prudent and necessary. Without having visibility on when the state of Nevada will be ready to roll into future phases or what the future phases will allow for, coupled with the unfortunate spiking of COVID-19 cases in the region, we know it is in the best interest of everyone in the vision community to not move forward with the show.” n

In the absence of the 2020 show, Simo will still run small weekly events throughout France and parts of Europe from October to November 2020.

Meanwhile, after deciding to consolidate the separate Vision Expo East and West shows in Las Vegas from 23 to 26 September, organisers have cancelled the show altogether due to ongoing COVID-19 restrictions.

“With the health and wellbeing of everyone in attendance at the show as

CORNEAL DONATION POLICY OUT-OF-STEP WITH EVIDENCE A US Food and Drug Administration (FDA) policy that automatically disqualifies men who have had sex with men in the preceding five years from donating corneas is not justified by current evidence, research shows.

The policy dating back to 1994 cost eye banks an estimated 1,600 donated corneas in 2018, according to research presented by Dr Michael Puente Jnr, an ophthalmologist at Children’s Hospital Colorado.

Presenting his findings at the virtual Association for Research in Vision and Ophthalmology meeting recently, Puente believes hundreds of corneas were never donated because MSM status (men who have sex with men) were turned away

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record if a donor is turned away due to MSM status, so they administered a three-question survey to each eye bank to determine the accuracy of their records. .

due to an antiquated policy.

As it currently stands, HIV tests administered to all potential donors in the US are more accurate and have a shorter window than tests available when the FDA policy was made in 1994. If an HIVpositive donor “slips through the cracks,” the risk of HIV transmission through a corneal donation is still low, Puente said.

Since 1985 there have been 10 reported cases of corneal transplants using tissue of donors who were HIVpositive but no recipients who received those corneas became HIV-positive.

According to the researchers, the FDA and the Eye Bank Association of America do not require eye banks to specifically

HIV transmission risk via corneal donation is considered low.

Of the 65 total eye banks, 54 responded to the survey. In total, 24 eye banks kept records of potential donors disqualified because of their MSM status. The other 30 said MSM donors turned away were labelled as “high risk” in their records, Puente reported. Of the 24 eye banks with records, 360 were turned away due to MSM status, equalling 720 corneas.

These eye banks were responsible for more than 46.2% of all corneas recovered in the US and Canada in 2018, leading to an estimate of 1,600 corneas disqualified in 2018, Puente said. n

TECHNOLOGY

RESEARCHERS CREATE FIRST SEE-THROUGH 3D MAP OF THE HUMAN EYE IN MAJOR BREAKTHROUGH German researchers have developed a method to make an intact human eye and other organs appear transparent for the first time, which could serve as templates for 3D-bioprinting technologies in future.

Using microscopic imaging, a team comprising researchers from Helmholtz Zentrum München (HZUM), Ludwig Maximilians University Munich and Technical University of Munich revealed underlying complex structures of seethrough organs at the cellular level.

Rendered 3D images of the eye, brain and kidney were presented in their findings published in the journal Cell, which could one day lead to the creation of on-demand artificial organs.

In biomedical research, deciphering the structural complexity of human organs has been challenging due to the lack of imaging technology at the cellular level.

Recent developments in tissue clearing

allowed researchers to obtain the first cellular views of intact transparent mouse organs in 3D, but this did not work in human organs.

“We had to change our approach completely and start from scratch to find new chemicals which can make human organs transparent,” Ms Shan Zhao, PhD student at HZUM and first author of the study, said.

The team discovered a detergent called CHAPS could make small holes throughout entire human organs, allowing additional solutions to travel centimeters-deep and convert them into a transparent structure.

They also developed a new laserscanning microscope with a large sample holding capacity called ‘Ultramicroscope Blaze’, which enabled imaging of human organs as large as the kidney. Next, the team developed deep

learning algorithms that analyse hundreds of millions of cells in 3D.

Ms Shan Zhao, HZUM.

According to the researchers, cellular maps of human organs could be used to engineer large scale human tissues and organs with emerging 3D-bioprinting technologies. Towards this goal, Dr Ali Ertürk, director of the Institute for Tissue Engineering and Regenerative Medicine at HZUM, and his team are working on mapping major human organs, starting with the pancreas, heart and kidney.

“There is a huge shortage of organ donors for hundreds of thousands of people,” says Ertürk. “The waiting time for patients and the transplantation costs are a real burden. Detailed knowledge about the cellular structure of human organs brings us an important step closer to creating functional organs artificially on-demand.” n

RESEARCH

ASYMPTOMATIC COVID-19 PATIENTS LEFT VIRUS IN EYE EXAM ROOM

TRIAL SHOWS VALUE OF PROACTIVE THERAPY New data has highlighted the importance of proactive treatment for diabetic retinopathy after more than half of untreated patients in a trial developed vision-threatening complications.

Regeneron Pharmaceuticals, who sponsored the trial, announced positive results from the two-year trial evaluating its drug Eylea (aflibercept) in patients with moderately severe to severe nonproliferative diabetic retinopathy (NPDR).

Known as the Phase 3 Panorama trial, more than half (58%) of the patients in the untreated sham group developed diabetic macular edema or vision-threatening complications, including proliferative diabetic retinopathy or anterior segment neovascularisation, within two years of entering the trial.

Conversely, a 2 mg (0.05 mL) injection of Eylea was shown to reduce the likelihood of these vision-threatening events by at least 75%.

Study investigator Dr Charles Wykoff, a retinal surgeon and ophthalmologist, said: “These data reinforce that regular Eylea treatment can be highly effective at reducing the risk of new visionthreatening events among patients with moderately severe to severe nonproliferative diabetic retinopathy.

“More than half of all untreated patients developed vision-threatening events over two years, underscoring the value of treating patients proactively and regularly.”

The two-year results also showed a greater benefit for Eylea patients treated at regular intervals compared with patients who received the treatment less frequently.

"THIS STUDY SHOWED THE PRESENCE OF COVID-19 VIRAL MATERIAL IN A CIRCLE ONE METRE IN DIAMETER AROUND WHERE THE PATIENTS SAT" HASAN AYTOGAN, IZMIR TEPECIK TRAINING AND RESEARCH HOSPITAL

A new study has revealed the potential for asymptomatic carriers who have passed COVID-19 triage to leave traces of viral material in the ophthalmology exam room – even after wiping down chin and forehead rests between patients.

The small study, published in the The Journal of the American Medical Association last month, investigated the presence of SARS-CoV-2 at the biomicroscope stage, slit lamp breath shield, phoropter, tonometer and door handles after visits by patients who had no symptoms.

Author Dr Hasan Aytogan, from the Department of Ophthalmology at the Izmir Tepecik Training and Research Hospital in Turkey, said there appeared to be no objective data demonstrating the risks of encountering individuals carrying the virus asymptomatically in maintained elective examinations.

According to the study, after triaging, 31 people visited the room, with 22 of those undergoing ophthalmic examination and nine being companions. Seven samples were taken before examinations and returned negative results. Another seven were taken after, with two samples positive for COVID-19; one from the slit lamp breath shield and the other from the phoropter.

Despite passing triage, asymptomatic patients left virus material in the exam room.

This was despite the room being cleaned with hydrogen peroxide 3% after the last exam and there being no visitors for approximately 18 hours after cleaning.

No room cleaning was done between patients, but chin and forehead rests were wiped with isopropyl alcohol 70% between patients.

“This study showed the presence of COVID-19 viral material in a circle one metre in diameter around where the patients sat,” the study noted.

“In conclusion, this study provided objective data about the potential for patients who are asymptomatic, those accompanying them, or healthcare personnel in an eye examination room to leave viral material on the surfaces tested. Further studies are needed to determine the clinical relevance of these findings.” n

TRIAL OF TOPICAL FORMULA TO TREAT DRY EYE COMING ALONG IN STRIDES Results of a two-week study investigating ocular corticosteroid loteprednol etabonate in a novel formulation for dry eye disease found it was well-tolerated and had a favourable safety profile.

The group of trial patients who received Eylea every eight weeks in the first year were switched to receive it when their doctor determined they needed it (called pro re nata, or PRN) in the second year.

Loteprednol etabonate (LE) ophthalmic suspension 0.25%, manufactured by Kala Pharmaceuticals under the brand name Eysuvis, but formerly known as KP121, met its primary and key secondary endpoints in a third Phase 3 clinical trial.

The study is one of the largest dry eye clinical trials.

The PRN group showed an 80% improvement in DR severity at 52 weeks but deteriorated to 50% at 100 weeks. Comparatively, patients who continued to receive the therapy every 16 weeks remained consistent with 65% improvement in severity at 52 weeks versus 62% at 100 weeks. n

Dr Elizabeth Yeu, assistant professor of ophthalmology at Eastern Virginia Medical School, told the Ophthalmology Times the Phase 3 study, known as STRIDE III, showed the “statistical superiority of LE 0.25% suspension compared with the control for improving signs and symptoms of dry eye”.

“Collectively, these studies enrolled almost 3,000 patients, making STRIDE the largest dry eye disease clinical trial program to date, and the results indicate that LE 0.25% suspension is a rapid-acting, safe, and effective antiinflammatory therapy.” n

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INSIGHT September 2020

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PRESBYOPIA

BLENDING VISION FOR BETTER OUTCOMES More presbyopic patients are seeking a safe, effective and affordable surgical solution to break free from their spectacles. Ophthalmologist DR ANTON VAN HEERDEN discusses his early experience with a laser blended vision procedure in his new Melbourne clinic.

W

ith Australian adults over the age of 45 now accounting for 45% of the population, there has arguably never been greater demand for the presbyopia-correcting expertise of cataract and refractive surgeons.

“But it really comes down to functionality. People in their 50s are a lot more active than they used to be. Another key driver is the fact that everyone is on screens and the presbyopia symptoms really become apparent when using smartphones and computers.”

Estimates vary, but government data indicates that as many as 690,000 people live with presbyopia in Australia, with millions more considered hyperopic. As more people seek permanent spectacle independence, ophthalmic device manufacturers are meeting this demand with incremental improvements in intraocular lens designs and advances in laser surgery sophistication.

The convergence of these factors has resulted in demand for presbyopia-correcting surgical solutions, including clear lens exchange procedures and conventional monovision laser methods.

As an ophthalmologist who has made presbyopia correction a point of interest in his career, Victorian cataract and refractive surgeon Dr Anton van Heerden has been an early adopter of cutting-edge procedures in this field.

He heads the Surgical Ophthalmology Services Department at the Royal Victorian Eye and Ear Hospital and is the director of Armadale Eye Clinic and Mornington Peninsula Eye Clinic.

Earlier this year, he became principal surgeon at Eye Laser Specialists, one of Melbourne’s newest laser eye clinics. It was the first to offer small incision lenticule extraction (SMILE) in the state on an ongoing basis and is Australia’s first and only clinic to provide Zeiss’s Presbyond Laser Blended Vision as a standard clinical offering.

In recent years, van Heerden has watched the presbyopia surgical market grow considerably due to a combination of factors.

“There’s a large population in their early 50s and they’re generally good income earners. For many there is a massive frustration with glasses, with reading glasses, in particular, a symbol of aging,” he says.

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INSIGHT September 2020

But with the introduction of the Presbyond system into his clinic in January this year, van Heerden says he is witnessing a growing appetite for a blended laser correction option that eliminates many of the drawbacks and risks of the more traditional presbyopia-correcting surgical options.

“Presbyond is a program that’s written into the Zeiss MEL90 excimer laser system. It’s an induction of spherical aberrations so you get an increased depth of focus for each eye – even though you have mini-monovision on the cornea,” he says.

“The concept is very similar to EDOF IOLs, so you have a greater range of focus per eye, which allows good distance, intermediate, near vision and binocularity. It’s unlike monovision laser where you only get good distance and near vision, so it’s really promising.”

To further explain the underlying principles of Presbyond, Zeiss product information states the dominant eye is corrected for distance vision to almost plano, while the non-dominant eye is corrected to be slightly myopic for near vision to -1.50 D. This mini-monovision strategy is said to be further enhanced by a key difference: an increase in the depth of field of each eye using a wavefrontoptimised ablation profile to create a continuous refractive power gradient for the whole optical zone of the cornea.

As a result, customised fusion of the two images for near and distance vision is created for each patient to create a ‘blended vision zone’, making it easier for the brain to merge the images in both eyes and achieve true binocular vision. This is opposed to monovision laser, which can create an intermediate ‘blur zone’.

According to Zeiss, clinical studies have demonstrated that stereoacuity is maintained in Presbyond patients, with virtually no loss of contrast sensitivity.

The side effects of conventional monovision, such as multiple images in one eye, are almost eliminated.

It is also proven to be tolerated by more patients than conventional monovision and is effective in treating up to 97% of all presbyopia-related forms of impairment.

MEETING DEMAND Van Heerden says almost half of all his patients presenting for laser assessment are now over the age of 50, so providing an advanced corneal refractive procedure has helped fill a distinct gap in his suite of procedures.

From a financial perspective, it’s also several thousands of dollars cheaper to perform than a bilateral lensectomy.

Dr Anton van Heerden with his clinical team at Eye Laser Specialists in Melbourne.

“It’s great to be able to give patients the option. We get a lot of people over the age of 50 who are coming in for laser vision correction and we know that if we just correct their distance vision they are not going to be happy because they will still need glasses to read, and a lot of the time they don’t understand that until you explain it to them,” he says.

“Since we have opened in January, a third of our patients have had Presbyond, so a significant portion of our laser surgery is in that category.”

There is also little doubt that operating on the cornea is a safer option than inside the eye, particularly for a patient cohort that will typically live for several more decades.

“And that’s for a number of reasons: it’s quicker, safer, more predictable and it’s instantly reversible with a pair of glasses if needed,” van Heerden explains.

“If you’re operating on someone in their 50s, they are going to potentially live till their 90s, but you don’t know what the eye is going to do in that time.

If you remove a healthy crystalline lens and put a multifocal IOL in, there’s still a good chance that even though they don’t have macular degeneration or glaucoma, they could develop those as a pathology down the track.”

While there are other competing laser techniques that adopt multifocality for presbyopia, van Heerden says Presbyond and its EDOF principle has produced impressive results in his patients so far.

Compared with standard myopic/hyperopic laser surgery, he says it demands more from the ophthalmologist in terms of the patient work up and counselling – a hallmark of most presbyopia-correcting procedures.

This includes careful management of expectations, such as the fact they may need to drive with glasses for a short period, particularly at night.

“Whether it’s on the cornea or the lens, patients need to know there’s no perfect solution – we can’t give their accommodation back. Due to it being a mini-monovision set up, the compromise with Presbyond lies in the fact that it does take a bit of time for the brain to adapt, so it’s important to try iron out those patients,” van Heerden says.

“It’s not for the fastidious engineer, the perfect patient is a 55-year-old electrician or plumber who is a hands-on worker that’s frustrated with putting their glasses on and taking them off.”

Van Heerden says patients are also advised about the prospect of residual accommodation changes. They are warned they might require enhancement later on, but the customisable nature of Presbyond means surgeons can adjust the power in each eye.

In terms of the ocular system, van Heerden says patients must have a healthy eye, with normal corneas and best corrected vision of 6/6 or better in each eye. There should also be clear ocular dominance in order to set each eye for its respective distance and avoid issues such as cross dominance.

The blended vision zone allows the brain to easily merge the images in both eyes.

Patients undergo a cross-blur tolerance test which gives a good indication if they are suitable for Presbyond. A contact lens trial is not encouraged as many patients who tolerate Presbyond will not tolerate an extended contact lens trial.

“They must also have the normal requirements for laser, without any pathology – especially in the lens. If there is any cataract or pending cataract then obviously you’d avoid any corneal refractive surgery and opt for a lensbased option,” he says.

“People often ask about those who may develop a cataract in an eye that’s had Presbyond. Our formulas for working out the power of lenses post refractive surgery are now quite accurate, so that’s not an issue. The only thing that’s not advised is to put a multifocal lens in an eye that’s had a refractive corneal procedure.”

Mr John Ring, Zeiss Australia and New Zealand’s business development manager for refractive lasers, told Insight that Presbyond has been available in Australia since 2013-14, with a small number of trial sites conducting early Presbyond treatment on the older MEL80 excimer laser platform. Van Heerden has been the country’s first surgeon to provide it as a standard clinical offering and on the MEL90 platform.

The company conducts educational webinars by global experts, and offers in-person Presbyond courses, including by laser eye surgery pioneer Professor Dan Reinstein from London Vision Clinic.

“Each patient is different and Presbyond is another tool in the toolkit of the busy refractive surgeon to be offered to their patients,” Ring says. “As for the future, going by its strong uptake in New Zealand, Presbyond has the potential to be an important element in the suite of treatments available to Australian patients.” n

INSIGHT September 2020 29

EYEWEAR RETAIL

MAKING YOUR EYEWEAR

KNOWN IN THE Insight explores how optometrists and eyewear retailers are using costeffective and creative marketing techniques to attract patients in today’s ultra-competitive market landscape as more consumers venture online.

I

t is estimated that the average independent optometry practice in Australia generates anywhere up to 75% of total revenue from retail or product sales.

For many practices, finished spectacles and plano and prescription sunglasses account for a large portion of those sales. However, with increasing operational costs and marketing spends varying between 1-6% of turnover, more practices are seeking cost-effective eyewear marketing techniques that also work to align with consumer trends.

When it comes to identifying the most influential factors shaping consumer behaviour, shopping habits and purchasing decisions in 2020, global market research firm Euromonitor International has coined the terms ‘proudly local, going global’ and ‘catch me in seconds’.

The former helps to explain the value that consumers place on home culture and products tailored to local tastes. Meanwhile, ‘catch me in seconds’ refers to the urge to seek quick, concise and multisensory content for instant gratification.

These trends are being increasingly reflected in eyewear retail where independent practices like WINK Optometrists in Melbourne have become

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savvy adopters of social media to promote their business in a ‘proudly local, going global’ vein.

Meanwhile, the power of social media influencers in eyewear was perhaps most evident when a $20 pair of blue light blocking glasses became a best-seller on Amazon after a New York fashion blogger was spotted wearing them on Instagram. Closer to home, other retailers are leveraging influencers or ordinary customers who can connect on a more personal level.

PROUDLY LOCAL, GOING GLOBAL How much do eyecare practitioners spend on marketing their practice, and how much revenue does their marketing generate?

In Australia, independent practices generally allocate a marketing spend between 1-4% of turnover, compared with corporate practices, which may spend in the region of 6%.

It’s similar in the US, according to an industry marketing and sales expert, who estimated between 5-10% of gross revenue is an average marketing budget for an independently owned optometry practice, depending on location and relative competition.

The same author notes that while marketing budgets tend to be 70% spent on traditional forms of marketing such as print advertising, direct mail, billboards, radio and television versus 30% spend on digital marketing such as website, SEO, Google advertising and social media participation and advertising, that ratio is shifting closer to a 50/50 split.

with its widely recognised catchphrase “Should’ve gone to Specsavers” now part of the public lexicon.

Specsavers director of communications Mr Charles Hornor says that under its Joint Venture Partnership model, a certain percentage of each practice’s monthly sales revenue goes into a joint marketing fund, which is owned by the franchise partners.

Specsavers central support office administers the fund on behalf of the partners and allocates how it is spent across its financial year, split between marketing directly to consumers, and within the eyecare sector, as part of its goal to transform eye health.

WINK Optometrists in Melbourne uses social media as a primary vehicle to market its practice and range of frames.

It’s this concept of transforming eye health that drives a significant proportion of its marketing dollars to support annual eye health campaigns raising awareness about conditions including glaucoma and macular disease, and programs such as KeepSight.

Purveyors of independent eyewear, the boutique practice only stocks brands that are primarily handmade by craftspeople from around the world.

A selection of these are currently seen by nearly 4,000 Facebook and Instagram followers.

Last year Specsavers also reviewed its branding on social media and decided on a new direction.

Owner and optometrist Ms Jo Twaddell opened the practice in 2006. She leads a three-person team including an optometrist, optical dispenser and practice manager and dispenser, Ms Lucy Rouw.

“We looked at how we interact with people and made a deliberate choice to move away from overly-orchestrated material in favour of real people doing real things,” Hornor says.

For large corporations, like Specsavers and EssilorLuxottica, a large public profile and substantial revenue make that 50/50 split attainable.

But for independent practices, including two Insight spoke with, digital marketing is often the only form of marketing they use because it is costeffective and immediate.

Rouw is largely responsible for curating WINK’s vibrant, active social media presence on Facebook and Instagram, Twaddell explains, adding that they bounce ideas off each other.

Social media and word-of-mouth are WINK’s only form of marketing – the practice isn’t advertised through any other medium.

“Our best marketing tactic is having the right frame on someone’s face.

Providing advice to our patients on what frame works best for them is important to us,” Twaddell says.

Mr Rick Taylor, optometrist and owner of independent Gold Coast practice Ashmore Optical, has turned to Facebook and Instagram with increasing regularity to promote his business and showcase its product range.

“For us, I see it as the way of the future. Responses to our posts have been huge. We’re trying to use social media to publicise our range of frames and to let people know when a new range comes in,” he says.

Taylor employs two optometrists and seven support staff in the practice he has owned for 28 years.

“We’re in a small suburban shopping centre in a family-orientated area, and our patients are mainly locals. About 10 years ago, we placed ads in the local newspaper and tried radio advertising too, but we got little to no response out of it,” he says.

It can be said that the opposite is true of Specsavers, which has used traditional forms of marketing including print and television to great effect,

Ashmore Optical leverages social media to showcase its selection of frames.

“While we still use some ‘style ambassadors’ on our social media platform they are also Specsavers customers living their lives in Specsavers eyewear and they’re capturing that.

“In summary, we are featuring real people posting images online on Instagram and Facebook, which is 10 times our biggest social media platform,” he says.

CUT-THROUGH While ‘word of mouth’ marketing is still considered a top generator of new patients for optometry practices, consumers are continuing to shift their attention to their mobile devices, where conversations about healthcare, referrals and recommendations may be happening more frequently via text and social media.

When a new patient is asked how they heard about the practice it’s increasingly more likely they’ll say they discovered it through their connections on Facebook rather than through a friend or family member.

So, how can optometrists use cost-effective digital marketing techniques to compete in today’s landscape as more people head online to buy eyewear?

Marketing experts recommend practices update their website to ensure

INSIGHT September 2020 31

EYEWEAR RETAIL

it appears high in searches for eyecare, eye disorders, brands of eyewear they stock – and ensure it loads quickly on mobile devices.

Others suggest that practices add an online appointment scheduling tool on their website – as many younger patients do not want to call to make an appointment – and enable practice staff to have conversations via messaging, as this is how many younger patients (under 40) prefer to communicate.

They also recommend featuring a selection of eyewear on the practice website, Facebook and Instagram.

WINK Optometrists combines all these digital marketing techniques, including online appointment booking, powered by MyHealth1st, and its stockist’s frames are a staple on its website and social media.

Twaddell says their inspiration for online content comes from their love of eyewear.

“It’s Lucy and my passion, and it extends into fashion, design and art.

We engage with and support our social media family. We have a nice relationship with creative types, people we relate to and that reflects the people we attract,” she says.

WINK is located in Elwood Village alongside a greengrocer and gourmet butcher together with a bespoke range of independent retailers lining the high street.

In addition to a local patient demographic, WINK attracts patients and customers from all over Melbourne, Victoria, interstate and New Zealand, prompting WINK to introduce virtual fittings to keep up with demand during the COVID-19 restrictions.

The practice also has a visually-engaging website, which was designed using copy and photography from current customers.

Ashmore Optical on the Gold Coast doesn’t yet have the social media audience that WINK has built, but it too uses social media to showcase its selection of frames.

Taylor wants to grow Ashmore Optical’s audience on Facebook and Instagram, which he says started small but is gradually growing.

Lucy Rouw (left) and Jo Twaddell, WINK Optometrists.

Optometrist David Angus, who joined the practice in 2000, has curated Ashmore Optical’s social media posts during the past few years but now a marketing manager has taken over the role, pro bono.

“We use frame suppliers’ marketing material when we can but it’s getting harder and harder to get promotional material to use in-store with the disruption from COVID-19,” Taylor says.

“Generally, suppliers come to the party with posters, and their logo to use on digital marketing material,” he says.

"GENERALLY, SUPPLIERS COME TO THE PARTY WITH POSTERS, AND THEIR LOGO TO USE ON DIGITAL MARKETING MATERIAL" RICK TAYLOR

Twaddell says she set out to differentiate her practice through the range of frames she chooses to stock. She usually goes to Silmo Paris to select frames but that won’t happen this year due to ongoing uncertainty surrounding the COVID-19 pandemic.

“We stock interesting frames and attract interesting clientele as a result,” she says.

“We don’t stock licensed brands – we deliberately choose frames that aren’t heavily branded on the temples, for instance. We always choose the unusual frames you’d think would never sell but they are often the first to go.”

She continues: “We don’t use models or influences on social media – we use real people, real patients, wearing their own frames. We ask their permission to share their photo on social media – most are happy to oblige.”

Ashmore Optical uses competitions, giveaways and sales to grow their customer base on social media. Part of social media’s appeal, Taylor says, is the fact there is no cost involved.

In July, the practice promoted a $200 in-store voucher giveaway in exchange for participants following their Facebook page and tagging four friends or family members. In the same month, they promoted Initium Eyewear, as worn by Robert Downey junior’s character in Marvel movies, Iron Man and The Avengers.

“Initium Eyewear is exclusively available through Ashmore Optical and part of the reason we decided to take this brand on was the fact that Initium is a strong supporter of Autism Awareness, a charity David is involved in,” Taylor says.

Taylor says utilising social media to showcase non-prescription frames and sunglasses is essential to reaching younger age brackets.

“It’s 100% the best platform to promote our range of sunglasses to millennials,” he says.

CATCH ME IN SECONDS In an online article titled: ‘Social Influencers: How optical is leveraging followers, clicks and pics for marketing’, the authors note the incorporation of social media and influencers into marketing strategies is evidence that both techniques are viewed as affecting the path-to-purchase.

“With most people spending so much time on their digital devices, the path-to-purchase is no longer linear, but has evolved into more of a cycle in which an influencer at the evaluation stage can directly affect the decision of his or her follower in the awareness or consideration stages,” they note.

“Over the last couple of years, we’re seeing younger people who appreciate craftmanship and design.”

The evolution in the path-to-purchasing is not lost on Australian eyewear brand Baxter Blue, which was this year named emerging online retailer of the year by e-commerce group, Power Retail.

She says WINK’s Instagram feed garners more interaction with followers than its Facebook page. Even so, advice WINK shared on how to avoid glasses from fogging while wearing a face mask attracted 31 shares and 29 comments on Facebook.

Based in Sydney with a unique selling proposition, ‘eyewear for the digital age’, Baxter Blue sells non-prescription blue-light blocking glasses and readers for the singular price of $89, but is not, and does not claim to be, an optometry practice.

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Mr Aaron Telford co-founded Baxter Blue three years ago. Prior to joining the online retail industry, he was a creative services director at Warner Bros.

His own experience of eye strain, and a background in manufacturing, led him to establish the direct-to-consumer business.

He says the business has grown since its inception, and now counts professionals in the health and wellbeing industries, including chiropractors and optometrists, among its customer base.

“We’ve had a massive surge in orders in the last three months from optometrists. We’ve had a sharp increase in orders for non-prescription blue-light glasses, and an increase in wholesale from optometrists because of COVID-19, as more people are working online at home, so there’s been a surge in demand,” Telford says.

He says Baxter Blue uses social media organically to promote its products, as well as paid advertising placement on Facebook and Instagram. It also partners with influencers to connect with their predominantly young demographic.

“We did a collaboration with health and wellness entrepreneur Rachael Finch (292,000 Instagram followers) in February, which we launched on social media, and reached a large audience through Rachael’s following,” Telford says.

"WE DID A COLLABORATION WITH HEALTH AND WELLNESS ENTREPRENEUR RACHAEL FINCH ... AND REACHED A LARGE AUDIENCE" AARON TELFORD

Telford says Baxter Blue has “very high standards” when it comes to the quality of their frames and lenses.

“We have rigorous quality control procedure whereby a QC professional is sent to the factory to inspect and approve every pair of frames before they are despatched.”

“It creates exposure. But we only partner with people who have the same values as us.”

He believes it’s this quality of product and en-pointe social media marketing that helps them beat their competitors.

It also counts Instagram coach Eloise Smith (11,400 Instagram followers) and content creator Emma Giacca among its social media influencers “doing business in their Baxters”.

“In terms of marketing, it’s business as usual at Baxter Blue. As I said, we’re seeing an increase in demand for wholesale from the optometry sector. There is greater demand for non-prescription glasses, costeffective, straight from manufacturer to consumer. As non-prescription glasses can’t be claimed back on private health insurance, we think $89 is palatable to our customers.” n

Although Baxter Blue boasts more than 10,000 online reviews and has strict quality control, which Telford is particularly proud of, online retail is a crowded space and competition is strong.

The new Missoni eyewear collection is now available in Australia.

For more information contact your Safilo Area Manager or Customer Service: 1800 252 016 safilo.orders@safilo.com

OCT

IN OCT TECHNOLOGY? Few technologies have had such a swift and profound impact on eyecare as much as optical coherence tomography. Insight takes a deep dive into the evolution of OCT and the bearing this may have on future models.

S

ince its development in 1991, OCT has become a cornerstone in the diagnosis and assessment of most vision-threatening diseases and has helped transform vision research.

As to be expected, there were many early adopters in ophthalmology – and to a lesser extent optometry – from the beginning. But as the utility of OCT became undeniable, and often despite the lack of a financial incentive to incorporate OCT into a practice, uptake of the technology began to trend upward.

Today, its ubiquity in Australia’s ophthalmic sector is perhaps best demonstrated by its increasing prevalence in both independent and corporate optometry practices and its inclusion in MBS items for ophthalmology (but not optometry) since November 2016.

OCT’s developmental path started with time-domain (TD)-OCT, followed by spectral-domain (SD)-OCT, and ultimately swept source (SS)-OCT models.

The technology is advancing through its next major evolutionary step in the form of OCT-angiography (OCTA), introduced in 2014, with other variations also inching closer to commercialisation.

And eyecare isn’t the only sector benefitting, with the technology now extending into oncology, cardiology and dermatology.

Engineer and Massachusetts Institute of Technology alumni Mr Eric Swanson is a co-inventor of OCT technology and a co-founder of the first ophthalmic OCT company, later acquired by Zeiss. He is also editor of OCT News, a notfor-profit website providing the latest news in the field.

In a presentation he gave at a conference in Singapore in 2017, Swanson

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says OCT continues to benefit from “tectonic advancements” in other fields, such as augmented reality, and says high-speed lasers, integrated photonics, and computer-aided detection and diagnosis are among the most active areas of OCT research and design.

He also notes that the commercialisation and growth of OCT during the past 25 years has had enormous scientific, clinical, and economic impact.

To illustrate the latter, he cites statistics that between 2008-2015, OCT-guided anti-VEGF therapy in age-related macular degeneration saved more than US$9 billion (AU$12.6 b) by avoiding unnecessary injections.

In a paper he co-authored in Biomedical Optics Express, Swanson estimated there was more than US$500 million (AU$693 m) of venture capital and corporate research and development investment developing OCT related products, and more than US$500m (AU$693 m) of government funding towards OCT research.

But despite the tremendous accomplishments in advancing OCT technology and clinical applications, Swanson believes the best of OCT technology is still to come.

“We’re still at the beginning of this technology – we’re not even at an inflection point.”

BUILDING ON BREAKTHROUGHS With the relatively recent introduction of OCTA, eyecare professionals now have access to an additional imaging modality for the retinal and choroidal microvasculature, helping inform decisions in glaucoma and retinal diseases.

Compared with the gold standard fluorescein angiography, it has unique

benefits as well as certain disadvantages. However, software and hardware improvements are evolving to mitigate these limitations.

Two recent projects, reported in Biomedical Optics Express in July this year, have published findings that could assist greater translation of OCTA into ophthalmology clinics.

In one project, a group at Boston University School of Medicine has developed what is said to be the first visible light OCTA (vis-OCTA) for human retinal imaging.

The other project, involving a team of researchers at Oregon Health and Science University (OHSU) in Portland, including Swanson’s OCT co-inventor Dr David Huang, devised a prototype to improve OCTA image quality without excessive sacrifice in field of view and device complexity, which they believe may have potential for clinical translation.

“Over the past decade,” the authors note, “we have witnessed the rise of optical coherence tomographic angiography (OCTA) in retinal imaging. Unlike fluorescein angiography, OCTA does not require intravenous dye injections and uses intrinsic motion contrast provided by the flowing blood cells. OCTA is acquired within a few seconds; making it ideal for translation into routine ophthalmic clinical practice.”

While OCTA can image the retinal blood flow, they argue that visualisation of the capillary calibre is limited by the low lateral resolution.

The researchers developed a sensorless AO-OCTA prototype with an intermediate numerical aperture (NA) to produce depth-resolved angiograms with high resolution and signal-to-noise ratio over a 2 × 2 mm field of view (FOV), with a focal spot diameter of six microns, which is about three times finer than typical commercial OCT systems.

“Despite OCTA’s advantages over fluorescein angiography, a historical limitation of OCTA has been the smaller field of view. Because of the constraint imposed by the shorter depth of focus, adaptive optics instruments restrain OCTA’s field of view even further,” they note.

With OCTA, eyecare professionals now have access to an additional imaging modality for the retinal and choroidal microvasculature.

in detail,” Tong says.

“However, it is important to recognise that acquiring imaging using adaptive optics techniques and scan montaging are skill-intensive and time-consuming procedures, so without further developments to improve ease of use it is difficult to see it translating to routine clinical practice at this stage.”

She adds: “Nevertheless, I am excited to see what this research holds for the future, and there is lots of potential to facilitate better detection of vascular anomalies in the eye.”

“Designs like ours based on intermediate-NA imaging beams alleviate this problem and present a potential to either achieve a clinically useful field of view in a single scan or to reduce the number of acquisitions needed for larger field of views by montaging partially overlapping scans.”

ADDRESSING LIMITATIONS

TRANSLATING RESEARCH INTO REAL-WORLD

Previously manager of Zeiss Australasia’s medical division, Hall took time away from the profession to pursue an Executive MBA.

Speaking from her clinical experience, optometrist Ms Janelle Tong at the Centre for Eye Health (CFEH), says while some retinal vascular abnormalities can be difficult to visualise on funduscopy, photographs and routine OCT, OCTA can be invaluable in identifying these subtle changes.

“In particular, the ability to detect both retinal and choroidal neovascularisation and areas of ischaemia, associated with diabetic retinopathy for example, means that it can definitely improve the way in which retinal diseases are diagnosed and managed. Research into the applicability of OCTA in optic nerve disease is also showing great potential,” Tong says.

Prior to joining the CFEH, Tong worked in a full-scope private practice in Sydney, where she developed her interest in managing posterior ocular disease. She is involved in both clinical and research aspects of CFEH, with her current research looking at modelling normal ageing changes to the eye using advanced imaging.

She says that while OCTA is not often seen in clinical practice settings, current models are rapidly evolving through faster scan speeds and subsequent wider fields of view.

“Combined with ongoing research in this field, it is likely that the uptake of this technology will expand rapidly in the future.”

She says Huang’s OHSU prototype is interesting because it presents an option which combines higher resolution imaging of the retinal capillaries with a wider field of view than most adaptive optics-based OCT scans.

“This presents a key concern of commercially available OCTA, which uses a slightly different principle to adaptive optics, where despite the larger field of view the resolution is often too coarse to visualise the retinal capillary networks

Ms Kylee Hall is the vice president of sales and marketing at Cylite, a Melbourne-based start-up taking on the giants of ophthalmology with its own device that aims to address some of the longstanding shortcomings of OCT.

On her return to Australia last year, she saw an Insight article about Cylite’s debut patented hyperparallel-OCT (HP-OCT), which she says stood out in an otherwise entrenched and saturated field.

The device’s key differentiating feature is its so-called hyperparallel optical basis that allows the instrument to take an OCT volume ‘snapshot’ image of the subject’s eye – rather than scanning a single spot across the eye, the modus-operandi of current commercial OCT products – thereby negating the effects of eye movement.

Currently, the company is in the final stages of the process of applying for CE certification that indicates Cylite HP-OCT conforms with health, safety, and environmental protection standards for products sold within the European Economic Area.

Once it has CE, the company will start the process of applying for Therapeutic Goods Administration approval.

Shortly after Hall joined Cylite

The Australian-developed Cylite HP-OCT.

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OCT

as their first non-engineering appointment in February, the coronavirus outbreak disrupted the industry and resulted in the cancellation of several international and national conferences. However, they have demonstrated their device to ophthalmic professionals both locally and around the globe via Zoom.

Generally speaking, Hall says OCT scanning technology is getting faster, reducing some motion artefact, but not all.

photography are commercially available, they are relatively recent developments that are not yet widespread in Australian optometry practices.

“In particular, combined widefield technology and OCT shows great potential for investigating and managing peripheral retinal pathologies, and OCT models are increasingly incorporating additional widefield scanning options.

Furthermore, several software options are currently available to help colocalise scans from cameras and OCTs,” she says.

“The eye is constantly moving, for accurate OCT measurements this movement issue needs to be addressed. It is an inert issue that motion artefacts cannot be overcome with just faster lasers or better software algorithms,” she says.

Both Hall and Tong have their ear to the ground in their respective fields and see different futures for OCT technology.

“The majority of advancements in OCT technology have been in the posterior segment, such as OCTA, where the individual B-scans are each aligned into a volume image by using the blood vessels as landmarks. For the anterior segment, OCTA is in its development infancy.”

“A slit lamp examination is the current gold standard of eyecare, but with the recent pandemic it has eyecare practitioners asking: ‘How do we offer the same level of clinical care but be at a safe distance? When will OCT technology, especially for the anterior segment, be advanced enough to replace the slit lamp examination?’.”

These shortcomings of OCT technology planted the seed for Cylite to reinvent the engineering behind OCT. Hall says the Cylite HP-OCT has been received positively once eyecare practitioners understand the technology behind it and what sets it apart from other forms of the technology.

TIME AND SPACE CONSTRAINTS Tong says the wider range of models and decreasing costs have resulted in OCT becoming much more widespread in optometry practices within Australia, to the point where both corporate and independent optometry clinics are marketing availability of OCT in their practices.

Hall agrees, adding that some devices, like the Optos Monaco, that combine OCT and ultra-widefield imaging are popular in practices where space is a determining factor.

“Footprint is a big cost for practitioners, it’s cost-effective if you can combine multiple instruments and reap the advantages of more functionality in one device,” she says.

Through an abundance of education on the technology, Tong, at the CFEH, says optometrists now have a solid understanding of when OCT imaging would be beneficial and subsequently can arrange appropriate referrals if one is not available in their practice.

She says at this point in time it is more common for optometrists to have access to an OCT device that is either stand-alone or combined with fundus (posterior pole) photography.

“Typically, practices offering ultra-widefield photography have a separate machine to perform this. Current common OCT models, in conjunction with standard and other widefield photography options, are generally able to easily image diseases affecting the central retina,” she says.

She says that while OCT devices incorporating OCTA or ultra-widefield

JANELLE TONG CENTRE FOR EYE HEALTH

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Hall says one of the more recent talking-points in ophthalmology and optometry circles is the slit lamp.

In contrast, Tong says a recent ‘hot topic’ in the research world is adaptive optics OCT, where methods enabling visualisation of the cellular structures of the retina are being developed.

“It would be very interesting to see the clinical applications of adaptive optics OCT and, in turn, its translation to a commercially available device,” she says.

Currently, Tong says, there are improvements in OCT technology with each new version released. She predicts future developments are likely to incorporate faster scan acquisition, new methods to analyse the data and application of machine learning for automated identification of anomalies within acquired OCT scans.

“In addition to OCTA and combined ultra-widefield imaging/OCT becoming more widespread, I also believe future versions of OCT will place a greater emphasis on capturing a wider field of view, as many commercially available OCTs are hampered by the same limited field of view as OCTA,” she says.

In contemplating how OCT will fit into the future of optometry in Australia, Tong points to Optometry Australia’s Optometry 2040 project which she says highlighted that a focus towards detection and management of ocular diseases was the most preferred future for currently practising optometrists.

“With a greater emphasis on disease management comes an increased need for collaboration with other health practitioners, and the concept of optometrists being part of integrated care networks to ensure best-practice patient care is an exciting prospect,” she says.

“An example of this is screening for retinal toxicity secondary to hydroxychloroquine (Plaquenil), which would require collaboration between the patient’s rheumatologist, GP, optometrist and ophthalmologist should referral be required. OCT certainly would facilitate the expansion in this scope of practice by enabling more accurate diagnosis, monitoring and management of ocular diseases.” n

ERIC SWANSON OCT CO-INVENTOR

KYLEE HALL CYLITE

COVID-19

THE

MOUNTING CASE FOR

With a steady stream of new evidence, masks have become a hot topic in eyecare during COVID-19. But the issue has been confusing and contentious.

MYLES HUME examines the mask debate and the risks airborne transmission and asymptomatic patients may pose.

T

he necessity of face masks during general consulting of asymptomatic patients has swiftly become a central point of debate within ophthalmology clinics and optometry practices across Australia.

While many individual practitioners have long argued that universal, routine use of masks is a key weapon against infection in the practice, it has taken some time for the literature to catch up and for the establishment to form its subsequent recommendations.

During the intervening months, use of personal protective equipment (PPE) by eyecare professionals has remained a contentious, frustrating and at times confusing issue for practitioners to navigate.

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COVID-19

Arguments against their use have focused on a lack of evidence, the potential for more problems if not worn or removed correctly, complacency with other infective precautions and limited supplies of PPE. The Australian Department of Health’s guidelines only go as far as recommending surgical masks for both patient and practitioner in the presence of a suspected or confirmed COVID-19 case, while those in frequent close contact or conducting aerosol generating procedures (AGPs) on a positive patient are advised to wear P2/N95 respirators.

In other words, practitioners do not always have to use PPE when caring for other patients, nor get their patients to wear masks.

Although it differs from the national guidance, RANZCO stepped up its advice on 20 July to align with the Victorian and New South Wales governments and recommend that all Australian ophthalmologists, staff and their asymptomatic patients wear surgical masks in routine, face-toface consultations.

Associate Professor Adrian Fung, who is on the RANZCO COVID-19 Taskforce and Clinical Standards Committee, says the advice has shifted following the review of new literature.

"BEING INACTIVE UNTIL THE ‘EVIDENCE’ ARRIVES IS NOT A RATIONAL OPTION" EHUD ZAMIR

“My personal take is that I am yet to see any part of the establishment being nimble and responsive enough to provide the answers you need when you need them, and that includes federal government, state government and even the medical and surgical colleges.”

Zamir believes the so called “lack of evidence” earlier on is not an acceptable excuse for advocating against what he describes as a simple, cheap and logical step.

“In an emergency, where we desperately need simple preventive steps, being inactive until the ‘evidence’ arrives is not a rational option … While shortage of PPE was a real problem early on, nothing stopped us from telling everyone to make their own masks and use them in public spaces like hospitals, public transport, supermarkets and clinics. This has been done in other countries,” he says.

“My advice to my colleagues from the start has been that you all have what it takes to judge this situation for yourself reasonably well, draw your own conclusions and do what it takes to protect your patients, your staff and yourself.”

Western Australian ophthalmologist Dr Chathri Amaratunge believes the profession was left to its own devices to stump up with its own PPE early on in the crisis – particularly in public settings. She says there was a lack of ophthalmology-specific information, with some early information only related to telehealth.

“Because ophthalmologists in China were infected early on I think most ophthalmologists were thinking we are in pretty close contact with our patients and we need to be on top of this,” she says.

“I felt the information hospitals were giving us was almost irrelevant.

They were saying you don’t need to wear a mask or be careful unless you’re with the patient for more than 15 minutes. But the problem is no one has actually looked into the risk of infection if you’re within 30cm of someone and the difference between being with someone in the same room for 15 minutes versus being right in front of their face and talking to them directly for 15 minutes.

“I wasn’t happy with that and I think a lot of other people weren’t either.”

“In the past we didn’t have strong evidence to guide us one way or another, but I do think we are getting strong evidence now to form this recommendation,” he says.

THE CASE FOR UNIVERSAL MASKING

“But it’s important to note these are only one weapon in our fight against COVID-19. Even though everyone is focusing on masks right now, hand hygiene, cough etiquette, distancing, minimising speaking, breath shields, trying not to touch the patient or wearing gloves are all just as important.

A key study supporting RANZCO’s updated position was published in The Journal of the American Medical Association (JAMA) on 14 July.

“Masks have become topical because at the start of the pandemic – and less so now – supplies were low, and when we didn’t have strong evidence people were reluctant to be using them for asymptomatic patients.”

Fung, who is also a vitreoretinal surgeon at Sydney’s Westmead Hospital, cautions the latest recommendation should still take into account the local prevalence of disease, local policies and importance of preserving supplies of PPE. If supplies are limited in a public health setting, ophthalmologists should be permitted to wear their own PPE, if they feel this is clinically justified.

Some ophthalmologists – particularly in Melbourne where there has been a surge of cases – have expressed frustration in the time it has taken to recommend masking of both practitioner and patient.

Associate Professor Ehud Zamir is the principal ophthalmologist at McKinnon Eye Clinic in Melbourne. In the absence of clear advice, he took it upon himself to supply masks for all staff, patients and visitors in his clinic since late March and actively advocated for their broad use.

“I would like to think that I’ve been on the correct side of caution, rather than erring on the side of caution,” he says.

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Fung says the decision to recommend universal masking needed to be made on the best available evidence. And that is now available.

In it, healthcare workers from Mass General Brigham – the largest healthcare system within Massachusetts with more than 75,000 employees – demonstrated a linear reduction in SARS-CoV-2 positivity rates from 14.65% to 11.46% after the implementation of masking for healthcare professionals and patients. This is despite a state-wide increase in COVID-19 cases during the same period.

Separately, in a retrospective review of 493 medical staff at Zhongnan Hospital of Wuhan University, none of 278 staff became infected when wearing N95 respirators versus 10 of 213 staff who were infected when they did not wear a mask. This is despite the non-mask wearers working in departments considered a lower risk.

When asked to wear face coverings, experts note that many people think in terms of personal protection. But face coverings are also widely and routinely used as source control. Dr Derek Chu’s systematic review in The Lancet on 27 June, regarded as the most comprehensive study to date, showed risk of infection or transmission when wearing a mask was 3% versus 17% when not wearing a mask.

Fung explains further: “Surgical masks are only really designed for droplet protection; it does have some protection to the wearer but it’s more about protecting other people, so that’s why it’s important that it’s not just the doctor wearing a mask, but also the patient.

“The studies vary in terms of whether there’s a difference between

N95 and surgical masks; some show a difference and others don’t.

There’s a paper in The Medical Journal of Australia (MJA) where the authors strongly recommended we should be wearing N95 respirators when caring for COVID-19 confirmed or suspect cases (not just when performing AGPs which is the current Australian Government recommendation). However, this is less relevant for ophthalmologists because currently we aren’t frequently seeing patients with confirmed COVID-19.”

"IN THE PAST WE DIDN’T HAVE STRONG EVIDENCE TO GUIDE US ONE WAY OR ANOTHER"

OPTOMETRY AND MASKS

ADRIAN FUNG

As an indication of the perplexing nature of PPE information earlier on, one only needs to look as far as the situation facing Optometry Australia.

Chief clinical officer Mr Luke Arundel said the organisation experienced a 300%+ increase in member inquiries over the pandemic period, prompting it to expand its member support services.

He says it has often been difficult to source information specifically for allied health practitioners and some advice now differs between national and state health departments.

“Information was changing at an incredible pace at the start of the pandemic which fuelled confusion and uncertainty – our masks and PPE web page for example is at version 43. But thankfully things are slowing down a little,” he says.

OA has updated, evidence-based information on its website to help optometrists decide the best approach. While masks are advised in all public-facing areas of all Victorian practices and in NSW hotspots, in other states optometrists are being told to consider their age, health

status and the rate of local community transmission as important factors in making decisions about masks.

From a supply point of view, Arundel says the Australian Government is providing allied health professionals with some access to the government stockpile of masks.

“Operating under the assumption that optometrists will triage patients with respiratory symptoms, optometry has been classified as moderate priority for masks amongst allied health,” he says.

In clinical settings, fogging issues are an inherent part of mask use, particularly during visual fields or use of the phoropter.

Arundel says anti-fog sprays, detergent left to dry on glasses, a tissue folded under the top edge of the mask or taping this edge down with

REPURPOSING SURGERY FABRIC TO ADDRESS MASKING SHORTAGE Early on in the COVID-19 outbreak, Melbourne ophthalmologist Associate Professor Ehud Zamir was not alone in his concern for dwindling mask stocks.

is how well it seals. Without a good seal, no mask will protect the wearer, regardless of material. The great thing about our masks is that it sits tightly on your face. It seals well, you can see it breathing in and out. It also blocks various odours, including perfumes, which to me proves that it is an effective filter,” he says.

He had previously used the common surgical fabric Halyard Sterilization Wrap for domestic purposes, prompting him to consider its potential as a basis material for masks.

The mask has been tested and has apparently performed well in qualitative fit tests.

“The material was designed and proven to be permeable to gas/air while providing a barrier against bacteria and liquids. It’s used in large quantities in every operating theatre and is usually discarded after unwrapping the surgical packs,” he says.

Zamir conducted some encouraging preliminary testing. Then his daughter, Ms Maya Zamir, a veterinary student, stumbled upon Dr Bruce Spiess, a Professor of Anesthesiology at the University of Florida, who had already published a method of producing masks with the same fabric.

Using Spiess’s approach, Maya Zamir formed a volunteer group that is sewing masks for Victorian health professionals, using Halyard material gathered from Melbourne hospitals. More than 400 free masks have now been supplied to ophthalmologists, GPs, anaesthetists and theatre nurses, among other allied health professionals.

While correctly fit P2/N95 masks remain the

The mask made from Halyard Sterilization Wrap.

gold standard, Zamir notes their availability can be limited and highly regulated for those in intensive care units (ICU).

He cautions his hand-made masks haven’t been tested or proven effective. However, he says they probably offer greater protection than a standard surgical mask.

“With masks there are two main parameters; the first is how well it filters and the second

“The filtration ability probably isn’t as high as an N95, but N95 respirators are designed to meet a very high filtration standard, not necessarily representative of clinical exposure.

For most of us who don’t work in an ICU, where there are presumably large quantities of virus-containing aerosols, I think the Halyard/ Florida mask will provide some protection, especially if your patients also wear masks.”

In terms of reusability, Halyard masks are made of a material designed to go through the autoclave.

For decontamination and reuse, they can be put in 70C dry heat for 60 minutes, as per the US National Institutes of Health paper on N95 decontamination.

Other methods include hydrogen peroxide mist before hanging to dry, or dipping the mask for 30 seconds in five parts water to one part bleach prior to hanging to dry.

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COVID-19

micropore tape, may help avoid such issues.

“The other issue that has been flagged is mask wear also affects communication. Many optometrists have suggested that as long as it is kept clean and disinfected regularly and covers face and upper neck, face shields are better for patient communication, more comfortable and create less waste,” he says.

“Unfortunately, our current guidance from Victorian Department of Health and Human Services states that a mask should be used in conjunction with a face shield – it is not a case of using one or the other.

They have also advised cloth masks are not suitable in a healthcare setting.”

AIRBORNE AND ASYMPTOMATIC RISKS RANZCO and Optometry Australia both acknowledge the perception eyecare professionals may be at higher risk of infection compared with the general population due to their proximity to patients.

Perhaps the most conclusive evidence supporting this was published in an American Academy of Ophthalmology article in April, which highlighted a total of 28 eyecare professionals from 10 hospitals in Wuhan, China, who contracted COVID-19. This included 14 ophthalmologists, 12 ophthalmic nurses, and two ophthalmic technicians.

Eight professionals (28.5%) demonstrated severe disease, including three deaths, one of those believed to be after contact with an asymptomatic glaucoma patient.

Australian optometry and ophthalmology practices are now familiar with

"INFORMATION WAS CHANGING AT AN INCREDIBLE PACE AT THE START OF THE PANDEMIC WHICH FUELLED CONFUSION" LUKE ARUNDEL

the raft of strict protocols to ensure their practices are COVID safe. The installation of screens, mask use and other measures have also helped to prevent the virus’ primary form of transmission – via droplets.

However, the World Health Organization (WHO) has acknowledged that “urgent high-quality research” is needed for other ways the virus may be bypassing infection controls: via asymptomatic carriers and infectious aerosols that can be suspended in air over long distances (airborne transmission).

It has been reported that the mean incubation period is 5.1 days, meaning patients infected by SARS-CoV-2 can be asymptomatic and spread the disease during that time.

Testing of the entire population of Vo, Italy, found almost 3% of residents tested positive and most were asymptomatic.

The WHO says a recent systematic review estimated the proportion of truly asymptomatic cases ranges from 6% to 41%, with a pooled estimate of 16%. A JAMA study last month revealed that traces of COVID-19 were found in a Turkish ophthalmology exam room – even though the room was extensively cleaned and each asymptomatic patient passed COVID-19 triage. Also of concern to some is the evidence indicating potential aerosol transmission, which could have implications regarding the ventilation of eyecare settings.

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Until recently, the WHO has maintained that the primary form of coronavirus transmission is via respiratory droplets, followed by contaminated surfaces. Airborne transmission was said to only occur in healthcare settings during aerosol generating procedures.

However, on 9 July, the WHO updated its position to state airborne transmission was possible in some indoor settings such as crowded and inadequately ventilated spaces over a prolonged period of time.

It also noted that some studies conducted in healthcare settings where symptomatic COVID-19 patients were present, but where AGPs weren’t performed, reported the presence of SARS-CoV-2 RNA in air samples.

“Further studies are needed to determine whether it is possible to detect viable SARS-CoV-2 in air samples from settings where no [AGPs] are performed and what role aerosols might play in transmission,” the WHO noted.

Further, in an MJA article, Professor Raina MacIntyre, a University of NSW emerging infectious diseases expert, says guidelines on ‘droplet precautions’ (masks) and ‘airborne precautions’ (respirators) assume that respiratory emissions can be separated into mutually exclusive groups – droplet and airborne spread.

But she said this assumption is based on limited data and newer studies show droplets and aerosol particles exist in a continuum; a single large droplet may reduce in diameter and become airborne during its trajectory, because of evaporation.

Fung says there are a number of studies – at least experimentally – accompanying a belief that SARS-CoV-2 can be transmitted by aerosol.

“And so there is a concern, however the predominant feeling is that even though that is possible, most of the time it’s spread by droplets, and the reason why is because the reproductive rate in most countries is fairly low at about 2.5 and the secondary attack rate, the number of close contacts that become infected, is also about 5%, so if this was predominantly aerosol spread, those rates would be a lot higher.”

Amaratunge, the WA ophthalmologist, believes the evidence is beginning to catch up for airborne transmission.

An asthma sufferer, she wore recycled P2 respirators when case numbers were high in WA. “I think we kind of knew there was some airborne transmission going on, it was just a matter of time before the proper solid research said it’s happening. It’s a hard one because it’s not like you can do a controlled trial on this.”

While some ophthalmologists have exercised caution by wearing P2/ N95 masks, particularly those with underlying conditions, Fung believes broader use of respirators is not supported by evidence for eyecare professionals.

“I don’t think that the data supports ophthalmologists using respirators when caring for asymptomatic patients at this stage, but I guess that’s the great difficulty in all of this; we are all learning, and that’s why things are changing all the time as more studies come out and change thinking.” n

ORTHOPTISTS AND CLINICAL RESEARCH ORTHOPTISTS PLAY AN INTEGRAL ROLE IN CLINICAL RESEARCH ACROSS AUSTRALIA. WESTERN AUSTRALIAN ORTHOPTIST GARETH LINGHAM OUTLINES HIS WORK AT THE LIONS EYE INSTITUTE AND HOW IT HAS BENEFITED HIS PRACTICE.

A

ccurate and meticulous collection of data is an essential component of good research.

This can be a real challenge, particularly in uncooperative or unwell patients, who are often the very population in which research is required.

GARETH LINGHAM

"IT IS EXCITING TO BE ON THE CUTTING EDGE OF NEW RESEARCH AND GRATIFYING TO SEE SOME STUDIES PROGRESS TO A STAGE WHERE THEY CAN IMPACT PATIENTS’ LIVES"

Orthoptists’ understanding of eye conditions, expertise in ophthalmic investigation and ability to interact with patients and research participants makes us particularly suited to clinical research. Perhaps then, it is no surprise that orthoptists are extensively engaged in clinical research throughout Australia.

At the Lions Eye Institute (LEI), orthoptists are embedded in clinical research teams such as the clinical trials, genetics and epidemiology teams – and they are valued for their ability to efficiently and precisely conduct investigations.

LEI is a not-for-profit, world-class research institute and the largest ophthalmic research institute in Western Australia. There are more than 20 sponsor and investigator-initiated clinical trials currently active at LEI and the institute outputs approximately 50 to 100 scientific publications annually.

Research participants are given the ‘VIP’ experience at LEI and are often seen by clinical research teams, including orthoptists, allowing them to skip the clinic queue. Participants are seen in a dedicated research suite, complete with waiting area, two consulting rooms and a tea and coffee area. There is a stream of patients, orthoptists and other staff regularly coming and going from this research suite, with orthoptists doing everything from assessment of best-corrected visual acuity and colour vision to ocular motility examinations, microperimetry and fundus imaging.

I first became involved in clinical research through my work in clinical trials, mainly recruiting patients and collecting data for multi-centre clinical trials. I’ve since become involved in epidemiological studies and clinical trials that are initiated and conducted at

the LEI, allowing me to become more actively involved in study design and data analysis and interpretation. I enjoy being able to communicate with the research participants and find that they are always interested in discussing the study or finding out about the latest results and updates in eye research.

An understanding of how studies are run, conducted and the collection of research data also enables orthoptists (or any researcher) to interpret and understand the data and results.

I’ve been fortunate enough to be involved in studies on refractive error, strabismus and amblyopia, glaucoma and pterygium and having the insight of having collected the data has always been of enormous value. This was reinforced recently as I analysed data on strabismus and amblyopia in a birth cohort.

I’ve also been lucky to work on many exciting studies such as atropine for the treatment of myopia, intravitreal implants for the treatment of macular telangiectasia, intravitreal injections for geographic atrophy, and studies on retinal gene therapy and of intravitreal brolucizumab (Beovu) for wet agerelated macular degeneration. It is exciting to be on the cutting edge of new research and gratifying to see some studies progress to a stage where they can impact patients’ lives.

Being involved in clinical research has benefited my ability to practise as an orthoptist. Although I spend most of my time in clinical research, I do have the flexibility to work sporadically as an orthoptist in retinal and paediatric clinics in regional Western Australia. Patients (not so much the children!) are often interested in learning about the latest research and advances in treatment of their eye condition and what current clinical trials they may be eligible to participate in.

I appreciate maintaining this patient contact as it is a reminder that all research is ultimately intended to improve the lives and vision of patients.

While it often takes some time for

Involvement in clinical research has helped Gareth Lingham's practice as an orthoptist.

research to have an impact on patients' lives, it is nonetheless gratifying to see the importance of clinical research to patients and to know that the research I am involved in as an orthoptist will go on to make a difference.

Of course, it isn’t just orthoptists involved in clinical research and I am lucky enough to work alongside ophthalmologists, optometrists, nurses, doctors, scientists, programmers and engineers. I enjoy interacting with researchers from such a variety of backgrounds and I have no doubt that the mix of views this variety generates improves the research that we are able to do. Within the mix of professions and specialties within eye research, orthoptists continue to make a valuable contribution to research at LEI. n

ABOUT THE AUTHOR: Gareth Lingham is an orthoptist based in Western Australia. He graduated in 2014 and has since worked in clinical research at the Lions Eye Institute, recently completing his PhD. ORTHOPTICS AUSTRALIA strives for excellence in eye health care by promoting and advancing the discipline of orthoptics and by improving eye health care for patients in public hospitals, ophthalmology practices, and the wider community. Visit: orthoptics.org.au

INSIGHT September 2020 41

DISPENSING

WHAT MAKES A GOOD DISPENSER GREAT? HOW DISPENSERS INTERACT WITH PATIENTS CAN CREATE NEW OPPORTUNITIES FOR INCREASED REVENUE AND CUSTOMER RETENTION. TRACEY BANNISTER SPOTLIGHTS THE IMPORTANCE OF EXCEPTIONAL COMMUNICATION.

H TRACEY BANNISTER

"A GREAT DISPENSER DOES NOT JUST RECOMMEND PRODUCTS WITHOUT FIRST ENSURING THEY HAVE COACHED THE CUSTOMER ABOUT THE PRODUCTS"

ave you ever come across someone that you are instantly drawn to, but can’t decipher what it is that makes you gravitate towards them? What is this invisible pull we feel and why does it happen? Let’s unpack these questions and get to the source of what makes a good dispenser ‘great’ and how this can translate into the success of our business.

Optical dispensers are the lifeblood of the practice and are on the frontline serving our customers and offering product advice. And although we spend time and money training our staff and ensuring they gain a qualification, a good dispenser versus a great dispenser is not all about the technical skills or knowledge.

It enters a whole different realm.

The essence of a great dispenser incorporates several key elements and they may not be what you expect.

And once pointed out, they may seem obvious, simple, or even basic. But not everyone exhibits them and therein lays the difference.

I believe the most important skill any dispenser should develop are exceptional verbal and non-verbal communication skills. These are first and foremost what the customer will experience from us even before we serve them.

When I am shopping and looking at the various staff members to see who I want to assist me, it quite often comes down to what I am seeing and hearing in those moments. For example; their facial expression, do they have a smile that reaches their eyes and can be heard in their voice?; their body language, are they holding themselves upright and not slouching?; how they move their body, are they demonstrating open body language by facing the customer and maintaining eye contact?; and their tone of voice, is it clear, friendly and engaging? These elements demonstrate they care about the customer and are happy to serve them. All of which are attractive and makes the customer want to connect with the dispenser.

No less important than communications skills – but essential to dispensing – are

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INSIGHT September 2020

Connecting with customers on a basic human level can build valuable and lasting relationships.

relationship building skills. Assuming, between two dispensers, they have the exact same knowledge, skills, and years of experience, what makes one dispenser the kind of person customers keep coming back wanting to see?

So, are you a good dispenser or a great one? Do you demonstrate the above elements? You might be thinking to yourself ‘Oh yeah, I do that’. But do you really? And how effectively are you doing it?

The answer is they know how to connect with customers on a basic human level and build valuable relationships. They do not come across as a ‘sales’ person, but instead are a ‘people’ person.

Next time a customer comes into your store take note of your verbal and non-verbal communication. Analyse if you are listening to your customers or demonstrating active listening skills.

Are you building relationships or just trying to make a sale? Are you coaching customers about products or telling them? Because, like the example I gave above about choosing which staff members to assist me, your customers are doing the same thing when they walk into your optical practice.

Active listening and coaching skills are essential in the dispensing process too. Active listening, not to be mistaken for just listening, enables you to gather and clarify the information you need to be able to effectively recommend appropriate products and services (which generally results in higher order value). But a great dispenser does not just recommend products without first ensuring they have coached the customer about the products; clearly explaining the features and how they relate to them. They know how to deliver and impart their knowledge in a way that customers will understand. They are educating the customer.

How you interact with customers and deliver information to them opens up new opportunities and possibilities for your business in terms of increased revenue and customer retention.

Consider the skills of you and your team to determine where there may be gaps relating to these key elements; verbal and non-verbal communication, relationship building, active listening, and coaching.

Develop a plan of action to create awareness around these. Then witness the effect they can create and see your good dispensers achieve greatness. n

TRACEY BANNISTER is the director of Victorianbased Emerald Eyes Optical. She is an optical dispenser, practice manager and trainer with 29 years’ experience.

MANAGEMENT

‘I’M AFRAID THE NEWS ISN’T WHAT WE’D HOPED’ AS A PRACTITIONER, BREAKING BAD NEWS CAN BE ONE OF THE MOST DIFFICULT PARTS OF THE JOB. AVANT MEDICAL ADVISOR DR MARK WOODROW AND LEGAL AND POLICY OFFICER ROCKY RUPERTO DISCUSS THE KEY STEPS.

H MARK WOODROW

aving to advise a patient of a poor prognosis is an unavoidable part of most health practitioners’ jobs, and it is never easy. Recognising the importance of doing this well, and being prepared, can help ensure such consultations go as well as possible, for you and for the patient.

to recognise and allow for a patient’s emotional response.

Mr S suffers from diabetic retinopathy and has come to you for his regular eye examination. He has been able to continue driving, but you now believe his vision has deteriorated to the point where he is no longer safe to drive. How do you tell him?

In a situation like this, it is understandable if you feel sorry for the patient, having to tell him he can no longer drive. He may be upset or angry.

Some patients may try to exert pressure on you to change your assessment.

Approaching the conversation with care and demonstrating respect and concern for the patient will help. It is important though to remain objective and clear in your assessment, and ensure you are not swayed by patient pressure. Never offer false or misleading hope.

BEING PREPARED TO DELIVER BAD NEWS ROCKY RUPERTO

Such a consultation is often challenging, and it is essential you communicate very clearly so Mr S understands what you are telling him, and the implications.

Preparing as much as possible for the consultation is important.

Some of this preparation will involve practical issues: • Bad news can take time for patients to process, can you take extra time if needed for a difficult consultation?

• Do you know what the next steps for the patient’s care will be?

• Do you have information in a form they can take away with them – including referrals to support services if necessary?

• It is always important that the discussion occurs in an appropriate setting to protect the patient’s privacy, but consider whether the patient will need support or interpreter services for the consultation.

Some practitioners also find it helpful to have considered and rehearsed common scenarios in their field.

HAVING THE DISCUSSION Even if you can only spend a few moments, collect your thoughts and think about how to approach the discussion. If you have a long-standing relationship with the patient, you may already have talked about how their condition may progress.

Nevertheless, the news will likely still come as a shock and it is important

In either case, it is also often helpful to start by checking what the patient knows about their condition, or what others have told them. This can help you understand what they are expecting to hear, and to focus on information they need.

Patients may have many questions about the prognosis and implications, so be as prepared as possible before the consultation. However, always take your lead from the patient; check how much information they want and can take in. Speak clearly and try to avoid using medical jargon. Consciously try to pause and break the information into small chunks. This will allow a patient more time to absorb it, and moments of silence will give them an opportunity to ask questions or express concerns.

If patients do have questions, always try to answer as concisely as possible. Avoid speculation and if you don’t know the answer, be confident to say so.

At some point it may be important to ask whether the patient will need support to tell relatives or carers. However, make sure you prioritise the patient’s privacy and only speak to family with the patient’s permission. You may also need to discuss a plan for informing other health practitioners involved in the patient’s care.

Before you finish, summarise the discussion and ensure the patient has had enough opportunity to ask questions.

Reinforce what you agreed about next steps, follow-up appointments or referrals. Provide any appropriate

It is important to ensure the patient has had enough opportunity to ask questions.

further information, including about support services. Make sure the patient knows how to get in contact if they have further questions. Check they can get home safely.

DOCUMENT THE DISCUSSION Patients who receive a shock are particularly likely to mishear, or misremember, what was discussed in a consultation. Always document the details of the consultation carefully, including the names of anyone else present, the matters discussed with the patient and information provided. It is good practice to keep a copy of the actual version of any prepared information you provide as such publications are regularly updated and may have changed if you ever need to check what the patient was told at the time.

Finally, remember to take care of yourself. Delivering bad news can challenge even the most experienced practitioner, so make sure you have your own support strategies. n

DR MARK WOODROW is a Senior Medical Adviser and Claims Manager at Avant, a full-time emergency physician and facilitates workshops on risk management and communication in healthcare.

ROCKY RUPERTO is the Legal and Policy Officer in the Advocacy Education and Research team at Avant and also a solicitor with Avant’s Medico-legal Advisory Service, which provides legal advice and support to doctors, medical practices and other health professionals.

INSIGHT September 2020 43

SPECSAVERS – YOUR CAREER, NO LIMITS Full or part-time optometrist opportunities – Specsavers Sunshine Coast, QLD

All Specsa ve stores rs no with O w CT

Specsavers Sunshine Coast are looking for a patient-focused optometrist to join our warm and welcoming team. With seven stores located across the Sunshine Coast, we can offer flexible rosters (full or part-time), the latest technology and equipment, including OCT for every patient at no extra cost, experienced retail support teams and excellent opportunities for career development, plus a competitive salary including PII and access to the Specsavers Perks staff discount program.

Graduate optometrist opportunities – Specsavers Mackay, QLD

Specsavers is currently recruiting for two graduate optometrists to join our Mackay team. If you are looking for a new challenge or perhaps a fresh start, a move to Queensland could be the first step in strengthening your professional career!

All Specsavers stores are equipped with the latest optometry equipment including OCT, and you’ll gain exposure to a wide range of pathology across a loyal patient base. If you believe in providing best value eye care, exceeding the customer’s expectations then contact us and find out more. And, if you relocate with a friend, you’ll be eligible for our ‘Go with a Friend’ incentive.

Joint Venture Partnership optometrist opportunity - Benalla & Wangaratta, VIC We have a unique opportunity for a Joint Venture Partner across two growing stores. Our Benalla store opened in 2008 and has four dispense desks, two spacious testing rooms equipped with OCT and two pre-test rooms. Due to growth in the region – and to meet the demands of our patients – we opened the Wangaratta store at the beginning of 2019. The store boasts seven dispensing desks, two test rooms equipped with OCT and has over 1000 frames on display.

SRS – full-time or part-time positions in Perth At Specsavers, our vision is to provide the best value eye care to everyone, simply, clearly and affordably, exceeding customer expectations every time. We are currently seeking Perth’s most dedicated and driven optometrists to join our Specsavers family. We have full and part-time roles available across the state. We will provide you with a fantastic working environment, a supportive team, state of the art equipment – including OCT, and the opportunity to deliver optimal patient care whilst further developing your clinical skills to their full potential.

SO LET’S TALK! In a few short years, Specsavers has achieved market leadership in Australia and New Zealand with more people choosing to have their eyes tested and buy their prescription eyewear from Specsavers than any other optometrist. To learn more about these roles, or to put your hand up for other roles as they emerge, please contact us today: Joint Venture Partnership (JVP) enquiries: Maria Savva – Partner Recruitment Manager

maria.savva@specsavers.com or 0401 353 587 NSW/ACT, SA & WA enquiries: Madeleine Curran – Recruitment Consultant

madeleine.curran@specsavers.com or 0437 840 749 QLD/NT & VIC/TAS enquiries: Marie Stewart – Recruitment Consultant

marie.stewart@specsavers.com or 0408 084 134 Locum employment enquiries: Cindy Marshall – Locum Team Leader

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

chris.rickard@specsavers.com or 0275 795 499 Graduate employment enquiries:

Locum opportunities – ACT calling!

Specsavers have six stores in the Canberra region which require additional locum support throughout September, with the possibility to extend until November/December. We are seeking an optometrist to support the current growth in customer demand who will be flexible to work predominantly in the Gungahlin and Canberra stores, but assist other stores in the region if required. Accommodation can be provided and centrally located for ease of travel to the stores, if required.

*

SP EC TR VISI UM T -A NZ .CO M

apac.graduateteam@specsavers.com

Careers at EyecarePlus Optometrists ®

EYECARE PLUS OPTOMETRISTS Eyecare Plus provides business support and marketing services to over 150 clinically focused independent full scope optometry practices throughout Australia. Our practices are owned and operated independently by our member Optometrist and Dispenser owners. All of our practices have complete clinical independence and are equipped with the latest diagnostic equipment.

Eyecare Plus offers three membership options; branded, co-branded and unbranded.

Further benefits include marketing support, business tools and advice, exclusive territories, conferences, workshops and staff training.

We also actively assist Optometrists and Dispensers who are looking to establish their own practice. If you are looking to buy, or sell, an optometry practice, please contact us.

For more information call Philip Rose: 0416 807 546 or email: Philip.rose@eyecareplus.com.au.

OPTICAL DISPENSER – WARNERS BAY, NSW An established independent optometry practice in the suburb of Warners Bay, NSW is looking for an enthusiastic, hard-working dispenser to join our friendly team.

The successful applicant should have the following skills and attributes: Optical Dispenser qualifications with a passion for providing the highest customer service and aftercare. An ability to build rapport and demonstrate good interpersonal skills when dealing with customers. Able to show initiative, be punctual and reliable.

The position can be Full-Time or Part-Time with 4.5 days/week; Tue to Fri 8.30am – 5.30pm & Sat 8.30am – 12.30pm available. You will need to be flexible to work shifts to cover other staff that are on leave.

Please forward your resume to lakesideoptical@bigpond.com

OPTOMETRIST – GOLD COAST The practice is located in the Miami One Centre, a short distance from the beach, and has a very good level of equipment and excellent support staff. A broad base of patients makes for an interesting clinical profile, and a high level of autonomy, with patient care being the primary focus. There is a full range of clinical optometry services offered to patients, including Orthokeratology and other forms of contact lenses.

This is a very effective small team and a great opportunity to make your mark in a friendly and professional practice.

To Apply: Please apply with your CV and cover letter to Mark Overton, Ideology Consulting. mark@ideologyconsulting.com.au

CASUAL OPTICAL DISPENSER – GOLD COAST Eyecare Plus Mermaid Beach have a primary focus on eye health. We pride ourselves on putting our patients first and exceeding patient expectations.

We are currently seeking an experienced, energetic, enthusiastic and highly motivated Optical Dispenser to join our busy team. The applicant should have good organisational skills and excellent communication skills. A passion for delivering outstanding customer service in a health focused practice and a willingness to learn and broaden your skills is essential.

To be considered you must have experience selling prescription eyewear and contact lenses. Be confident with eyewear adjustments and face measurements as well as know how to sell multicoat, Transitions, premium progressive lenses, prescription sunglasses and multiple pairs.

Due to the nature of the business, high attention to detail is essential. You will need to be available to work Thursday nights and attend occasional training sessions outside of work hours.

If you think you are the perfect fit for our friendly dedicated team, we would love to hear from you.

Please email your CV to Shaina Zheng: s.zheng@eyecareplus.com.au

CURRENT POSITIONS VACANT for more: www.eyecareplus.com.au/careers/ OPTICAL DISPENSER / SALES ASSISTANT: Warners Bay, NSW. Mermaid Beach, QLD. OPTOMETRIST: Miami, QLD.

20/21 CALENDAR SEPTEMBER 2020 RANZCO BOARD MEETING Australia 12 September ranzco.edu

CONGRESS OF OPHTHALMOLOGY AND OPTOMETRY CHINA Shanghai, China 18 – 20 September cooc.org.cn

OCTOBER 2020 20TH EURETINA CONGRESS Amsterdam, Netherlands, 1 – 4 October euretina.org

5TH WCPOS Amsterdam, Netherlands 2 – 4 October wspos.org

EUROPEAN SOCIETY OF CATARACT AND REFRACTIVE SURGEONS CONGRESS Amsterdam, Netherlands 3 – 7 October escrs.org

AMERICAN ACADEMY OF OPTOMETRY MEETING Nashville, USA 7 – 10 October academymeeting.org

CONFERENCE OF THE GERMAN SOCIETY OF OPHTHALMOLOGY Berlin, Germany 8 – 11 October dog.org

RANZCO COUNCIL MEETING Australia 9 October ranzco.edu

ASO EXPO 2020 Melbourne, Australia 23 – 25 October asoeye.org

INTERNATIONAL OPTICAL FAIR

JANUARY 2021 OPTI 2021 Stuttgart, Germany 8 – 10 January opti.de

Tokyo, Japan 27 – 29 October ioft.jp

GLOBAL SPECIALTY LENS SYMPOSIUM

NOVEMBER 2020

Las Vegas, USA 20 – 23 January na.eventscloud.com/

ASIA-PACIFIC VITREO-RETINA SOCIETY CONGRESS Taipei, Taiwan 6 – 8 November 2020.apvrs.org

OPTOMETRY NSW/ACT CANBERRA CONFERENCE Canberra, Australia 8 November optometry.org.au

100% OPTICAL London, UK 23 – 25 January 100percentoptical.com

EUROPEAN MEETING OF YOUNG OPHTHALMOLOGISTS Brussels, Belgium 30 – 31 January emyo2020@seauton-international

FEBRUARY 2021

AAO ANNUAL MEETING Las Vegas, USA 14 – 17 November aao.org

OV/SA BLUE SKY CONGRESS 2020 Adelaide, Australia 19 – 21 November optometry.org

AUSCRS 2020 Noosa, Australia 22 – 25 November www.auscrs.org.au

MIDO EYEWEAR SHOW

Bangkok, Thailand 25 – 27 November silmobangkok.com

DECEMBER 2020 14TH EUROPEAN GLAUCOMA SOCIETY CONGRESS 2020 Brussels, Belgium 14 – 16 December egs2020.org

apots2020.com

AUGUST 2021

OPHTHALMOLOGY UPDATES! Sydney, Australia 28 – 29 August ophthalmologyupdates.com

5TH ASIA-PACIFIC GLAUCOMA CONGRESS Kuala Lumpur, Malaysia 13 – 15 August apgc2020.org

SEPTEMBER 2021 O=MEGA21 & WORLD CONGRESS OF OPTOMETRY Melbourne, Australia 2 – 4 September omega21.com.au

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

Milan, Italy 6 – 8 February mido.com

EUROPEAN ASSOCIATION FOR VISION AND EYE RESEARCH CONGRESS

silmobangkok.com

Nice, France 30 September – 2 October ever2020.org

MARCH 2021

AUSTRALIAN VISION CONVENTION 2021 Brisbane, Australia 27 – 28 March optometryqldnt.org.au silmobangkok.com

SILMO BANGKOK

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

APRIL 2021

NOVEMBER 2021 RANZCO ANNUAL SCIENTIFIC CONGRESS Brisbane, Australia 19 – 23 November ranzco.edu

BARCELONA SPECS Barcelona, Spain 10 – 11 April barcelonaspecs.com

JULY 2021 APOTS MEETING Bali, Indonesia 1 – 4 July apots2020.com

INSIGHT September 2020 45

SOAPBOX

REFLECTIONS ON A PRESIDENCY selection, registrar training, CPD and congress, which was cancelled for 2020.

The ophthalmology workforce is affected by withdrawal of those who are infected, who have to self-isolate due to exposure, those who are immunocompromised or otherwise at risk, and possibly even prompting retirements. Doctor well-being is important to promote, given we are in the front-line delivering eyecare, and all well aware of the fate of the Chinese ophthalmologist whistle-blower Dr Li Wenliang who died after acquiring COVID-19 infection during a routine glaucoma review. At the time of writing the situation in Victoria is rapidly changing, we do not yet know what the ‘new normal’ will look like.

T

wo years has passed quickly and I will hand over to Associate Professor Nitin Verma on 10 October 2020. My learning curve was steep as RANZCO faced many challenges including Australian Medical Council (AMC) reaccreditation, Medicare Benefits Schedule Ophthalmology taskforce review, and promoting diversity and inclusion in RANZCO, even before the once-in-a-century COVID-19 pandemic due to SARS-CoV-2 hit our region in February 2020.

RANZCO is the sole accredited provider of ophthalmology training in Australia and New Zealand, and can be viewed as a small medical university.

The AMC is the regulator of RANZCO’s educational programs in Australia, and in New Zealand through the Medical Council of NZ. An AMC review is an onerous undertaking, but is helpful in setting direction for further developing our ophthalmology training programs.

The accreditation team visited sites throughout Australia, and then spent several days in the Sydney headquarters interviewing staff, Fellows and the Board. We were successful in maintaining accreditation until 2023, with several conditions and recommendations for improvement.

Early 2019 saw the release of the draft ophthalmology committee Medicare Benefits Schedule (MBS) review. This was part of a system-wide review of all MBS item numbers aimed at modernising the schedule and adding numbers for contemporary treatments. The report

46

INSIGHT September 2020

recommended changes in intravitreal therapy, viewed as contentious across the eyecare sector, and RANZCO provided detailed submission in reply. At the time of writing the final report had been completed, but not released, and we await this with interest.

During my presidency we have worked to increase diversity within the college.

I was the first female president in the college’s 50-year history, although Professor Dame Ida Mann was president of the Ophthalmological Society of Australia in 1954. I was very pleased to award Associate Professor Anne Brooks with a College Medal, our highest honour in 2019. Anne is the first ever female College Medal recipient, following 28 male awardees. During the 2019 Congress we launched the college’s Aboriginal and Torres Strait Islander Reconciliation Action Plan, which was developed with and endorsed by Reconciliation Australia. We have also been working on a NZ Maori action plan, and overall aim to increase our indigenous trainees and ophthalmologists in Australia and New Zealand.

Then in February 2020 the COVID-19 pandemic hit Australia and New Zealand.

Australia had a prolonged lockdown, and NZ even harder restrictions. All healthcare was hit hard, with cancellation of elective surgery. Just as we appeared to be on top of things Victoria has had a second wave of infection, further impacting practice across Melbourne, with the situation changing almost daily. COVID-19 is transforming many college operations:

I have been privileged during this time to work with my vice-presidents Associate Professor Nitin Verma and Dr Grant Raymond, the RANZCO Board and Council members who work hard with little recognition and the RANZCO staff, particularly Dr David Andrews, our CEO. After my term concludes I will be spending time with family and friends who supported me during this two-year period – COVID-19 permitting! I will return to practice in medical retina, but I intend to refocus my work and spend more time working with patients who have inherited retinal degenerations, particularly as we are on the cusp of the Therapeutic Goods Administration approving Luxturna in Australia. I will also extend my work in clinical trials Phases 1-3, and intend to continue contributing at board level in the eyecare and biotech sectors.

The world today, and RANZCO, are very different from when I started as president. We are well placed to face the ‘new normal’ and the many changes that will be coming our way. I wish Associate Professor Nitin Verma all the best as I hand him the RANZCO baton. n

Name: Heather Mack Qualifications (in abbreviations): B Med Sc, MBBS, MBA PhD, FRANZCO, FRACS, GAICD Business: Eye Surgery Associates Position: Senior Associate Location: Melbourne Years in the profession: 23

I WILL RETURN TO PRACTICE IN MEDICAL RETINA, BUT I INTEND TO REFOCUS MY WORK AND SPEND MORE TIME WORKING WITH PATIENTS WHO HAVE INHERITED RETINAL DEGENERATIONS

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For further information, please contact your Bausch + Lomb Territory Manager or Bausch + Lomb Customer Service on 1800 251 150 References: 1. Biomaterial Optical Purity Report & Appendix 1, G.U. Auffarth, University Hospital Heidelberg, May 2017. 2. R. Bilbao-Calabuig, MD et al.: Visual outcomes following bilateral implantation of two diffractive trifocal intraocular lenses in 10,084 eyes, American Journal of Ophthalmology, July 2017. Š 2020 Bausch & Lomb Incorporated. Ž/TM denote trademarks of Bausch & Lomb Incorporated and its affiliates.

Other product names/ brand names are trademarks of their respective owners.

Bausch & Lomb (Australia) Pty Ltd. ABN 88 000 222 408. Level 2, 12 Help Street, Chatswood NSW 2067 Australia. (Ph 1800 251 150) New Zealand Distributor: Toomac Ophthalmic. 32D Poland Road, Glenfield 0627 Auckland New Zealand (Ph 0508 443 5347) FIV.0017.AU.20

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