Insight February 2024 by Prime Creative Media

FEB 2024

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975 FEBRUARY 2024

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RANZCO's blueprint to improve access to ophthalmology in Australia’s most populous state

WHAT'S IN STORE FOR 2024? New macular drugs, novel workforce solutions, and glaucoma's watershed moment

CHRONIC SHORTAGES ON MULTIPLE FRONTS

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REALISING THE POTENTIAL OF CONTACT LENSES Many practices believe they have a positive culture, but consistency is their downfall

You’d look good in Specsavers Ranked as one of Australia’s Best Workplaces for 2023.

FEB 2024

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

RANZCO DELIVERS MULTIPRONGED PLAN TO FIX OPHTHALMOLOGY IN NEW SOUTH WALES RANZCO has laid out its blueprint to improve access to ophthalmology in Australia’s most populous state. Its submission highlights a “chronic” lack of funding in the NSW ophthalmic public health sector, contributing to a “worsening shortage” of paediatric ophthalmologists, and calls for outsourced-to-private services in regional areas to alleviate pressure. The NSW Government launched its Special Commission of Inquiry into Healthcare Funding on 24 August 2023 to identify areas of opportunity for equitable healthcare in the state. In the RANZCO submission, NSW branch chair Associate Professor Ashish Agar and CEO Mr Mark Carmichael said the ophthalmic public health sector has failed to deliver adequate services due to a “lack of funding, accountability of NSW Health governance structure,

and procedural waitlist data "results in low visibility of and thus poor transparency regarding outpatient and procedural service delivery".

and maldistribution of eyecare services and workforces”. The submission states that funding uncertainty has compromised the quality of service delivery. To prevent this, RANZCO suggests that NSW Health commit to medium- to long-term planning for a higher level of funding certainty. “At least medium-term (four-to five year) financial certainty is required to adequately plan service delivery, secure and retain the skilled workforce needed in our public hospitals, and keep medical facilities adequately appointed to enable the delivery of safe, high-quality healthcare,” the college said. It was recommended that this expectation be outlined in a set of compulsory governance requirements that would be detailed in the National Health Reform

Of 290 FTE opthalmologists in NSW, only around 11% practise publicly. Image: Passkphoto/Shutterstock

Agreement (NHRA). Nationally, public eye healthcare services are delivered within each Local Hospital Network (LHN), but RANZCO has identified governance shortfalls where the NHRA has emphasised the need for equitable delivery of services without enforced mechanisms to ensure this. The college said that a lack of public (ophthalmology) outpatient

“This is particularly impactful for ophthalmology as outpatient services represent 80% of ophthalmological service delivery encompassing cost-effective, sight-saving treatments for highly prevalent, blinding conditions such as diabetic retinopathy, glaucoma, and age-related macular degeneration.” As such, the college suggested mandatory reporting of this data, as well as an Eye Health Services Delivery Plan for NSW for a state-wide overview of eyecare delivery. “This would facilitate NSW Health in working with the eye healthcare sector to design and equitably provision timely, cost-efficient, continued page 8

OPTOMETRY RATES HIGHLY IN CONSUMER SCORECARD A new consumer snapshot of Australia’s health industry has shown that satisfaction is highest for optometrists among all disciplines, with the profession also scoring highly in terms of affordability, ease-of-access to care and visitation rates.

representative sample of more than 1,000 Australians aged 18 years and above.

Meanwhile, the 'Health Insights Special Report (Part 1)', commissioned by NAB bank and published in late 2023, found specialist doctors, including ophthalmologists, harder to see and more expensive than a year ago.

In 2023, satisfaction was highest for optometrists (8.4 vs 8.5 a year ago), followed by chiropractors, osteopaths and physiotherapists, private hospitals, pharmacies, dentists, other health providers and vets. It was lowest for public hospitals psychologists and psychiatrists, and GPs.

The way Australian consumers perceive and experience healthcare was revealed in NAB’s 12th annual report that surveyed a

The overall health system scored 6.5 points out of 10 (where 10 is completely satisfied), and 37% were ‘very’ satisfied (scoring eight or higher).

While access to care remained generally good, the report found

this does vary significantly by practitioner type and had worsened in several cases over the past year. Australians believed it was still “very easy” to see or use a pharmacy (8.8 vs 8.9 a year ago), optometrist (unchanged at 8.5), vet, chiropractor, and osteopath and physiotherapist. But Australians reported it was only “moderately easy” to see or use a specialist doctor (6.5 vs 7.0). Despite the economic headwinds of 2023, there was a sizeable increase in Australians visiting an optometrist in the past 12 months (35%, up from 28% in 2022), as well as a smaller increase in the proportion who visited a specialist continued page 8

HIGHLIGHTS FROM SCC 2023 Insight was at Sofitel Sydney Darling Harbour to cover the two-day 2023 Specsavers Clinical Conference, considered one of the cornerstones of professional development in Australian primary eyecare.

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IN THIS ISSUE

FEBRUARY 2024

EDITORIAL

FEATURES

WHAT TO EXPECT IN 2024 Many unexpected developments happen in the ophthalmic sector. Eyewear import tariffs, Chemist Warehouse’s optometry venture and a TGA approved red light therapy for myopia were some of the headlines I didn’t expect to write in 2023. So what will 2024 hold for our industry? Many informed predictions can be found on page 15 where industry figures share their hopes and concerns for the year ahead. Drawing on these, and trends happening globally, there are several events I believe will define the coming 12 months.

PUSHING BOUNDARIES How Amanda Cranage rose from orthoptist to CEO at Vision Eye Institute.

ACHIEVING SUPERVISION With new laser tech, Dr Chandra Bala replaced his eye charts as patients ran out of lines to read.

Firstly, Australia can expect the first approved therapy for geographic atrophy (GA). This long-awaited milestone will be the biggest for the macular disease community since the first anti-VEGF was listed for neovascular AMD in 2007. While promising, it will present new challenges for already-busy eyecare providers to manage a cohort previously without a treatment. The concept of remote optometry consultations will become a reality on a larger scale in 2024. OPSM just revealed it would expand on a successful pilot to benefit under-serviced communities, and Specsavers also has something in the works. There are many facets to an eye test, and it will be fascinating to see how these players leverage technology to offer a service akin to the optometrist attending in-person. The optical industry’s broadening expansion into hearing care will also be worth watching. Momentum behind George & Matilda’s audiology rollout will continue and Specsavers will likely claim more market share, but also of interest is the Australasian College of Audiometry, launched by optical dispensing trainers Mr James Gibbins and Mr Chedy Kalach at the end of 2023.

OPTIMAL DOSE Dr Pauline Kang explores ideal atropine concentrations for myopia management.

REALWORLD INSIGHTS The registry informing clinicians on the performance of dry eye therapies.

EVERY ISSUE 07 UPFRONT

62 MANAGEMENT

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63 SOAPBOX

60 OPTICAL DISPENSING

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61 ORTHOPTICS AUSTRALIA

66 PEOPLE ON THE MOVE

Meanwhile, the strained ophthalmology workforce will remain a prominent issue. It’s heartening to see Vision 2020 Australia launch a cross-discipline working group comprising RANZCO, Optometry Australia and Orthoptics Australia to focus on collaborative care models. Starting with paediatric eyecare, having new, clearly defined roles and pathways will only optimise the finite ophthalmic workforce. With Insight, we will continue bringing the latest news, features and educational content, much of which isn’t possible without the generous support of industry and expert contributors. We also have some news of our own to be announced in due course. MYLES HUME Editor

INSIGHT February 2024

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UPFRONT Just as Insight went to print, Australia's first ZEISS VISION CENTRE store opened in Westfield Booragoon, Perth. Mr Martin Feng's Sigo Eyecare business is involved in the initiative. “Being able to leverage the ZEISS brand and open a practice with the latest in ZEISS technology and consumer experience is a privilege," Feng said. "ZEISS has no ownership, yet this concept store enables me to leverage the brand and access the tools and processes to provide a superior patient experience.”

WEIRD A surgical team from NYU Langone Health in the US has performed the world’s first human whole-eye transplant, with encouraging early signs. The landmark surgery, performed on a 46-year-old military veteran who survived a work-related high-voltage electrical accident, involved transplantation of the left eye and a portion of the face from a single donor. It is reported to be the only successful combined transplant of its kind in medical history.

IN OTHER NEWS, Optical by National Pharmacies stores in Adelaide have become the first in Australia to collect and recycle contact lens waste from customers through a partnership with end-to-end optical recycling company Opticycle. The network is aiming to divert about 230,000 empty disposable contact lens blister cases over a six-month period. As part of the deal, Opticycle will separate the contact lens cases into plastic and aluminium for repurposing into building products, including plastic fence posts and plastic wheel stops, and

in the production of steel. FINALLY, Melbourne-based biotechnology company PolyActiva has reported promising clinical trial results for its ocular implant in glaucoma patients. The interim results, from an ongoing phase 2a clinical study for the company’s PA5108 device in subjects with mild to moderate glaucoma, revealed a >20% reduction in IOP at 12 weeks and 26 weeks in the initial cohort. The implant is designed to deliver six months of latanoprost and is biodegradable, which allows for repeat dosing.

STAT

WACKY Oakley has partnered with the video game Fortnite on two eyewear designs for gamers. Oakley Helux Fortnite eyewear has Prizm Gaming 2.0 lenses to reduce screen glare alongside sharp visual acuity, while Oakley Hydra Fortnite features golden Prizm 24k lenses.

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379 Docklands Drive, Docklands VIC 3008 T: 03 9690 8766 www.primecreative.com.au Chief Operating Officer Christine Clancy christine.clancy@primecreative.com.au Group Managing Editor Sarah Baker sarah.baker@primecreative.com.au Editor Myles Hume myles.hume@primecreative.com.au Journalist April Hawksworth april.hawksworth@primecreative.com.au Commissioning Editor, Healthcare Education Jeff Megahan Business Development Manager Luke Ronca luke.ronca@primecreative.com.au

WONDERFUL A new Moorfields Eye Hospital study will examine if mindfulness-based cognitive therapy (MBCT) can improve the static-type images people experience with visual snow syndrome. Funded by the Visual Snow Initiative, it builds on an earlier feasibility study carried out by the same team that featured an eight-week course of MBCT in small groups. Participants reported improvements to their vision, reflected in the results of functional MRI scans.

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CAPITALISING ON CONTACT LENSES Only 49% of optometry practices surveyed admitted to discussing the possibility of contact lenses with most of their eligible non-wearing patients. Image: Romankrykh/AdobeStock. Page 31

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PRECARIOUS FUTURE FOR SUBSPECIALTY continued from page 3

collaborative eye healthcare services across the state underpinned by the principles of the right care, at the right time and in the right place,” RANZCO said. “This plan would link service delivery in primary and community care clinics, outer urban collaborative care clinics, the private sector, and public hospital ophthalmology departments.” Additionally, RANZCO has highlighted NSW Health’s allocation of funding in public hospitals and community settings. For example, public healthcare funding is concentrated towards acute and elective inpatient services. This is disadvantageous for ophthalmology services because 80% of services are outpatient-based, with 20% of surgery completed using a day surgery model. The chronic underfunding, according to RANZCO, has resulted in a shortfall of public ophthalmology services which has pushed most specialist ophthalmology full-time equivalents (FTE) to the private sector.

THE PAEDIATRIC PROBLEM Furthermore, RANZCO raised concerns about the workforce composition to deliver a comprehensive scope of ophthalmology services. The paediatric ophthalmology sub-speciality is especially in chronic short-supply due to limited training opportunities. “Presently, not all ophthalmic trainees in NSW can access a dedicated paediatric ophthalmology training rotation and when they do this rotation is for just three months.

This is a key contributor to the worsening shortage of paediatric ophthalmologists in NSW. This has become a circular problem, which needs to be addressed urgently with additional funding of public hospital paediatric ophthalmology services,” RANZCO said. Paediatric ophthalmology also hasn’t been able to attract enough newly graduated fellows to train in the subspecialty. “Consequently, the paediatric subspecialty workforce is ageing and is not sustainable and there are insufficient subspecialists to meet the population’s requirements for these services," the college said.

“THE PAEDIATRIC SUBSPECIALTY WORKFORCE IS AGEING AND IS NOT SUSTAINABLE AND THERE ARE INSUFFICIENT SUBSPECIALISTS TO MEET THE POPULATION’S REQUIREMENTS.” RANZCO SUBMISSION

Thus, RANZCO recommended NSW Health concentrate additional public ophthalmology services in localities where they are needed most and provide appropriate resources to existing paediatric ophthalmology services. For regions with population catchments of less than 200,000, and/or LHNs without public hospital outpatient and/or inpatient ophthalmology services, the college proposed LHNs deliver public services via outsourced-to-private outpatient and inpatient services. “[This] model of care for outpatient services would make the most efficient use of the limited regional specialist FTE resource,” RANZCO said.

Another major concern RANZCO highlighted was the largely absent investment in public hospital infrastructure and equipment to increase ophthalmology services, with new hospitals and outpatient departments being constructed without consideration of including a public ophthalmology outpatient department.

To meet growing demands, RANZCO has called for scope-of-practice optimisation, especially in poorly serviced areas, with the implementation of collaborative care models. This entails ensuring optometrists, orthoptic nurses, general practitioners and other health professionals are practising to their fullest scope.

As such, most regional and outer urban LHNs don’t fund public outpatient services, which is also devastating to Aboriginal and Torres Strait Islander peoples.

“The scope-of-practice for each health professional group must be clearly defined to ensure that a high standard of care is maintained,” RANZCO said.

“This means that 37% or three million people need to access services elsewhere increasing the risk of prolonging visual impairment and blindness. The wait for cataract surgery is the longest in inner and outer regional NSW due to underinvestment in regional services,” the submission stated.

These models can alleviate the strain on private and public clinics, with some aspects of care redirected to other practitioners. “This results in more efficient utilisation of health resources, reduced healthcare system costs, improved access to specialist services, and increased patient attendance and convenience.”

“One third of Australia’s total Indigenous population live in NSW, and three quarters of this population have no access within their LHD to public ophthalmology outpatient services.”

OPTOMETRY AMONG MOST AFFORDABLE DISCIPLINES continued from page 3

doctor (28%, up from 24% in 2022). Optometry was also considered one of the most affordable health disciplines. The profession scored 7.5 out of 10, with public hospitals unsurprisingly rated the highest (8.3), followed by pharmacies (7.6) and GPs (7.5).

Specialist doctors were rated among the least affordable providers (6.1 vs 6.4 a year ago), alongside vets (5.1), psychologists & psychiatrists (5.9), and dentists (6.2).

The report noted during the past two to three years, 14% of Australians switched GP because they were dissatisfied in some way, and around one in 10 (8%) changed their dentist. Far fewer (5%) An analysis of the optometry affordability switched specialist doctor or pharmacy, and even fewer their optometrist (4%). figures showed it was rated highly among Mr John Avent, customer executive at almost all demographics, even regional NAB Health and Medfin, said the report consumers, low income earners and contained “actionable data, together with the over 65 age backet. The 18-24 age unique insights”, to help health clinics bracket rated optometry affordability inform the way they operate to meet the the lowest at 6.2 out of 10, but this was expectations of patients now and in future. still at or above the average of some other disciplines.

INSIGHT February 2024

“Satisfaction with healthcare varied by

Optometry affordability was rated highly among most demographicss. Image: Robyn Mackenzie /Shutterstock.

region, with the number of very satisfied people higher in capital cities compared to those in regional cities. While this year’s survey found that GPs, pharmacies and dentists were again the most commonly visited practitioners, there has been a drop in visitations across several areas, including doctors and pharmacies,” he said. “Cost may be a factor here, with Australians reporting a deterioration in affordability for most providers compared with last year. Access to care, too, may play a role in the fall in visitations. While access is still generally good, it has worsened in a number of cases over the year, in particular for public hospitals and psychologists and psychiatrists.”

ESSILORLUXOTTICA ACQUIRING EYEQ OPTOMETRISTS The EyeQ Optometrists network is being sold to EssilorLuxottica, in a significant deal involving 25 practices. On 5 January, it was announced EyeQ Operations Pty Ltd – the owner of EyeQ Optometrists practices – would be purchased by Luxottica Retail Australia Pty Ltd (EssilorLuxottica), subject to the key terms of the transaction being met. “As EyeQ Optometrists grew in size and reputation, there have been regular approaches from interested parties regarding the potential to amalgamate, merge, or be purchased, to create a larger sustainable business,” EyeQ said. “After numerous interactions, EyeQ Optometrists have agreed to a transaction which will be good for the future of the company, their employees and patients.” EyeQ is currently described as an Australian-owned, optometrist-led company. Founded in 2007, it has been led by a team with extensive optometric experience, with the foundation practices in operation for more than 40 years. The network has since expanded across

the country, with the majority located in NSW where EyeQ has a presence in Sydney and notably down the NSW coast, as well as some regional areas like Bathurst, Young and Cootamundra. EyeQ also has several locations in Victoria, mainly in suburban Melbourne, and one practice in Queensland, ACT and South Australia, respectively, and two in Western Australia. While the business ownership will change, EyeQ said “significant and important elements will be retained”. Namely, practice names will not change, with the EyeQ brand remaining in place. EyeQ employees will continue with the business while the EyeQ national office merges in future with the Luxottica support office located in North Sydney. EyeQ said it had made this decision to ensure the company and employees continued to deliver the same high quality and specialised eyecare for their patients. “For EssilorLuxottica, the decision to acquire EyeQ Optometrists is for their strong local presence, particularly in geographic areas they do not currently service, and a similar commitment to

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WORLD’S T H I N N EST LENS DIGITALLY MADE IN JAPAN

"Significant and important elements" of the Eye Q business will be retained. Image: EyeQ Optometrists.

exceptional care. EssilorLuxottica also believes that EyeQ Optometrists has the potential to continue to expand the brand,” EyeQ’s announcement said. “EyeQ Optometrists see many benefits for the future with the significant resources available through EssilorLuxottica. These also include benefits to EyeQ employees such as broader career opportunities, education, training and volunteer programs, to name just a few.” EyeQ Optometrists and EssilorLuxottica leadership are working to ensure a smooth transition for the EyeQ business.

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OPTOMETRIST WAREHOUSE UNAFFECTED AMID PARENT COMPANY MERGER

IN BRIEF EYEWEAR DEAL European eyewear brand Silhouette Group has announced a new distribution partnership with VMD Eyewear for the Australian market. The deal builds on an existing relationship with VMD Eyewear’s associated company in New Zealand, Vision Marketing & Distribution Ltd, which has been a partner of Silhouette for more than 30 years. “In VMD Eyewear, Australian customers will find a distributor with knowledge and understanding of our products and company values,” Silhouette said. The new distribution partnership comes after Silhouette and Mimo Pty Ltd ended their collaboration. Since 2017, Silhouette has been a full service provider of frames and lenses, and in 2022 recorded 1.3 million unit sales worth €160 million (AU$262 m).

Peter Larsen, Optometrist Warehouse. Image: Optometrist Warehouse.

EYES AND EARS The Australasian College of Optical Dispensing (ACOD) has expanded into the hearing care industry, launching a new division called the Australasian College of Audiometry (AuCA). Audiometrists are hearing care professionals who primarily specialise in the non-medical assessment and management of communication difficulties caused by hearing loss. With more 50 years of combined industry and vocational education experience, ACOD directors and senior trainers Mr James Gibbins and Mr Chedy Kalach said they were passionate about leading the new arm of ACOD to focus on providing student-centred training in audiometry. AuCA has a team of audiologists throughout Australia and a newly hired general manager, Ms Heather Joseph. From December 2023, AuCA will be offering: HLT47415 – Certificate IV in Audiometry, and HLT57415 – Diploma of Audiometry.

HICAPS EXPANSION American Express is expanding its partnership with Health Industry Claims and Payments Service (HICAPS) to enable 90,000 healthcare providers, including optometrists, to accept American Express payments. It will also enable American Express card members to earn membership rewards points when visiting a HICAPS provider. The expanded partnership coincides with the roll-out of HICAPS’ new “best-in-class” trinity payment terminals which are designed to streamline the patient payment experience with fast claim processing. The rollout is expected to be complete by the end of 2024. For practices, this is said to reduce the need to manually input claims, transactions and quoting and to reduce administration requirements.

INSIGHT February 2024

Optometrist Warehouse managing director Mr Peter Larsen has confirmed it’s “business as usual” for the new optometry network after major news that Chemist Warehouse will merge with Sigma Healthcare to create Australia’s largest pharmacy group potentially worth more than $8.8 billion. Announced on 11 December, Chemist Warehouse’s parent company CW Group (CWG) Holdings said the “transformational merger” with Sigma would create a leading healthcare wholesaler, distributor and retail pharmacy franchisor. The ultimate aim is to combine Sigma’s distribution infrastructure with CWG’s retailing know-how. CWG is described as a leading Australian retail pharmacy franchisor, with around 600 stores, mainly operating under the Chemist Warehouse banner. Chemist Warehouse also made headlines earlier in 2023 when it announced plans to “disrupt” the optometry market by launching Optometrist Warehouse in the Melbourne suburb of Malvern in February. It has since opened a second store in Campbelltown in Sydney, with plans for a “mass network

rollout”. Asked about what the merger would mean for Optometrist Warehouse, Larsen told Insight: “At this stage it is business as normal. Clearly, we are very excited to be part of an organisation that has so much scale and reach in health care.” Meanwhile, Sigma is a major Australian pharmaceutical wholesaler and pharmacy franchisor, with shopfronts such as Amcal, Discount Drug Stores, Guardian and PharmaSave. According to the ABC, Sigma also operates nine distribution centres across Australia, and creates its own products that it sells through its own stores and supplies to other pharmacies. As part of the deal, CWG shareholders will receive $700 million in cash, as well as Sigma shares that will see CWG shareholders owning 85.75% of the merged company and Sigma shareholders the remaining 14.25%. The proposed merger is subject to approval by the Australian Competition and Consumer Commission (ACCC) and the New Zealand Overseas Investment Office. If approved, it would become one of Australia’s largest ASX-listed companies.

NEW REGS FOR NONSURGICAL COSMETIC PROCEDURES

Treatment of conditions such as rosacea could fall under the new guidelines. Image: AdobeStock.

Optometrists providing non-surgical cosmetic services around the eye may need to grapple with new rules governing the way they perform these procedures and how they are advertised via testimonials and before and after images. Amid a crackdown on the cosmetic surgery industry, the Australian Health Practitioner Regulation Agency (Ahpra) and the National Boards are consulting on three documents over the regulation of registered health practitioners offering non-surgical cosmetic procedures. The consultation will be of interest to optometrists who perform skin treatments in the periorbital region with intense pulsed light (IPL) and other technologies. Optometry Australia chief clinical officer Mr Luke Arundel confirmed to Insight the Ahpra consultation could have implications for optometry. “We have noted recently some member interest in providing non-surgical cosmetic services and it will be important for optometrists who provide such services

to comply with any changes in regulatory requirements ongoing,” he said. Ahpra said the non-surgical cosmetic procedures sector had unique features that increase public risk, including a lack of information on practitioner experience, advertising that minimises procedure risk and 'upselling' of procedures, among others. If actioned, the changes would apply to any registered health practitioner performing non-surgical cosmetic procedures, but will exclude practitioners who had pre-existing cosmetic practice guidelines implemented 1 July 2023. “Much like the Medical Board’s new cosmetic surgery advertising guidelines – now in place – these advertising guidelines include guidance around issues such as before and after images, claims about experience and qualifications and the ban on the use of testimonials. The use of social media influencers is also a focus,” Ahpra stated. The consultation was open for 10 weeks, closing on 2 February 2024.

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GLAUCOMA MOUTH SWAB TEST A STEP CLOSER

SPECSAVERS TOPS CUSTOMER EXPERIENCE AWARD RANKINGS Specsavers has been named among Australia’s top retailers in delivering exceptional customer service, The report celebrated according to new brands that excelled reports from KPMG and in customer service. Image: Specsavers. Reader’s Digest. The 2023 KPMG Customer Experience Survey surveyed more than 20,000 people globally and over 2,500 in Australia asking which brands deliver the best customer experience. Specsavers was ranked 4th on the list, which recognised those brands Australians felt delivered personalised service, provided greater value for money and had a deeper level of understanding of what customers need. In addition to its top five inclusion in the KPMG report, Specsavers optical and audiology businesses also took out the Gold Award in the 2024 Reader’s Digest Quality Service Awards for the categories of Optometry and Hearing Care. These Quality Service Awards recognise Australian businesses for their exceptional customer service, as determined by research conducted by Catalyst Consultancy and Research. Specsavers managing director Mr Paul Bott said: “At Specsavers, our mission is to change lives through better sight and hearing, and that starts with providing our customers with an exceptional experience - every time. “Specsavers has always put the customer at the heart of what we do, and we continuously listen to our customers and our team members to ensure we are innovating and improving the customer experience. We are, and always will be, committed to our core values of providing accessible and affordable eye and hearing care for all Australians, so to be recognised by our customers as delivering on that promise is a huge honour. Bott added: “As the KPMG report highlights, great customer service revolves around creating authentic connections and meaningful relationships. At Specsavers, we are proud of our diverse and inclusive workplace culture that empowers everyone to be themselves and create those great experiences. It is part of the reason we were recognised as one of Australia’s best workplaces earlier this year – a company built on great people, who come to work every day driven by the mission to help make a difference to the lives of Australians.”

INSIGHT February 2024

Prof Jamie Craig, Flinders University. Image: Flinders University.

A $2.9 million funding injection from the Federal Government will support the rollout of a new saliva-based genetic test for glaucoma in Australia.

with specialist input. Meanwhile, those at a low- and intermediate-risk level can be managed safely and less frequently in optometric primary care.

Ophthalmologists at Flinders University and The Council of the Queensland Institute of Medical Research have devised a novel glaucoma polygenic risk score (PRS) that identifies those at high risk of losing their sight and prioritises their treatment.

“This will be Australia’s first validation study of a clinic-ready PRS for glaucoma, with collaboration across academia, primary/specialist care, consumer and industry. It is an exciting new opportunity to give patients an early diagnosis of glaucoma which can then lead to vision-saving treatment,” Professor Jamie Craig said.

The substantial grant was announced on 23 November 2023 as part of the Australian Government Medical Research Future Fund (MRFF) Genomics Health Futures program, with the funding to help rollout the test across the country. According to a statement, until now, there has been no way of determining who will develop vision loss from glaucoma and how to better manage those at risk of developing the disease. Instead, they are commonly monitored every six months, which presents a burden to patients and healthcare systems. It’s hoped the saliva-based test will offer a more personalised approach where high-risk patients are managed

“Our strategy will focus on reducing the time it takes for a high risk patient to reach specialist care and intervention. We plan to develop and deliver a scalable approach for the genetic test, ready to be adopted in both community and specialist care settings across urban and regional locations.” Craig said the project would also evaluate patient and clinician satisfaction, safety and cost effectiveness. Once widely adopted, he said PRS would enable clinicians to develop new, and more targeted, interventions for high-risk glaucoma patients.

CHILDREN’S VISION THE FOCUS OF NEW COLLABORATION Vision 2020 Australia has launched a new cross-discipline working group to bring together three of Australia’s national eye health professional organisations for a focus on collaborative care models in paediatric eyecare. Launched at the Innovation in Eye Health and Vision Care function at Parliament House in November, the group will develop and implement models of collaborative care that enhance individual patient access to much needed eyecare services, as well as enhancing the overall effectiveness of the eye health system. The cross-discipline collaborative eyecare working group includes RANZCO, Optometry Australia (OA) and Orthoptics Australia. Paediatric eyecare is the first area of focus, with plans to be developed and implemented over the next 12 months. “We need equity in access to vision care in Australia, particularly for children.

RANZCO president Grant Raymond (from left), Vision 2020 Australia CEO Carly Iles, Vision 2020 Australia Chair Christopher Pyne, Optometry Australia president Margaret Lam and Orthoptics Australia president Amanda French. Image: Vision 2020 Australia.

Australian children with undiagnosed or untreated eye conditions experience poorer educational outcomes and face social exclusion,” Vision 2020 Australia CEO, Ms Carly Iles said. “Prioritising eye healthcare for children would have long-term benefits across all aspects of our health system and community wellbeing.”

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FEATURE

2024 Ophthalmic workforce constraints, further disruption of the optometry market and new therapies for myopia were key issues that shaped 2023. Prominent figures within the ophthalmic sector offer their predictions for 2024, with Insight asking three key questions: • What will be the key features to shape their segment of the eyecare landscape in Australia in 2024? • What will be the challenges and opportunities for their respective organisation?

SKYE CAPPUCCIO ORGANISATION: Optometry Australia, CEO AREA OF INTEREST: Optometry

In 2024, we anticipate a growing emphasis on digital health. In addition to the Federal Government’s 2023 commitment to enhance the integration of allied health with digital infrastructure, including My Health Record, several state governments are advancing plans to improve digital information sharing between community providers and public hospitals. Additionally, we foresee continued adoption of diagnostic artificial intelligence throughout the sector. Optometry Australia is working to secure optometry’s active participation in digital transformation initiatives, ensuring thoughtful integration into practise. We are hopeful that the outcomes of the lengthy review of optometry Medicare Benefits Schedule (MBS) items will be announced and implemented in 2024. While these changes are expected to be positive, they may not be revolutionary. Nevertheless, we are committed to ensuring that once announced, these changes are well-understood across the profession. Encouragingly, there is an increasing recognition of the full clinical scope of optometrists and the implementation of collaborative care models. These models aim to alleviate pressure on overstretched tertiary care systems. Looking ahead to 2024, we remain optimistic about the continued innovation and broader adoption of proven models in this space.

Image: RANZCO.

Image: Optometry Australia.

• Are there any major announcements to keep an eye out for in the coming year?

Image: Golden Dayz/Shutterstock.

Bringing I N T O F O C U S

DR GRANT RAYMOND ORGANISATION: RANZCO, president AREA OF INTEREST: Ophthalmology

The regulatory landscape for training ophthalmologists and assessing ophthalmologists trained overseas will change in 2024. RANZCO is likely to respond by increasing our focus on collaborative care, upskilling GPs, improving our internal processes and, of course, advocating for patient safety. The college will continue to focus on issues surrounding Indigenous eye health, workforce distribution and maintaining our high standards of education and training. The key challenge for the future is responding to legislative changes whilst advocating for sustainable, safe equity of eyecare. Increased resourcing is required by governments in Australia and New Zealand to deal with the backlog of elective eye surgery resulting from COVID. Also, an opportunity exists to draw government focus to the need for preventive strategies. In 2024 the college will be launching a new education and CPD platform. This is a one-stop-shop for our trainees, members and fellows to do everything relating to education, training, up-skilling and CPD.

INSIGHT February 2024

DR PETER SUMICH ORGANISATION: Australian Society of Ophthalmologists, president

Image: Loren Rose.

Image: ASO.

Bringing I N T O F O C U S

AREA OF INTEREST: Ophthalmology

DR KATHY CHAPMAN ORGANISATION: Macular Disease Foundation Australia, CEO AREA OF INTEREST: Macular disease

Macular Disease Foundation Australia’s (MDFA) second social impact survey has been completed and the feedback we have received from 2,000 people living with a macular disease will influence our work throughout 2024 and beyond. What we have learned from our community is that competing health priorities and the presence of mental health issues reinforce the need for comprehensive, ongoing and holistic support for people with macular disease. Our new My Eyes patient-focussed service launching in May 2024 will assist in supporting some of these needs. Our community also wants us to continue to advocate for more affordable eye injections and specialist fees, which are by far the most frequently mentioned areas of concern. Affordable low vision aids, assistance with the costs of transport to treatment, and improved access to bulk billed eye injection services in and outside of metropolitan areas are not new issues and will remain our focus in 2024.

INSIGHT February 2024

ORGANISATION: Myopia Australia founder; ophthalmologist AREA OF INTEREST: Myopia

In 2024, we will expand our knowledge of myopia progression in children, especially when it comes to interventions and learning how to apply and combine these based on patient risk and demographic. New interventions due for release will further our armaments. We will also be looking more into the progress of myopic adults and how we may be able to apply new technology to this group. As an ophthalmologist in the field, it provides an overview of all emerging therapies and a constant eye on more systemic concerns such as syndromic myopia. I am passionate and excited by our new ability to intervene with multiple therapies and am keen to do this safely. However, with the emphasis on myopia progression, we sometimes lose sight of the associations, which can be life and sight-threatening. An exciting new development is an International Myopia Registry via the Save Sight portal, in its early stages. This registry will be available to all eyecare professionals and help document the progression and treatments in Australia and overseas, including children and adults.

Image: ODMA.

Image: MDFA.

Clinically, 2024 will likely continue the demise of multifocal IOLs as EDOFs continue to offer almost the same benefits, with fewer downsides. Implantable glaucoma dosing devices are about to break ground, and this could be a paradigm shift. Economically, cost of living pressure will continue to limit discretionary spending and interest rates will bite harder. Eye services are often shielded, but the environment will be harder for clinics that are not offering “quality and higher service”. Public hospitals are not coping with surgical demand and this sector will continue to struggle with volume. Politically, the health minister has nominated the second half of his term towards private health reform. The competing priorities of medical providers, hospitals and private insurers currently appears insurmountable. The Australian Medical Association workshop, which I attended, clearly indicated nothing will get in the way of profits for insurers. Whilst we proposed a Private Insurance Authority to act as a cop on the beat, the insurers were determined to fund instead a “research institute” to cut costs out of the system and limit care to areas they perceive as "low value".

DR LOREN ROSE

AMANDA TROTMAN ORGANISATION: Optical Distributors and Manufacturers Association, CEO AREA OF INTEREST: Trade suppliers and manufacturers

The number of independent practices to do business with continues to be important to suppliers and distributors, so the maintenance of a good number of independent optometrists who can engage with their chosen suppliers – and who have a succession plan in place for upcoming optometrists wanting their own business opportunities – remains key. We are seeing suppliers more vested in practice outcomes and partnering with practices on marketing and products to match the practice’s specific demographics. There is strong demand for live events and seeing products on show under one roof, however, we still need to be innovative given the amount of free CPD now available through multiple channels. Work will continue on what have been slow moving projects such as with the TGA to finally see spectacle frames exempt as medical devices, and communications to government on the unacceptable situation that has seen the tariff concession revoked on spectacle frames. OSHOW24 Sydney will be a highlight on the calendar to see the latest products while ODMA eyetalk will leverage its consumer facing publication, Lookbook, more widely.

Image: ODA.

ORGANISATION: Optical Dispensers Australia, CEO

AREA OF INTEREST: Ophthalmic workforce

AREA OF INTEREST: Optical dispensing

Ongoing workforce challenges will feature in 2024, including worsening maldistribution impacting access to care in regional, and disadvantaged communities. There is an also an impending overall shortage with insufficient Australian training places. RANZCO’s redrawn Binational Selection settings have, over the last three years, seen 4% of trainees selected identify as Indigenous, and 30% have strong rural attributes. This will drive positive change in our specialist workforce diversity and distribution. Changes in the regulation of overseas-trained specialist, resulting from the ‘Kruk’ Review, may ease workforce pressures but presents challenges for RANZCO in changing processes whilst maintaining quality and safety. RANZCO continues to engage with the National Medical Workforce Strategy and Commonwealth Medical Workforce Division to seek KPIs for public hospital fulltime equivalents be implemented to support sustainable ophthalmic workforce growth. A wide-ranging government review to investigate how to equitably distribute health care workers is another opportunity. We also look forward to progressing the work of the RANZCO Collaborative Eyecare Working Group, by engaging with Optometry Australia, Orthoptics Australia, GPs, AONA, etc, to document evidence-based, patient-centred collaborative care models for an Australian context.

Image: ProVision.

APRIL PETRUSMA

ORGANISATION: RANZCO

TONY JONES ORGANISATION: ProVision, CEO AREA OF INTEREST: Independent optometry

In an increasingly-competitive market, patient satisfaction and profit optimisation will be important factors for future success in independent optometry. Seeking greater practice efficiencies through increased engagement with support systems and intelligence platforms, and executing more data driven decision-making, will also serve to strengthen independent practice fitness in 2024. Navigating an uncertain economic environment will be the universal challenge for all independents, but practice differentiation (through product, clinical, or service) is a significant opportunity. Many of our members have grown and nurtured areas of special interest in previous years to great success. ProVision is looking to launch some new technology-based services (including a business intelligence platform) to help our members meet the market in terms of expectation. These will be game-changers for our members and have been developed in response to member demand.

With strong industry backing, the education and resources offered by ODA will evolve in 2024 with some new training opportunities soon to be announced. In late 2023, ODA extended our popular ‘Webinar Wednesday’ program to New Zealand dispensing opticians. The 2024 program will provide CPD ODOB Accredited education to our New Zealand colleagues and offer Australian ODA Members ‘ODA CPD’ points towards their yearly ODA Currency Certificate. This year will see the first ODA and Optometry Australia (OWA) collaboration bringing together optical dispensers and optometrists at the WAVE conference in Fremantle, WA. Optical dispensers can engage in a full day dispensing stream on 16 March, with a combined lecture planned to conclude the conference. After last year’s successful ODA Gala and National Excellence Awards, it’s returning even bigger in 2024 on Friday 1 March at Melbourne Town Hall. It will recognise the achievements of outstanding optical dispensers and Cert IV graduates and feature an extended program with live entertainment. Plans are afoot for an ODA international aid trip to Fiji in mid-2024, which ODA Members can apply for. More details coming soon.

Image: Vision 2020 Australia.

Image: Kristin Bell.

DR KRISTIN BELL

CARLY ILES ORGANISATION: Vision 2020 Australia, CEO AREA OF INTEREST: Eye health advocacy

There are several key areas we are excited to progress in 2024 across the eye health landscape, particularly maintaining progress in collaborative care which will involve greater collaboration between optometry, orthoptics and ophthalmology, as well as the implementation of the Vision 2020 Australia children’s vision screening framework by the states. What is also a priority for 2024 is key sector collaboration to develop a plan for First Nations eye health to replace ‘Strong Eyes, Strong Communities’ post-2024. The rising rates of myopia and diabetic retinopathy will be a challenge as we move into 2024 and beyond. Ensuring the workforce is adequately equipped to deal with these challenges will be vital, as well as instilling good public awareness around prevention strategies. Additionally, ensuring the needs of people who are blind or have vision loss are better supported through the NDIS review process is an important priority, as is the imminent reforms across aged care.

INSIGHT February 2024

A/PROF MITCHELL D ANJOU ORGANISATION: Indigenous Eye Health Unit director, The University of Melbourne AREA OF INTEREST: Indigenous eye health

I anticipate 2024 will be characterised by continuing uncertainty and significant progress in the Aboriginal and Torres Strait Islander eyecare sector. There is a need to embrace Aboriginal and Torres Strait Islander leadership, support self-determination and a national plan is necessary. First Nations Australians still lose vision from preventable and treatable causes because they can’t access or afford care. The Australian Government goal of ending avoidable blindness by 2025 is not looking on track and the sector needs to urgently unite to achieve this goal. There is deep hurt from the referendum outcome and consequent responses are distressing. Reconciliation approaches have not delivered and those aspiring to be allies need to reconsider their strategies to better engage and support. I’m excited to see where the First Nations Eye Health Alliance (FNEHA) will take us. I know FNEHA will host a great conference in nipaluna (Hobart) in May (National Aboriginal and Torres Strait Islander Eye Health Conference 2024 – NATSIEHC24) and I expect the contribution of FNEHA to grow in 2024. First Nations leaders and organisations will shape activities and my guess is a focus on workforce, health promotion and community ownership of eye health.

Image: UniMelb.

Bringing I N T O F O C U S

SHAUN TATIPATA

(WUTHATHI/NGARRINDJERI)

ORGANISATION: First Nations Eye Health Alliance chair, Indigenous Eye Health Unit associate director, Deadly Vision Centre director AREA OF INTEREST: Indigenous eye health

What a ‘Deadly’ year 2024 is stacking up to be. I am excited by the growing strength of the Indigenous leadership across eye health and what that means for eyecare for Indigenous communities. With the establishment of the First Nations Eye Health Alliance and eye health featuring high on NACCHO’s agenda, I am predicting an Indigenous-led process to develop the next National Indigenous Eye Health Plan, helping to steer our collective efforts. If embraced, the sector (and governments) will have an opportunity to pursue an Indigenous perspective of success enabling us to tackle both the unmet eyecare needs in communities whilst increasing representation in the eyecare workforce improving cultural safety. A genuine commitment to such an approach can only strengthen the ongoing engagement of mob in the deep collaboration spaces that have led to the gains made to date in closing the gap for vision. Another exciting prediction is that ophthalmology will have a greater proportion of Indigenous trainees/students than any of the other eyecare professions. A big call to make – but wouldn’t that be something.

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MAKES YOUR PRACTICE PERFECT

AREA OF INTEREST: Independent optometry

Image: Specsavers.

Despite a drop in retail spending due to increased interest rates, independent optometry has continued to perform well in 2023. Average practice growth in our group has been healthy. During 2023, we further expanded our national advertising efforts. We incorporated Catch-Up TV into our digital advertising. This has been supported by our suppliers as they recognise the benefits of consistent messaging to our patients. Eyecare Plus’ aim is to increase our overall patient brand awareness in 2024, while our locally owned practices continue to operate as they are accustomed. Our National Office Marketing team has had great success helping members with their Google Business Profiles and their SEO results. Under the motto, “Get real with Reels” we have now launched a training program to help our members better utilise social media. Managing succession planning will also be our focus in 2024. This is an opportunity the whole independent optometry industry needs to embrace. We plan to help more young optometrists become owners of profitable practices.

PAUL BOTT ORGANISATION: Specsavers ANZ, managing director AREA OF INTEREST: Corporate optometry

At Specsavers, our commitment is changing lives through better sight and hearing. In 2023, we cared for the eye health of more than four million patients and screened the hearing of more than 600,000, and in 2024 we will continue to encourage Australians to have essential tests for their eyes and hearing. We know that the more people have routine eye tests, the more likely we are to detect sight-threatening eye conditions in early stages and give patients the best chance to protect their vision. Similarly, the earlier we detect hearing loss, the better the long-term outcomes can be for patients. Through all economic climates, we are, and always will be, committed to our core values of providing best quality, accessible and affordable services and products for all Australians. With nearly 400 practices across Australia and employing more than 7,000 team members who are each passionately focussed on their local communities, we are incredibly proud of the work being done to improve the lives of Australians and we look forward to continuing to increase our impact.

Image: Orthoptics Australia.

ORGANISATION: Eyecare Plus, general manager

DR AMANDA FRENCH ORGANISATION: Orthoptics Australia, president AREA OF INTEREST: Orthoptics

Recommendations from the Strengthening Medicare Taskforce have prompted investment in reviewing the health system and workforce, with initiatives set to continue well into 2024. There is a particular focus on allied health, through the ‘Unleashing the Potential of our Health Workforce Review’ with a view to enabling allied health professionals to work to the top of their scopeof-practice. Orthoptics Australia will continue to advocate for the improved efficiency and equity within eye health that would come from orthoptists working to the top of their scope and into advanced practice areas. Advancing technology within eye health has long been a significant driver of change, however, the Australian Digital Health Agency’s ‘National Healthcare Interoperability Plan’ and other work within the area of digital health is likely to prompt transformation in how health professionals work collaboratively and share information related to patient care. Orthoptics Australia has already begun to discuss increasing collaboration within eyecare, partnering with RANZCO and Optometry Australia to focus on improving paediatric eye health care, an area of speciality for orthoptists.

Image: Vision Eye Institute.

Image: Eyecare Plus.

PHILIP ROSE

AMANDA CRANAGE ORGANISATION: Vision Eye Institute, CEO AREA OF INTEREST: Private ophthalmology

Staff and doctor wellbeing and retention, the changing needs of an aging population and access to treatment, and sustainability are just some of the big issues that will affect private ophthalmology in 2024. When I became VEI CEO in June 2023, the long tail of COVID was a top priority and remains so. A fatigued workforce – prompting some to exit the industry – is an added challenge and places staff recruitment and retention front and centre. It’s a critical time, and the leadership teams who will succeed are the ones that show up in this space with actions – not words. Some ophthalmologists have also reconsidered their work life balance, straining surgeon availability. Simultaneously, there is an opportunity to partner with governments to reduce public cataract wait lists by utilising VEI's national network clinics and day hospitals. Elsewhere, the first approved geographic atrophy (GA) therapy is imminent and we need to consider how to manage the influx of GA patients into already-busy clinics. We see AI diagnosis playing a crucial role. Sustainable practices – weighed against quality and safety – remain front of mind too. VEI is a member of Global Green and Healthy Hospitals, and our sustainability working group is overseeing several projects to collect data, gather insights, and devise strategies to reduce our carbon footprint and overall waste.

INSIGHT February 2024

PROF KEITH MARTIN ORGANISATION: Centre for Eye Research Australia, managing director AREA OF INTEREST: Eye research

At CERA, we’re exploring transformational technologies like gene therapy, hyperspectral imaging, and laser therapies to beat vision loss and blindness. I’m excited that we’ll soon be able to bring our breakthroughs to even more people. Alongside our partners at the Royal Victorian Eye and Ear Hospital and the University of Melbourne, we have made great strides over the last few years to streamline research pathways for patients. As we announced in 2023, I am delighted that thanks to $10 million in support from Breakthrough Victoria, CERA is now building a state-of-the-art clinical trials centre here in Melbourne It will have the capacity to double our clinical trial activity when it opens in 2024. This will allow us to bring the new therapies we are developing locally, as well as more international clinical trials, to Victorian patients as early as possible.

Image: Glaucoma Australia.

Image: CERA.

Bringing I N T O F O C U S

RICHARD WYLIE ORGANISATION: Glaucoma Australia, CEO AREA OF INTEREST: Glaucoma patient support

Firstly, 2024 will be a watershed year for early glaucoma detection because now a sample of saliva can determine whether a person is at increased risk of developing glaucoma well before the disease can be diagnosed. This world-leading, Australian-developed technology now offers the potential to screen people at risk, in particular first-degree relatives, well before any signs of glaucoma (or sight loss) have occurred and provide a polygenic risk score for them developing glaucoma later in life. The second theme that will become more prominent in 2024 is the “mainstreaming” of enrolling patients into expert-led patient support programs. The data clearly shows that patients achieve better treatment outcomes when they are supported throughout their treatment journey, and these improved treatment outcomes have the potential to save the health system billions of dollars per year.

www.marchoneyewear.com.au AU: 1800 251 025 • NZ: 0800 141 444 CS.Aus@marchon.com

PROFILE

Amanda Cranage (left), CEO of Vision Eye Institute. Image: Vision Eye Institute

THE ULTIMATE

challenge

When Vision Eye Institute sought a new CEO in 2023, it didn’t need to look far for the ideal candidate. AMANDA CRANAGE traces her remarkable rise from orthoptist to leading Australia’s largest private ophthalmology provider.

he significance of Ms Amanda Cranage becoming CEO of Vision Eye Institute (VEI) is neither lost on her, nor her colleagues. When the network was first conceptualised by a group of Australian ophthalmologists 22 years ago, few would have expected the buck to stop with a trained orthoptist. But times have changed, and when it came to replacing her predecessor, Cranage and the organisation were ready for one another. “It is something I do reflect on at times, especially when I receive messages of support. In particular, the orthoptists have told me that having a fellow orthoptist as the CEO of Vision Eye Institute is incredibly inspirational and motivating. They do feel more connected to the organisation. Receiving such positive messages has truly validated the journey and made it exceptionally rewarding,” she says. As for the ophthalmologists – some considered international leaders in their field – they too have expressed support for Cranage. She believes they appreciate having somebody who understands the daily challenges of the clinics and day hospitals at a granular level. At the same time, Cranage has an equal respect for the operational and financial sides of the business and believes finding the right balance is the key to success. “I’ve known many of our doctors for quite a long time – some since the start of their career when I was in charge of recruiting doctors to VEI,” she says. “A lucky few will even have great memories of me driving them around Melbourne to tour each of our sites. So, they’re comfortable getting on the phone to let me know if there’s an issue or if things are going well. There’s a mutual respect.” In fact, Cranage was present before VEI’s inception. She started in 1996 as an orthoptist, progressing to orthoptic team leader at Camberwell Eye

Amanda Cranage early in her career as an orthoptist. Image: Vision Eye Institute.

Clinic – the eventual birthplace of Vision Group and, subsequently, VEI in 2001. Acquired by China’s Jangho Group for AU$200 million in 2015, VEI is now Australia’s largest private ophthalmology provider, with 18 consulting and laser clinics and 11 day hospitals operating under the Vision Hospital Group banner. “At Camberwell, I was running a 12-strong orthoptic team across a couple of locations and really enjoyed motivating and inspiring everybody. It became a great training ground for learning how to manage teams effectively and make sound decisions. But I felt I needed even more of a challenge – I guess I had reached a crossroads in my career,” she says. To understand this drive, it’s important to go back to the start where, from the outset, Cranage was never shy of a challenge. Soon after graduating, she worked in regional Queensland where she was frequently confronted with complex ophthalmic and orthoptic cases. The steep learning curve continued INSIGHT February 2024

PROFILE

The Footscray consulting facility in Melbourne is now the largest ophthalmic clinic in Victoria. Image: Vision Eye Institute.

an effort to keep me engaged with challenging and stimulating projects whenever I put my hand up for more.” Even with this penchant for hard work and her years of experience, the CEO role represented a whole new realm. While there’s advantages to being part of the organisational fabric for so long, Cranage was acutely aware of the challenges she would face running a large-scale private ophthalmology business in 2023 – and their complexity.

Amanda Cranage with staff at Vision Hospital Group’s Boroondara facility. Image: Vision Eye Institute.

at the Royal Children’s Hospital in Brisbane while showing parents how to fit contact lenses in aphakic babies. It was a robust training ground for an orthoptist so early in her career and embedded a mentality that followed her to Camberwell. “One of VEI’s founding doctors suggested I explore the business side of ophthalmology – and I haven’t looked back,” she says. “Various team leader and middle manager roles helped hone my leadership skills. Then I discovered profit and loss, and it was so just fascinating – to me at least. I was amazed by how simple efficiency strategies translated into better financial and operational results. We had happier doctors, happier staff and happier patients. It was really rewarding to contribute to the overall financial health of the organisation.” Since moving from the clinic to operations 15 years ago, Cranage has etched many highlights on her CV. This has included overseeing the Victorian and Brisbane businesses, a stint as national operations manager, leading the 2015 development of Panch Day Surgery Centre in Melbourne, refurbishing a palliative care unit into consulting rooms at RiverCity Private Hospital in Brisbane, and the expansion of VEI’s Footscray consulting facility in Melbourne (now the largest ophthalmic clinic in the state). Interspersed with these major projects was the establishment of several greenfield VEI clinics in Victoria. “At the same time, I was also leading negotiations with the health fund contracts for our day hospital business. I’m grateful that VEI has always made

INSIGHT February 2024

Appointed CEO in June 2023, Cranage credits her predecessor, Mr James Thiedeman, with leading the organisation through a “transformative” five and half years. Now, she will use her long-standing tenure at VEI to consolidate all aspects of the business. “Seeking somebody that had been in the organisation for a number of years with both clinical and operational expertise is a new and exciting perspective. About the time James was preparing to depart the organisation, we had several conversations about my suitability for the role and I’m thrilled the board and our owners agreed with him,” she says. Until recently, Cranage was also a director and board chair of Alina Vision – a social enterprise bolstering eye health services in underserved communities in Vietnam. This appointment was at the behest of The Fred Hollows Foundation and saw her play a pivotal role in expanding services in the north of Vietnam. A key project was setting up the ophthalmology department in one of Hanoi’s main hospitals. Despite her best efforts to juggle both commitments, she has recently relinquished Alina Vision to focus solely on leading VEI.

COGNISANT OF THE CHALLENGES Private health insurance funding, cost escalation, doctor recruitment and availability, and sustainability are just some of the big themes requiring Cranage’s short-term attention. She’s also keen to build further momentum around VEI’s research culture through its not-for-profit Future Vision Foundation that’s provided grants to 24 projects since its inception two years ago. Investing in people and career pathways are on her radar too, so VEI can continue its healthy track record of developing and promoting from within. When she looks at her top priorities, the first of these is addressing the long tail of the post-pandemic era. Ophthalmologists and healthcare workers are still fatigued, exacerbated by long wait lists in the public system and greater pressure on healthcare in general. The ongoing exodus from the industry adds more strain.

“Staff wellbeing and psychological safety are topics our executive leadership team discuss often, as it feeds directly into development and retention. These terms are bandied about a lot, but we do take them very seriously. As CEO, when I’m out and about talking to the staff, I’m not just listening and nodding my head but truly engaging in the conversation. Our people make VEI what it is, and they deserve to feel safe, feel heard and feel valued,” she says.

looking at how we will be able to cater for the sheer volume of patients that need diagnosis and then access to treatment in facilities that are already well-utilised and very busy,” she says.

“Many ophthalmologists across the industry have also had a rethink of their own roster and work-life balance. This has caused limited, or even no, ophthalmic services in some areas. When you combine that with the backlog of cataract wait lists in the public sector, it makes sense to explore partnerships between private ophthalmology and government. After all, we still have a common goal to ensure patients can access the care they need when they need it.”

Sustainability is also an inescapable part of running a business in 2024. The issue is a priority for organisations like RANZCO, which launched new Sustainable Practice Guidelines for cataract surgery and intravitreal injections at its congress in October 2023. Other examples include the European Society of Cataract and Refractive Surgeons and its Mission Zero initiative to have zero waste to landfill and zero net carbon emissions from its congress, while becoming a role model for social responsibility.

Naturally, VEI and the broader industry are looking at ways to better utilise the current workforce. Collaborative care models where orthoptists wield greater responsibility are among those being investigated. “Orthoptists are such crucial members of the eyecare team. They provide specialised care, help expand our services, promote preventative care, contribute to research and advocate for eye health policies. Their expertise now and into the future will be crucial in addressing the challenges eye health organisations such as VEI are facing,” Cranage says. Geographic atrophy (GA) presents another oncoming challenge or opportunity – depending on how one perceives it. For the better part of a year, VEI has been working internally to map out how it will deal with an influx of these patients once the first therapy is approved by the Therapeutic Goods Administration, which could occur in 2024. “The entire ophthalmic community needs to figure out how they’re going to deal with new diagnostic and management pathways for GA. We’re

“I think AI has a big part to play in diagnosis so we can streamline some of that care. The opportunity with AI is interesting. I would say we are looking at AI informally, but with the understanding that it’s an area of the business that needs a lot of time and attention.”

“It’s something eye hospitals, in particular, need to address,” Cranage says. “We look at it in our organisation as both an opportunity and a challenge. How it’s implemented and the financial viability – it’s a balancing act while ensuring our quality and safety isn’t compromised,” she says. “VEI has a sustainability working group to engage with different areas of our business and get insights from our clinic and hospital teams, which will guide strategies to reduce our carbon footprint.” While these are major challenges, Cranage prefers to reframe them into opportunities. She’s relishing the role and hopes to leave an indelible mark on VEI. “Of course, there are tough days, but I had a message just this week from someone letting me know the support and guidance I provided them was the best of their professional career. Comments like that absolutely make the hard days worthwhile,” she says.

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OPHTHALMOLOGY

Dr Chandra Bala, ophthalmologist and partner at PersonalEYES. Image: PersonalEYES

E yevatars and supervision

REDEFINING REFRACTIVE LASER SURGERY With perfect distance vision becoming the standard of refractive laser surgery, the goal of modern techniques is to go beyond 20/20 in even more patients. DR CHANDRA BALA discusses the excellent results he is achieving with technology that creates an ‘eyevatar’ for each patient and treats the eye, not the glasses.

ydney eye surgeon Dr Chandra Bala is achieving numbers that would have been the envy of ophthalmology just a couple of decades ago. Across 200 patients who received an advanced refractive laser procedure at his practice, the fact that all achieved uncorrected distance visual acuity (UDVA) better than 20/20 was a non-event. The real headline was the proportion achieving “supervision”: 89% with ≥20/16, 51% with ≥20/12 and 8% with a remarkable 20/10. The outcomes were so good that PersonalEYES – a 13-clinic ophthalmology network in NSW and ACT that Bala is a partner of – had to source new eye charts because patients were running out of lines to read. And with a touch up rate of less than 0.8%, it was the icing on the cake. How he has been able to achieve this comes down to refractive surgery technology from Alcon called Wavelight Plus. The concept is also known as ray tracing-based LASIK and PersonalEYES was the nation’s first to offer the breakthrough method that measures and combines multiple datapoints with artificial intelligence to generate a multi-dimensional model of the eye. Bala says this is a major advance over anything else he has seen in refractive surgery – allowing him to offer greater precision. “Suddenly everyone gets 20/20. There are always difficult cases; for example, those with a very high cylinder over 2.00 D of astigmatism, but even then, the quality of output in a regular clinical practice is astonishing. We’ve also corrected up to -8.00 D with -4.50 D of cylinder – we pushed this technology to its limit, and it performs well,” he says. Bala says Wavelight Plus’ ability to generate a highly accurate “eyevatar” using multiple refractive elements/interfaces is what sets it apart. The software uses measurements captured on Alcon’s SIGHTMAP all-in-one diagnostic device – including wavefront of the entire eye, corneal topography, corneal back surface, and biometric data including corneal thickness, anterior chamber depth, lens thickness, and axial length. After the ray-trace based algorithm in Wavelight Plus generates an individualised 3D optical eye model, it calculates a LASIK ablation profile unique to the eye.

INSIGHT February 2024

Traditionally, Bala says the inputs for refractive surgery were much fewer. It left room for assumptions and guesswork. “We were taking the person’s script – essentially their cylinder and sphere – and if it matches another person’s script, you basically perform the same treatment, but the fundamental problem is the eyeballs of these two individuals might be completely different,” he says. “The script is a manifestation of the paraxial optics, which is only about the central 4mm. Once you start going beyond that, you start getting aberrations. As a surgeon, I can’t do anything about the light coming from a faraway object; all I can do is change the angle of incidence of that light at the cornea, and once it’s crossed the front surface, I can’t control the path it will head down. "We therefore need to know before surgery what that internal path for each beam ought to be in this unique eye through a validated personalised model, then the angle of incidence can be altered to match the external and internal beam paths. Historically laser technology has not accounted for the internal element of the eye.” But Wavelight Plus and SIGHTMAP can achieve this, according to Bala. When the patient’s unique eye model is generated with their biometric datapoints, the software models what the wavefront will be on the front surface of the lens after passing through the cornea, and then compares this with the measured wavefront of the entire eye – at the same location. “It then asks, do these two match? Initially, they don’t, and then alterations are made iteratively such that the modeled starts to match the measured, and suddenly for the first time you have a real-life eye model. This eyevatar now tells you what will happen inside the eye for any beam of light hitting the cornea at about 600-700 different locations in the pupil,” Bala explains. “Finally, the system virtually treats the cornea of the eyevatar and calculates the effect using Snellen’s law and again iteratively, over four to six cycles, determines the best plan for this eye. This is automatic, the only surgeon input arises from taking the correct measurements.”

‘IT’S GOT EVERYTHING TO DO WITH INCIDENCE OF LIGHT’ To reach a final calculation with Wavelight Plus requires immense computing power. According to Bala, this is why it has taken several years to bring the concept to market. “The technology actually came out 12 years ago, but required so much computing power because it used Snell’s Law to calculate the path for each of these beams, which took 24 hours to process,” he says. “What’s more, the technology was taking information from multiple devices, so you had an aberrometer, topographer, axial length from the biometer, and so inter-instrument variability existed and these compounded, making a calculation harder. After the Arthur Cummings’ paper, published in Clinical Ophthalmology in 2013, it was clear that even in the difficult cases, which were the high myopes, the outcomes were far superior. We knew then it was going to be a game-changer, but it required so much computing power that it got shelved for almost a decade.” In the intervening years, Bala says the industry has relied on various options such as photorefractive keratectomy (PRK), laser in situ keratomileusis (LASIK), and small incision lenticule extraction (SMILE). All are good options and have been improved, but can be imperfect. “The technology has been focused on how we enact change in the eye and not what change is enacted,” he says. “The goal of refractive surgery has nothing to do with refraction, it’s got everything to do with incidence of light, and this concept has escaped us. On the other hand, cataract surgery has everything to do with refraction because we insert a new refractive element, but not in refractive surgery which is supposedly more advanced. In refractive surgery, we have gone down a path of removing a lenticule like element from the cornea because it was easier to calculate mathematically, but the problem has been we did not account for internal eye elements and ended up creating aberrations, instead of correcting existing aberrations. “This limit exists for all pre-existing laser surgery options. Attempts have been made to correct it, but none has been made to model an individual’s eye.”

REALWORLD PERFORMANCE For PersonalEYES, offering Wavelight Plus forms part of a major R&D focus. Bala himself has developed a novel DMEK punch, which can potentially improve surgical control of the graft in this surgery. Meanwhile, partner Dr Andrew White is developing a glaucoma tube device, and they are currently recruiting for a contralateral myopia LASIK study comparing a new UV laser and the current infrared femtosecond laser. “I love technology, but I don’t trust it, and so it’s integral for me to drill

To make the calculation, the SIGHTMAP all-in-one diagnostic device captures wavefront of the entire eye, corneal topography, corneal back surface, and biometric data including corneal thickness, anterior chamber depth, lens thickness, and axial length. Image: Alcon.

down and understand the nuances, and to not pretend it is a panacea for everything,” Bala says. “I like to know the original intent of a design to understand its physical and optical limits, rather than relying on marketing or heresy. We know there are assumptions in all design and as we push the limits, this will be challenged and improved.” Today in Bala’s clinic, ray tracing-based LASIK using WaveLight Plus has been performed on around 1,500 eyes. Four hundred of those were included in a study Bala and ophthalmology registrar Dr George He published in the Journal of Cataract & Refractive Surgery in November 2023. Involving 200 people, it is the world’s largest real-world examination of the technology. The major findings feature in the first paragraph of this article, but ultimately all achieved better than 20/20 UDVA at three-months, approximately half of eyes achieved ≥20/12.5 UDVA and 8% achieved 20/10. The technique was also found to be safe and effective for correction of myopia with and without astigmatism. With a low 0.8% enhancement rate and no clinically significant increase in total whole eye higher order aberrations, patients leave the clinic satisfied, but Bala often needs to remind them just how good their results are. Especially those who achieve 20/10. “They think it’s normal and how everybody sees the world, until we explain to them that only 8% of the population can actually do what they can do,” he says. “That line (20/10) didn’t exist on our eye chart, so we had to go out and buy new ones to put in each room so we can push to that next level.” Bala says the technology represents “a whole new world” in refractive laser surgery. The SIGHTMAP diagnostic device – and its various capabilities – has also proven a major space- and time-saver, taking around eight minutes to measure both eyes. The data is then pre-populated into the laser suite where calculations take place. While the industry could push such technology further by removing some still-used assumptions such as the refractive index of the cornea, lens and posterior surface of the lens, it’s a major step in the expanding era of personalised eyecare. “Many patients are coming in and their parents have had laser eye surgery. This technology is no longer experimental, it’s now in its maturity phase where the focus is on optimisation and customisation.”

A patient example of how the the ray-trace based algorithm generates an individualised eye model and calculates a unique LASIK ablation profile for the surgeon. Image: PersonalEYES.

NOTE: *WaveLight Plus is the alternative equivalent trade name for INNOVEYE treatments. INSIGHT February 2024

CAREER

Matthew Ding, George & Matilda Eyecare for My Optical. Image: Matthew Ding

FALLING IN LOVE WITH

Warwick

Optometrist MATTHEW DING made a decision for his family to move away from Sydney to eventually end up in the Queensland town of Warwick. He discusses everything he loves about regional life and working for George & Matilda Eyecare, including some curious cases.

r Matthew Ding had spent a large chunk of his optometry career in metropolitan Sydney, but as he settled into family life, it was soon apparent the trappings of city life had lost their appeal. The professional demands were also great: the store needed to be open seven days a week with late night shopping – much of which he covered.

After almost 11 years as a franchisee for a major corporate in Blacktown, in Sydney’s west, a life in regional Australia awaited. Locuming was the best way to get a flavour of where he could one day establish his family and put his son in school. Eventually, he landed on Warwick, a southeast Queensland town 130km inland from Brisbane. Today, Ding is the principal optometrist at George & Matilda (G&M) Eyecare for My Optical and is ticking the right boxes at this stage of his life: drawing a healthy salary, performing meaningful, autonomous work, lower cost of living, and a slower pace of life. “The priority was entirely about family. My son was about to start school and I needed a location that would suit his development. I couldn’t continue to locum and still be present for him and I wanted to move more rural so as to have more time to spend with him rather than be at work all the time,” he says.

that morning. He didn’t want anything for it, he just wanted me to take it off his hands," he says. While moving regionally can be both financially and professionally rewarding, Ding is realistic about what’s required to make the shift successful. His own experience in Warwick speaks to the importance of being confident in one’s own clinical ability. As the sole optometrist at the practice, responsibility rests on his shoulders, and the lack of public ophthalmology makes matters more challenging. Examples of this include patients who are at a high risk of vision loss, including closed-angle glaucoma attacks. Seeing a private specialist in Toowoomba can sometimes be beyond their financial means. So when the presentation is beyond his scope, his only option is to try convince them to be transported to the public Princess Alexandra Hospital in Brisbane. Ding might have struggled to resolve tricky cases like these with quick thinking early in his career. They also contrast to his experience in Sydney where patients could easily access public ophthalmology care 24/7. For

“I simply have far more time for family. In Sydney I was away from family more than I really wanted to be. In Warwick, we are only open Monday to Friday and every second Saturday so my time at home has increased significantly. There is also no travel time as I live only a few blocks from work.” Ultimately, Ding says moving regional pays off financially for optometrists due to less competition and more demand. “And the cost of living can be much lower, for example I bought my house for $480,000 – it’s a quarter acre block and two storey house.” The house also has a modern kitchen. For a “foodie” like Ding living in an agricultural town, it’s the ideal place to cook some of the freshest locally-sourced produce. “My wife and I got invited to a farm just recently and the owner asked if I wanted a lamb that he had killed and dressed

INSIGHT February 2024

Image: Alex Cimbal/Shutterstock

Warwick residents, Princess Alexandra Hospital is two hours away by car. “In Sydney I was always able to put people on a train off to the Sydney Eye Hospital in an emergency. In rural Queensland there is far less of that kind of support and if the patient doesn’t have funds to cover private ophthalmology, then for most conditions the nearest ophthalmology is in Brisbane which may not be possible for all people,” he says.

Matthew Ding says regional practise keeps his clinical skills sharp, along with his ability to think on his feet. Image: Matthew Ding

With this in mind, Ding has made it a priority to work closely with ophthalmologists in Toowoomba. These include Dr Andrew McAllister who has petitioned Queensland Parliament calling for public ophthalmology funding for the region. “I’ve got their mobile phone numbers, so if there’s ever an emergency, I can call them and describe the problem, show them the scans and ask the best approach,” he says. “Only recently I had a man who came in with major inflammation to his eye, with corneal swelling, fixed dilated pupil and high IOP. Looking at it, you may have thought closed-angle glaucoma. Strangely, the angles were open, but then his pressure was 50mmHg, so I was able to call an ophthalmologist (Dr Michael Statham) who diagnosed uveitis probably from a viral infection and he recommended what to do, which ultimately saved the patient financially too.”

FOCUSING ON THE EYE HEALTH THE TOWN NEEDS Over his 20-plus-year career, Ding has almost done it all. Whether it be Indigenous eyecare work through the Brien Holden Vision Institute, a short stint as an independent owner, a corporate franchisee for Luxottica, or locuming for Specsavers, he has enough experience to know what’s required for job satisfaction. So, when he says he is deeply satisfied working regionally in a G&M practice, it’s a statement to be believed. He enjoys all the benefits of being a G&M optometrist where the head office takes care of business functions like administration, HR, payroll and marketing, while the optometrist has clinical independence to care for patients in their own way. “While I can’t speak to the entire network, G&M has been very hands off for me professionally,” he says. “I have been allowed to focus on the eye health that the town needs. I have also been well supported in terms of the equipment in the store – they sourced me a used autorefractor from within the network – and professional development both with paid conference leave as well as online meetings to converse with colleagues.” As one of three optometry practices in Warwick, Ding says G&M Eyecare for My Optical focuses on quality solutions for the population while also doing a significant amount of government low-income work. The practice stands out by providing quality optometric products and working alongside Toowoomba’s ophthalmologists. “We are not always the cheapest, but we are happy with the quality of care that we are able to provide,” Ding says. “In terms of the product line, G&M tends to seek high quality product. So, the frames are great, and we use ZEISS lenses exclusively, which is great lens technology going back more than 100 years. It means I’m not chasing Warwick, southeast Queensland.

“PRACTISING REGIONALLY ATTRACTS A HIGHER SALARY AND LOWER COST OF LIVING, MEANING YOU HAVE MUCH MORE IN YOUR POCKET AT THE END OF THE DAY.” MATT BRADFORD GEORGE & MATILDA EYECARE to fix problems because of cheap product, which is never a good use of anyone’s time.” Looking ahead, Warwick will remain home for Ding and his family, while he expects G&M to remain his professional home for the long-term. “My son’s in year one at school. I have no intention of leaving this practice before he starts high school, and even if he does go to secondary schooling in Toowoomba and we move there, I’m close enough that it’s only a 50-minute drive to work,” he says. “People in Warwick think that’s a long drive, but that was my daily commute in Sydney to drive from Five Dock to Blacktown – and that is against the traffic on a direct freeway.”

PERKS OF A REGIONAL CAREER With around 50% of G&M’s practices regionally located, chief operating officer Mr Matt Bradford says challenges for optometry networks today include recruiting an optically trained team, providing training and ongoing support with peer connectivity, and other readily available allied health services for patient care. There are several benefits of a regional optometry career in Australia, however, as Ding’s experience attests to. “Optometrists get exposed to a broader scope-of-practice, including more pathology, so they’re able to experience far more co-management with ophthalmology than they would in the city,” Bradford says. “Practising regionally also attracts a higher salary and lower cost of living, meaning you have much more in your pocket at the end of the day.” In terms of the attributes that make G&M a worthwhile career move for optometrists looking to work in regional Australia, Bradford says clinical independence sits at the top of this list. “They would also have ongoing support through our professional services team, the opportunity to be a trusted healthcare professional and leader in the community and partnership opportunities to share in the fruits of their labour,” he says. INSIGHT February 2024

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CONTACT LENSES

Reframing CONTACT LENS CULTURE If contact lenses provide a myriad of benefits including clear, unobstructed vision, an enhanced ability to play sports and an opportunity for practices to expand their service – why is Australian market penetration lagging behind where many experts think it could be? Insight investigates how practices can leverage contact lenses for their business.

recent report by the Contact Lens Institute (CLI), in partnership with the Vision Council, has highlighted a disparity between attitudes on contact lens dispensing in practices and the actual behaviours that back this up. Entitled 'The Culture Calculation: Data-Backed Behaviors for Contact Lens Success', and published in October 2023, the report shines a light on the beliefs and behaviours of eyecare professionals and outlines opportunities for growth in this space. Prior to the Culture Calculation report, CLI had developed a range of consumer research reports as part of its 'See Tomorrow' initiative detailing often overlooked opportunities for practice success. However, with the latest report, the CLI sought to identify how certain actions were prioritised and to make practices think hard about their own contact lens culture. “A positive contact lens culture is something we have all experienced – a ‘we know it when we see it’ state. Our research was designed to pinpoint what elements are involved in creating, nurturing, and expanding on that ethos,” says CLI chairperson Dr Michele Andrews who doubles as vice president of professional and government affairs at CooperVision-Americas. “Our hope is that our Culture Calculation report makes professionals question if their own behaviours and those of their team are helping or

hindering their contact lens fits. If the latter, it’s exploring ways a team is falling short and making a plan to up their game.” The survey was deployed to gauge the sentiments of individuals representing a range of eyecare professions in North America – including optometrists, opticians, ophthalmologists as well as practice managers. With 173 qualified responses received, the report uncovered the complexity of contact lens culture and its untapped potential, with the findings having potential implications for contact lens prescribing habits in Australia. Insight talks to local practitioners with a special interest in contact lenses equipped with the expertise to counsel the industry on how to foster a positive contact lens culture in practices. They explain ways to leverage their benefits, have the right conversations with patients and implement strategic processes to harness the full scope-of-practice.

CULTIVATING A POSITIVE CONTACT LENS CULTURE In the Culture Calculation report, 94% of respondents said their practice has a positive contact lens culture. Yet, 84% of practices say they encourage doctors and staff to recommend contact lenses and encourage patients to consider contact lenses. What’s more, only 49% of respondents admitted to discussing the possibility of contact lenses with most of their eligible non-wearing patients. Additionally, CLI’s 2022 research revealed that two thirds INSIGHT February 2024

CONTACT LENSES

By educating staff and patients about the benefits and advancements in contact lens technology, Jillian Campbell says this can address misconceptions. Image: Jillian Campbell.

of vision-corrected patients did not recall having a conversation about contact lenses. And, in a related survey earlier in 2023, 44% of glasses-only wearers expressed interest in contact lenses, but stated the possibility was never raised by their doctor or staff. These disparities perhaps represent a disconnect between beliefs and actuality. “It’s good that almost nine in 10 practices encourage doctors and staff to recommend contact lenses, and encourage consideration by patients,” Andrews says. “The struggle comes in doing so consistently – only half of practices discuss the possibility of contact lenses with the majority of their eligible, non-wearing patients at every encounter. And more than half of practices indicate that less than 40% of patients are prescribed soft contact lenses. This is a struggle of our own making.” Mr Martin Robinson, a Tasmanian independent practice owner and national president of the Cornea and Contact Lens Society of Australia and optometrist of 30 years, believes optometrists envisage themselves as caregivers whose primary goal is to adhere to patient safety. Although true, this may mean that patient satisfaction is overlooked. “We can achieve patient happiness by giving them the full benefit of ocular corrections. Not just health, not just making sure their eyes are healthy, but actually ensuring that their lives are fulfilled,” Robinson says. Mr Gavin Boneham, of Boneham Optometrist Eyecare Plus in Sydney’s CBD – one of the oldest contact lens practices in the country – agrees with the sentiment that patient satisfaction should accompany patient safety. “Optometrists feel like they’re clinicians and they shouldn’t be selling things, but it’s a service that you’re offering to people,” he explains. The Culture Calculation found that eyecare professionals are often not

INSIGHT February 2024

discussing contact lenses with their patients who only wear glasses, as they assume the patient will ask if they’re interested. Andrews says it’s important that professionals raise the topic and waiting for a patient to ask isn’t best practice. Patients’ lifestyles should be discussed, such as workplace routines, sports, fitness and fashion, so it can be determined if they are well-suited for full-time or part-time wear. “We’ve found that many practices are waiting for patients to ask about contact lenses, while the patients are waiting for their eyecare professionals to raise the subject. There’s massive opportunity if we simply talk about what contact lenses offer, how they may improve a patient’s life and then recommend a trial,” she says. There’s also a myth that discussing contact lenses may take an inordinate amount of time, which Andrews says is far from accurate, especially if practices build those conversations into multiple aspects of the patient visit, from the intake form to the exam lane to check out and follow-up. She says this small investment of time can

“DUAL WEAR  PRESCRIBING BOTH GLASSES AND CONTACT LENSES  IS APPEALING TO PATIENTS AND IS VERY GOOD FOR PRACTICES. IT IS IMPORTANT TO RAISE THIS, SINCE MANY PEOPLE BELIEVE IT’S A ONE OR THE OTHER PROPOSITION.” MICHELE ANDREWS CONTACT LENS INSTITUTE

going to go start buying them over the internet’. They may think that’s a bit of wasted time,” he says.

“YOU’VE GOT TO HAVE AN IDEA ABOUT HOW YOU MANAGE CONTACT LENSES IN A BUSY PRACTICE AND THAT MEANS HAVING A SUPPORT TEAM MEMBER THAT’S DEDICATED TO THIS AREA.” MARTIN ROBINSON MARTIN’S EYECARE result in higher patient satisfaction and practice success. However, if patients are aware of the option, but apprehensive to the idea of contact lenses, Boneham emphasises the need for important conversations to quash fears, provide alternatives and offer a tailored service. “I find it to be pretty natural, to have a fear of putting something on your eye. Almost everyone has that fear,” Boneham says. Andrews says candidacy should not be a limiting factor, with most patients able to wear contact lenses. However, many people are unaware of their candidacy which results in low uptake. “For many patients, they’re simply not aware that they are candidates for contact lens wear. They may have presbyopia and are not familiar with multifocal contact lenses. They may have worn lenses years ago and aren’t familiar with advances in comfort and vision that could shift their experience. They may have heard a myth from a friend that scared them off, which our research says is not all that uncommon,” Andrews says.

BENEFITS ON MANY FRONTS For many patients, the benefits of contact lenses exceed the drawbacks. Chief among these is the seamless vision correction and unobstructed peripheral vision, according to Boneham. “The visual field of contact lenses is not restricted like it is with glasses. And patients often remark ‘wow, this is really good’,” he says. Ms Jillian Campbell, of Richard Lindsay & Associates in Melbourne, which primarily serves specialty contact lens wearers, uses benefits such as lifestyle flexibility, wide field of view and convenience as ways to drive contact lens uptake. “For patients, the benefits include improved vision quality, lifestyle flexibility, and comfort. For other (non-contact lens) practices, increased uptake supports their business by diversifying their services and enhancing patient satisfaction, which in turn promotes loyalty and referrals,” Campbell says. Robinson adds: “I’ve got a patient that wears disposables for a month each a year. She goes up to the tropics and dives every day. That’s what she uses contact lenses for. That’s something that gives her an ability to enjoy her passion,” Robinson says. The benefits of contact lenses extend beyond patient satisfaction and enable practitioners to expand their scope-of-practice too. Not only are there diverse options available, but selecting the right one for the patient and tailoring the service can make optometric practise more invigorating for the clinician. “Contact lenses are much more interesting to work with. Even though the latest contact lens technology is really good, you still have to choose the right ones and choose the right fit for people,” Robinson says. Boneham says that despite practitioners’ concerns that people will source contact lenses online, the service provides opportunity to expand the patient base. “Optometrists may think, ‘if I’m going put all this effort into teaching this patient how to put these lenses on and take them off, then they’re just

“The patient network doesn’t end with this patient. They may tell friends or family about the service they’ve received. Fundamentally, clinicians are providing a service to patients and will respond positively.” Andrews agrees, stating that there can also be revenue advantages, whether through providing both contact lenses and glasses, offering sunglasses, and through contact lens-specific services. “Beyond that – and our culture research points this out – 75% of practices believe fitting lenses leads to emotional gains among staff. They’re directly changing lives,” she says.

EDUCATION IS THE CRUX A first step in driving a positive contact lens culture is self-awareness. Making a conscious effort with staff empowerment and education can be key to cultivating this. Andrews cites the CLI’s See Tomorrow reports as a great baseline for enhanced practice productivity in this space, offering invaluable tools to identify challenges, and areas of strength that could still be improved. “Ongoing education offers fantastic opportunities to address those needs. That includes manufacturer-led training from the contact lens industry, whether at conferences, online, or within the practice environment. Reaching beyond the eyecare world to more general business management seminars might also provide a spark,” she says. The CLI’s report found 81% of respondents placed the greatest value in education and in-practice advocacy. In alignment with this, Campbell, Robinson and Boneham describe education as the crux of a positive contact lens culture – for patients and staff alike. They dedicate time during each staff meeting where they review the science and latest technology of contact lenses. If staff are up-to-date, this knowledge will help bolster purchasing incentives and provide a point-of-difference. “We emphasise continual education, ensuring our team is well-versed in the latest contact lens technologies and trends,” Campbell says. “This includes training sessions and encouraging staff to stay informed about industry advancements. Staff are involved in complex fits, including assisting with insertion and removal of lenses, conducting scans, and teaching patients. “By educating both our staff and patients about the benefits and advancements in contact lens technology, we can address misconceptions and highlight the practical and lifestyle advantages of contact lenses.” Boneham says practices should have staff meetings every week to discuss topics such as new lenses or new packaging of disposables. “I’ve been in the game for 40 years, and you can see it’s getting better and it’s going to be better in another five years. The range available to us now is fantastic,” he says. A positive contact lens culture should emanate throughout the entire team – from the front desk to the consultation room. Training staff and having them acquire the right qualifications to alleviate some of the work with contact lens education for patients is one step to achieving this. By investing in staff, Robinson says that practices can cultivate valuable resources. “If you have a support staff member that’s trained on it, they’re upskilling which means they’re really motivated, and it gives them time to shine. Why not make the most of those staff and utilise them in that way?” Robinson says. “They can also be trained on insertion and removal instructions and talk about contact lens care practices.” This can also be invaluable when optometrists are short on time with a full appointment book. “You’ve got to have an idea about how you manage contact lenses in INSIGHT February 2024

CONTACT LENSES

conversations on how to properly handle contact lenses as well as following up to seek the patient’s feedback.

“OPTOMETRISTS FEEL LIKE THEY’RE CLINICIANS AND THEY SHOULDN’T BE SELLING THINGS, BUT IT’S A SERVICE THAT YOU’RE OFFERING TO PEOPLE.” GAVIN BONEHAM BONEHAM OPTOMETRIST EYECARE PLUS

“You should be managing your patients if you’re doing new fits with them. You should be getting them back for reviews and not just giving them a trial and setting them up,” Robinson says.

ENGAGING THE ENTIRETY OF A PRACTICE The CLI’s report also unveils the power of dual wearing opportunities. It revealed 20% of glasses-only wearers considered purchasing contact lenses as well if they were bundled with the glasses at a discount. Meanwhile, 80% of respondents cited the importance of developing unique offerings and purchasing incentives for prospective contact lens patients. “Some of our past research showed that dual wear – prescribing both glasses and contact lenses – is appealing to patients and is very good for practices. It is important for eyecare professionals to raise this, since many people believe it’s a one or the other proposition,” Andrews says. “Our latest work on culture also indicates talking about what’s new in contact lenses works, including advances in materials and designs that allow wear by a much larger number of people than ever before.” Practitioners can provide customised solutions by trying to understand each individual’s needs. They should ask open-ended questions and discern what is suited to their lifestyle. “We leverage the potential of dual wearers by understanding their lifestyle and vision needs, offering them the flexibility of both contact lenses and glasses. This approach helps them appreciate the benefits of each option in different scenarios,” Campbell says.

Despite almost nine in 10 practices encouraging staff to recommend contact lenses, only half discuss the possibility of contact lenses with the majority of their eligible, non-wearing patients at every encounter. Image: CLI.

a busy practice and that means having a support team member that’s dedicated to this area. They might look after all contact lens ordering as well, for example,” Robinson says. Informed decision making also empowers patients, equips them with the knowledge to select options that are best for them and increases satisfaction. With this is mind, Boneham makes it a priority to inform patients of the risks and benefits. “We should be suggesting it to patients; let them make the choice,” he says. Robinson suggests having staff wear contact lenses. Ideally, this would include a variety of age brackets and different types of lenses to model as many options as possible to patients. “I had a practice manager who wore soft contact lenses for a very long time,” he says. “She had intolerances and other problems so we put her into dailies, and that’s what she would tell patients when we got her to talk to them about contact lenses.” Beyond education, the CLI’s report cites product accessibility – especially access to fit sets – as the chief component of a positive contact lens culture. Robinson recommends having trial lenses ready to go as availability and timely delivery are important. “Quite often they will be happy with the result of that trial,” Robinson says. “I’m happy to do trials for people for one week with a cheaper, generic contact lens and then one with a better lens and almost always those trials come back with significantly happier patients with the better contact lens.” However, once a trial is initiated, it’s imperative to take the time to have

Robinson cites dispensability as another important factor. If a practice has sufficient stock on hand, then it would be worth their while to discount contact lenses when sold in bulk. Although discounts can undermine practices’ bottom line, selling in bulk is advantageous. “I tell patients that this is the price for three months, but if you want to buy for six months, it’s this price, and if you want to buy 12 months, it’s this price. So, you can afford to offer some discounts on a bulk buy,” he says. Technological investments can also be invaluable to increasing contact lens penetration, according to Boneham. For example, he invests in OCT with anterior imaging to optimise contact lens fitting. “Always keep the patients informed about the latest technologies but also invest in contact lens related technology,” Boneham says. “You have to always be investing in the latest technology so you can fit the best lenses for your patients. That’s what it’s all about – looking after them and getting them seeing as well as you can.” Patients may also be concerned about factors such as makeup and makeup removal while wearing contact lenses. Robinson ensures he mitigates concerns by consciously stocking the appropriate products and educating patients on safe makeup use. “We sell ocular surface safe makeup and makeup removal products. I talk to people about makeup use, especially mascara use because it’s the most dangerous for the ocular surface,” Robinson says. “I also have my staff try the makeup so that they can also talk to patients about it.” Andrews emphasises the transformative role contact lenses play and the profound, untapped potential an expanded scope-of-practice can offer staff and patients. “Contact lenses play an incredible role in the lives of millions – with the potential to do the same for millions more. By engaging the entirety of a practice, we can find ways to embrace a positive contact lens spirit and convert those views into actions tailored for each setting and patient,” she says.

INSIGHT February 2024

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Cationorm (cationic nanoemulsion) is a preservative-free, hydrating and lubricating emulsion eye drop which protects the eye surface, relieving the discomfort Image: CSL Seqirus. and irritation of persistent dry eye caused by prolonged use of contact lenses, or environmental conditions.1 Its triple action repairs the lipid layer to reduce evaporation by lubricating and stabilising the tear film, and restores the moisture balance in the muco-aqueous layer of the tear film. It also forms a barrier to lock in moisture, giving dry eyes the time they need to heal. 2,3,4,5 Administered as one drop, up to four-times daily in the affected eye, Cationorm is suitable for use with contact lenses, 6 and gentle enough to use every day.7 PBS INFORMATION: Cationorm Multi Dose (10mL). Authority Required (STREAMLINED) 6172. Refer to PBS Schedule for full authority information. Cationorm (30 x 0.4mL) is not listed on the PBS.

MISIGHT 1 DAY: BACKED BY THE LONGESTRUNNING SOFT CONTACT LENS STUDY MiSight 1 day from CooperVision remains the only contact lens with US FDA approval for slowing the progression of childhood myopia. Now available in higher prescriptions, the range covers -0.25D to -10.00D (0.50D steps after -6.00D), allowing even more children to benefit from myopia management. “MiSight 1 day contact lenses are backed by the longest-running soft contact lens study among children. This extraordinary study, also confirmed the overwhelming preference children have for contact lenses, giving optometrists the evidence to support their decision-making and parental conversations,” the company stated. Practitioners can ask their CooperVision business development manager for more information or contact its Customer Service team via phone: 1800 655 480.

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OPTOPOL REVO SDOCT A MUST HAVE FOR CONTACT LENS FITTING

Image: Medmont.

Fast-track first-fit contact lens success with the Medmont Meridia. It boasts gold-standard topography and a suite of anterior assessment tools, so practitioners can boost patient outcomes and practice offerings. According to Medmont, the Meridia’s limbus-to-limbus topography makes it possible to achieve up to 11mm+ coverage in a single capture. It means users can obtain quality, real corneal data to the peripheral cornea where the contact lenses land, without extrapolation or guessing. Convenient lens design options further contribute to fit success. Medmont’s contact lens simulator can integrate with third-party design software or export maps directly to lens labs. Practitioners can then assess fit with subtractive maps and smart data insights from Medmont's accompanying software. “For ocular surface and dry eye analysis, the Meridia Pro model wields an HD colour camera with three light sources for high-quality anterior imaging and meibography. Use crystal-clear photos and video for detailed documentation as well as patient education and compliance,” the company stated. “The Medmont Meridia is your secret to contact lens success.” Contact: sales@medmont.com

INSIGHT February 2024

Optopol REVO SD-OCT has a built-in anterior lens allowing the user to perform anterior segment imaging without installing an additional lens or Image: OptiMed. forehead adapter. Now practitioners can display the whole anterior segment using a radial scan to view 18mm wide 6mm deep for various angles. This is a standard feature in any of the five REVO models T-OCT is described as a pioneering way to provide detailed corneal curvature maps by using posterior dedicated OCT. Anterior, posterior surfaces and corneal thickness provide the True Net Curvature information. With the net power, a precise understanding of the patient’s corneal condition is generated easily and free of errors associated with modelling of posterior surface. The REVO T-OCT module provides axial maps, tangential maps, total mower map, height maps, epithelium and corneal thickness maps. Practitioners can customise their favoured view by selecting various maps and display options. Fully Automatic Capture with examination time of up to 0.2 sec makes testing simple. The T-OCT follow-up feature offers the ability to compare corneal topography changes over time in LASIK, keratoconus and contact lens wearers. Email: sales@optimed.com.au

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Experience the latest evolution of the iStent® legacy of excellence in your practice. *Based on units sold. iStent inject® W IMPORTANT SAFETY INFORMATION INDICATION FOR USE. The iStent inject® 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 tumour, 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. Do not re-use the stent(s) or injector. 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 (nonpre existing), 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. GLAUKOS AUSTRALIA PTY. LTD. Suite 109/12 Corporate Drive • Heatherton VIC • 3202 • AUS • tel 03 9551 2220 • www.glaukos.com © 2022 Glaukos Corporation. Glaukos®, iStent®, iStent inject® and iStent inject® W are registered trademarks of Glaukos Corporation. Australian Sponsor: RQSolutions Pty Ltd / New Zealand Sponsor: Toomac. PM-AU-0208

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EIKANCE 0.01% eye drops (atropine sulfate monohydrate 0.01%) is indicated as a treatment to slow the progression of myopia in children aged from 4 to 14 years. Atropine treatment may be initiated in children when myopia progresses ≥ –1.0 diopter (D) per year.1 PBS Information: This product is not listed on the PBS.

Scan to review full Product Information and to order samples, or call 1300 659 646. This medicinal product is subject to additional monitoring in Australia. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse events at https://www.tga.gov.au/reporting-problems. References: 1. Approved EIKANCE Product Information, 14 March 2023. 2. Chua WH et al. Ophthalmology 2006;113:2285–91. 3. Chia A et al. Ophthalmology 2016;123:391–9.

Aspen Australia includes Aspen Pharmacare Australia Pty Ltd (ABN 51 096 236 985) and Aspen Pharma Pty Ltd (ABN 88 004 118 594). All sales and marketing requests to: Aspen Pharmacare Pty Ltd, 34-36 Chandos Street, St Leonards NSW 2065. Tel: +61 2 8436 8300 Email: aspen@aspenpharmacare.com.au Web: www.aspenpharma.com.au Trademarks are owned by or licensed to the Aspen group of companies. © 2023 Aspen group of companies or its licensor. All rights reserved. Prepared July 2023. AU-ATR-072023-07585. ASPPH3029.

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LEARNING OBJECTIVES:

CPD

At the completion of this article, the reader should be able to improve their management of progressive myopia with atropine... CLINICAL CPD HOURS This activity meets the OBA registration standards for CPD

Including: • Review the evidence in support of atropine (0.01%-0.05%) for myopia management • Understand the place for alternative regimens like step treatment, loading dose, or modified schedules for optimal myopia control • Consider myopia risk factors when deciding atropine concentration, weighing benefits against side effects • Acknowledge diverse responses from global trials, considering ethnic and regional variations.

WHAT IS THE IDEAL CONCENTRATION OF ATROPINE FOR MYOPIA CONTROL?

rogressive myopia can be managed through pharmacological, optical, behavioural and, more recently, light-based therapies.1,2 Topical atropine is currently the most widely prescribed pharmacological treatment for childhood myopia with numerous clinical trials establishing its efficacy in controlling myopia progression. 2

Although early studies explored higher concentrations of atropine (0.1-1%), 3,4 due to significant side effects – including photophobia and cycloplegia – lower concentrations ranging from 0.01% to 0.05% have been investigated and have been found to have positive treatment outcomes. 5-7 More recently, trials of atropine have been expanded to include investigation of its efficacy in children at risk of developing myopia. 8

WHAT IS THE IDEAL CONCENTRATION OF ATROPINE FOR MYOPIA CONTROL? Various concentrations of atropine for myopia control have been explored and clinical trials have provided suggestions of ideal concentrations to prescribe to myopic children. The seminal Atropine for the Treatment Of Myopia 2 (ATOM2) study prompted investigations of low-concentration atropine for myopia control

after it reported that 0.01% atropine effectively slowed myopia progression, when defined by refractive changes, at rates comparable to higher 0.1% and 0.5% concentrations, particularly during the first year of treatment. Further, children undergoing 0.01% atropine were found to experience minimal side effects, impact on visual function and rebound effects on cessation of treatment, which additionally supported its use. 5 Positive study outcomes led to the prescription of 0.01% atropine in clinical practices for the management of progressive myopia. The subsequent Low concentration Atropine for Myopia Progression (LAMP) randomised controlled trial explored 0.01%, 0.025% and 0.05% atropine to determine the optimal low concentration of atropine for controlling myopia and whether a concentration dependent response existed.7 Although all three concentrations caused minimal side effects and rebound effects on treatment cessation, the authors found a concentration-dependent response and proposed 0.05% atropine to be the best concentration to prescribe to myopic children.6,7 (The LAMP trial recruited only Chinese children and the authors have acknowledged that 0.05% atropine may not be ideal for other ethnic populations).

FINDINGS FROM OTHER STUDIES There have since been numerous clinical trials from around the globe exploring low-concentration atropine for myopia in children, typically aged six to 12 years, with mixed results.

Numerous clinical trials have explored low-concentration atropine for myopia in children, typically aged six to 12 years, with mixed results. Image: Life-literacy/Shutterstock.

Image: Pauline Kang.

When it comes to myopia, Dr PAULINE KANG says optometrists should consider prescribing atropine for management, and tailor the choices about concentration to individual requirements. Ultimately, a nuanced approach, informed by the latest evidence, will be the one that is most effective.

For example, in Australia, 0.01% atropine was found to reduce myopia progression in a multi-racial cohort only during the first 18 out of 24 months of treatment (0.25 D and -0.10mm difference between atropine and control groups at 18 months).9 Another randomised controlled trial in India reported that 0.01% atropine significantly reduced myopia progression through refractive changes (0.19 D) only over a one year treatment period.10 The Myopia Outcome Study of Atropine In Children (MOSAIC), which included

ABOUT THE AUTHOR: Dr Pauline Kang B Optom (hons) GradCertOcTher PhD FAAO School of Optometry and Vision Science, UNSW, Sydney, Australia

predominantly White Irish children, reported a modest treatment effect over two years with children undergoing 0.01% atropine experiencing less axial length elongation (-0.07 mm) compared to the control placebo group. However, this effect was not reflected in refractive changes where no significant difference was found.11 Another large trial, ChildHood Atropine for Myopia Progression (CHAMP) study, investigated 0.01% and 0.02% atropine across multiple clinical sites in the US and Europe and found 0.25 D and -0.13 mm less myopia progression in the 0.01% atropine compared to placebo group, and, interestingly, no significant difference between the 0.02% and placebo group over three years of treatment. A higher atropine concentration of 0.02% did not result in greater treatment outcomes or proportion of treatment responders.12

WHAT ATROPINE CONCENTRATION DO I PRESCRIBE A MYOPIC CHILD? Concentrations between 0.01% to 0.05% atropine are widely accepted as being appropriate for myopia management. Eye health care practitioners also need to consider myopia risk factors when selecting atropine concentration. The LAMP study found an age-dependent effect on treatment responses with younger children experiencing poorer responses to atropine INSIGHT February 2024

CPD

higher concentrations of atropine,6 studies have found low concentrations of atropine (between 0.01% to 0.05%) to be overall well tolerated.7,9-12 Eye health care practitioners also need to note that different levels of pigmentation within the iris – thus sensitivity to atropine side effects – will exist which may impact treatment acceptance. Side effects of atropine can be easily monitored during treatment follow-up consultations through history and symptoms, and pupil and accommodative function assessment. If the child is experiencing significant side effects, atropine concentration can be reduced, or treatment type changed. The Atropine for the Treatment Of Myopia 2 (ATOM2) trial is considered a seminal study and has prompted many other investigations into the optimal concentration for atropine in myopia management. Image: AAO.com

treatment compared to older children. The authors suggested that a higher concentration of 0.05% atropine may be required for younger children to be able to experience similar treatment outcomes to older children.13 Considering faster myopia progression is associated with younger age of onset, selecting a higher concentration of atropine and being more ‘aggressive’ with treatment may be appropriate. The impact of baseline refractive error on treatment response is unclear. Some studies have found an association with higher baseline myopia and better treatment outcomes while others have reported no effect.11,13,14 Positive parental history

YOUR ONE-STOP OPHTH

of myopia is also another risk factor that may be associated with poorer treatment outcomes,14 although the LAMP study found no impact of parental history.13

CONSIDERING SIDE EFFECTS Side effects with atropine is another important consideration when selecting atropine concentration. The main side effects of atropine include photophobia due to pupil size increase and reduced accommodation amplitude causing near vision blur. Although concentration-dependent side effects have been noted with greater increase in pupil size and reduction of accommodation amplitude with

IS STEP TREATMENT OR LOADING DOSE AN OPTION? Step treatment involves a stepwise increase in atropine concentration when treatment responses are suboptimal. This approach stems from clinical trials that have demonstrated concentration dependent responses to atropine, with higher concentrations resulting in greater myopia control. 5,6 A retrospective study conducted in Taiwan included myopic children undergoing 0.05% atropine. If myopia progression of greater than -0.50 D was evident at any six-month follow-up visit over a minimum three-year treatment period, the concentration of atropine was increased to 0.1%. Forty-four out of the 97 enrolled children treated with 0.05% atropine were switched over 0.1% atropine. Although details of change

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in myopia progression after increasing atropine concentration was not discussed, the authors supported a step treatment approach.15

that increasing atropine concentration with a reduced dosage regimen is another potential management option.

More recently, a Danish study investigated the impact of loading dose where participants were treated with 0.1% atropine for the first six months of treatment, followed by 0.01% atropine for the remaining 18 months. Treatment outcomes were compared to another treatment group undergoing 0.01% atropine only for the entire 24 months, and a placebo control group.16 Preliminary one-year results indicated modest treatment effects with atropine which was not statistically different from the control group. Loading dose did not have a significant impact with minimal differences in myopia progression in children who received a loading dose of 0.1% atropine during the first six months compared to children who were consistently treated with 0.01% atropine.16 Two-year treatment outcomes will confirm whether loading dose of a higher concentration atropine has any longer term benefits.

PATIENT COMPLIANCE AND TREATMENT OUTCOMES The impact of patient compliance to low concentration atropine treatment and myopia control outcomes is not well understood as compliance rates have generally been high in clinical trials. 5,6 However, based on optical treatments which have shown full-time wear to result in best myopia control outcomes, it could be assumed that a similar effect will be experienced with atropine and high treatment compliance is recommended.19 Minimal side effects with low concentration atropine is likely to aid in greater treatment compliance which further supports its use. Further research into the impact of treatment compliance on treatment outcomes is required.

MODIFIED TREATMENT SCHEDULES Most clinical trials have explored daily atropine treatment on myopia progression. A handful of studies have explored modified treatment schedules where atropine, typically at higher concentrations, were prescribed at reduced frequencies to decrease side effects. A retrospective study reviewed clinical records of children using 0.125% atropine either once every night or once every two nights. Six-months of atropine treatment was considered baseline myopia progression and was measured one year after this baseline date. No significant difference in myopia progression was found between the two groups and the authors proposed that 0.125% atropine every second night may be an appropriate treatment option for children who cannot tolerate side effects related to daily use of 0.125% atropine.17 Another recent study explored the impact of reducing the frequency of 1% atropine eye drops in Chinese children.18 During the first two years, children administered 1% atropine eye drops once a month at night (one eye at day one and the other eye at day 16). During the following year, the frequency of atropine treatment was reduced to once every two months and, in the final year, children ceased atropine treatment. Myopia progression during the four years of treatment were compared to a control group. During first two years, children treated with once a month 1% atropine had significantly less myopia progression compared to the control group (axial length change: 0.12 ± 0.10 vs 0.39 ± 0.19 mm; refraction change: -0.21 ± 0.22 vs -0.89 ± 0.23 D), and significant differences maintained during the following year with once every two month 1% atropine treatment (axial length change: 0.14 ± 0.09 vs 0.39 ± 0.14mm; refraction change: -0.31 ± 0.29 vs -0.80 ± 0.66 D), and during the last year of no treatment (axial length change 0.19 ± 0.13 vs 0.40 ± 0.16 mm; refraction change: -0.41 ± 0.23 vs -0.75 ± 0.64 D). The authors concluded

SUMMARY  CURRENT EVIDENCEBASED MANAGEMENT Atropine is an effective and established treatment for progressive myopia. Clinical studies support the use of low concentration atropine ranging in concentration between 0.01% to 0.05% in myopic children. The ideal concentration is likely to vary between individuals, but understanding the child’s risk profile can aid in selecting the optimal concentration. Based on current evidence, younger age and positive family history of myopia may indicate a higher atropine concentration but clinicians must weigh benefits of higher atropine concentrations with side effects. Although concentration-dependent side effects have been noted, 0.01% to 0.05% atropine is generally well accepted in myopic children and eye health care practitioners should continue to monitor ocular health and function at follow-up consultations to determine if atropine treatment is causing any significant adverse effects. If starting treatment on a lower 0.01% atropine yields poor results, eye health care practitioners may use a step approach and increase atropine concentration. Loading dose, or increasing atropine concentration, but reducing frequency of administration are other treatment regimens that are being explored and may offer a strategy to improve treatment efficacy with atropine. With commercial and compounded low concentration atropine formulations available for prescribing, atropine is an effective and readily-available treatment option for myopic children.

NOTE: Insight readers can scan the QR code or visit insightnews.com.au/cpd/ to access a link to this article to include in their own CPD log book.

Concentration-dependent side effects have been noted with greater increase in pupil size and reduction of accommodation amplitude with higher atropine concentrations.6 Image: Gatot Adri/Shutterstock.

REFERENCES: 1. Salzano AD, Khanal S, Cheung NL, Weise KK, Jenewein EC, Horn DM, et al. Repeated Low-level Red-light Therapy: The Next Wave in Myopia Management? Optom Vis Sci. 2023. 2. Jonas JB, Ang M, Cho P, Guggenheim JA, He MG, Jong M, et al. IMI Prevention of Myopia and Its Progression. Investigative ophthalmology & visual science. 2021; 62 (5): 6. 3. Chua WH, Balakrishnan V, Chan YH, Tong L, Ling Y, Quah BL, et al. Atropine for the treatment of childhood myopia. Ophthalmology. 2006; 113 (12): 2285-91. 4. Shih YF, Chen CH, Chou AC, Ho TC, Lin LL, Hung PT. Effects of different concentrations of atropine on controlling myopia in myopic children. J Ocul Pharmacol Ther. 1999; 15 (1): 85-90. 5. Chia A, Chua WH, Cheung YB, Wong WL, Lingham A, Fong A, et al. Atropine for the treatment of childhood myopia: safety and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology. 2012; 119 (2): 347-54. 6. Yam JC, Li FF, Zhang X, Tang SM, Yip BHK, Kam KW, et al. Two-Year Clinical Trial of the Low-Concentration Atropine for Myopia Progression (LAMP) Study: Phase 2 Report. Ophthalmology. 2020; 127 (7): 910-9. 7. Yam JC, Zhang XJ, Zhang Y, Wang YM, Tang SM, Li FF, et al. Three-Year Clinical Trial of Low-Concentration Atropine for Myopia Progression (LAMP) Study: Continued Versus Washout: Phase 3 Report. Ophthalmology. 2022; 129 (3): 308-21. 8. Yam JC, Zhang XJ, Zhang Y, Yip BHK, Tang F, Wong ES, et al. Effect of Low-Concentration Atropine Eyedrops vs Placebo on Myopia Incidence in Children: The LAMP2 Randomized Clinical Trial. JAMA. 2023; 329 (6): 472-81. 9. Lee SS, Lingham G, Blaszkowska M, Sanfilippo PG, Koay A, Franchina M, et al. Low-concentration atropine eyedrops for myopia control in a multi-racial cohort of Australian children: A randomised clinical trial. Clin Exp Ophthalmol. 2022; 50 (9): 1001-12. 10. Saxena R, Dhiman R, Gupta V, Kumar P, Matalia J, Roy L, et al. Atropine for the Treatment of Childhood Myopia in India: Multicentric Randomized Trial. Ophthalmology. 2021; 128 (9): 1367-9. 11. Loughman J, Kobia-Acquah E, Lingham G, Butler J, Loskutova E, Mackey DA, et al. Myopia outcome study of atropine in children: Two-year result of daily 0.01% atropine in a European population. Acta Ophthalmol. 2023. 12. Zadnik K, Schulman E, Flitcroft I, Fogt JS, Blumenfeld LC, Fong TM, et al. Efficacy and Safety of 0.01% and 0.02% Atropine for the Treatment of Pediatric Myopia Progression Over 3 Years: A Randomized Clinical Trial. JAMA Ophthalmology. 2023; 141 (10): 990-9. 13. Li FF, Zhang Y, Zhang X, Yip BHK, Tang SM, Kam KW, et al. Age Effect on Treatment Responses to 0.05%, 0.025%, and 0.01% Atropine: Low-Concentration Atropine for Myopia Progression Study. Ophthalmology. 2021; 128 (8): 1180-7. 14. Zhang X, Wang Y, Zhou X, Qu X. Analysis of Factors That May Affect the Effect of Atropine 0.01% on Myopia Control. Frontiers in Pharmacology. 2020; 11: 01081. 15. Wu PC, Yang YH, Fang PC. The long-term results of using low-concentration atropine eye drops for controlling myopia progression in schoolchildren. J Ocul Pharmacol Ther. 2011; 27 (5): 461-6. 16. Hansen NC, Hvid-Hansen A, Moller F, Bek T, Larsen DA, Jacobsen N, et al. Safety and efficacy of 0.01% and 0.1% low-dose atropine eye drop regimens for reduction of myopia progression in Danish children: a randomized clinical trial examining one-year effect and safety. BMC Ophthalmol. 2023; 23 (1): 438. 17. Chen ZR, Chen SC, Wan TY, Chuang LH, Chen HC, Yeh LK, et al. Treatment of Myopia with Atropine 0.125% Once Every Night Compared with Atropine 0.125% Every Other Night: A Pilot Study. J Clin Med. 2023; 12 (16). 18. Zhu Q, Tang Y, Guo L, Tighe S, Zhou Y, Zhang X, et al. Efficacy and Safety of 1% Atropine on Retardation of Moderate Myopia Progression in Chinese School Children. Int J Med Sci. 2020; 17 (2): 176-81. 19. Wu PC, Chuang MN, Choi J, Chen H, Wu G, Ohno-Matsui K, et al. Update in myopia and treatment strategy of atropine use in myopia control. Eye (Lond). 2019; 33 (1): 3-13.

INSIGHT February 2024

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LEARNING OBJECTIVES:

CPD

At the completion of this article, the reader should be able to imrpove their management of people with low vision... CLINICAL CPD HOURS This activity meets the OBA registration standards for CPD

Including: • Identify three key questions to ask all patients with vision loss to assist with appropriate intervention or referral • Review the relevant low vision services available for patients • Understand how support and resources for patients can enable them to maintain independence

OPTOMETRISTS AND MANAGING THE VISUAL CONSEQUENCES OF LOW VISION Too often, low vision predicts a decline in confidence for independent daily living. CAROL CHU and MICHAEL YAPP detail the crucial role optometrists can play in identifying and assisting patients with low vision, and they include a useful case study.

patient presents to an optometrist’s practice with symptoms of reduced vision in their ‘better’ left eye – reportedly, the right has been worse for years. Examination shows visual acuities of 6/24 in the right and 6/15 in the left with geographic atrophy in the right eye and exudative age related macular degeneration in the left eye. The optometrist arranges a prompt referral to a medical retinal specialist and ensures the patient is seen. The optometrist’s role in this patient’s care is now complete, or is it?

WHAT IS LOW VISION? Terms such as ‘vision impairment’, ‘vision loss’, ‘low vision’ and ‘blindness’ are often used interchangeably. Vision impairment can be categorised as mild (visual acuity <6/12 and ≥6/18), moderate (visual acuity <6/18 and ≥6/60), severe (<6/60 and ≥ 3/60) and blind (<3/60), as adopted by the World Health Organisation.1 Major causes of low vision in developed countries include diabetic retinopathy, age related macular degeneration, glaucoma and inherited retinal dystrophies. A more patient-centred and practical definition however is: “any symptomatic impairment in vision that cannot be corrected with conventional methods including glasses, medical or surgical intervention.” It is important to remember that visual acuity is only one measure of vision disability/impairment. Individuals with vision impairment typically also experience diminished contrast sensitivity, difficulty with glare and light sensitivity as well as limitations in their field of vision. Accompanying the visual loss are negative functional, social, economic and psychological consequences. For example: in comparison to the general population, people who are blind or have low vision experience more than four times the rate of unemployment, suffer twice as many falls, have three times the risk of depression, are admitted to residential care three years earlier than people in their age bracket and often lose confidence to independently manage everyday life. 2

THE NEED AND NUMBER OF PEOPLE RECEIVING LOW VISION SERVICES It is estimated that over 284,000 people in Australia currently live with low vision or blindness. 3 Population growth and ageing of the population combined with the increase in risk of eye disease with age means that the number of people suffering from low vision is expected to rise significantly, in particular at the early end of the scale. This risk is significantly higher for Aboriginal and Torres Strait Islander people, who experience six times the rate of blindness and three times the rate of vision impairment compared to the rest of the population.4 Vision 2020 Australia created The Adult Referral Pathway for Blindness and Low Vision Services 5 with the aim of ensuring that patients with newly-diagnosed vision impairment are connected to the supports and services they need to maintain their independence. Despite this, work and the many benefits of low vision services, it is estimated that fewer than one in five people with low vision in Australia receive appropriate assessment and access to low vision aids.6 There are a number of factors occurring at various levels which contribute to this problem:

Location While low vision providers in Australia often provide transport facilities or home visits to assist, physically accessing low vision services has been shown to be a barrier to access of

ABOUT THE AUTHORS: Carol Chu

B.Optom (Hons), GradCertOcTher Senior Staff Optometrist Centre for Eye Health (CFEH) University of New South Wales

Michael Yapp

B.Optom (Hons), M.Optom, GradCertOcTher, FAAO Head of Clinical Operations Centre for Eye Health (CFEH) University of New South Wales

services for patients. This is exacerbated in remote and regional locations, highlighting the need for local optometrists to advise and support these patients.7-9

Costs Although low vision assessment and training in the use of aids in many cases is provided at no-cost to patients, low vision aids themselves can be a considerable out-of-pocket expense to a person with low vision. Government welfare support (such as the National Disability Insurance Scheme and My Aged Care) can assist with these costs, however, navigating these systems is complex. Other priorities A study by the Royal Society for the Blind10 found that one of the most common reasons

Figure 1. Three questions to ask any patient with central or peripheral vision loss, regardless of the extent. Image: Centre For Eye Health.

INSIGHT February 2024

CPD

stages of vision loss. This also works the other way in that referrals are often not triggered until the patient has moderate or severe loss. There is, however, well-established evidence for the benefit of early intervention.11 It is also easier to build skills such as learning to effectively use low vision aids in earlier stages before patients experience more severe vision loss. Other key factors include patients not wishing for others to know that they have a visual impairment, language barriers and cultural sensitivities.12,13

Assistive mobile phone software and electronic canes can help people with low vision find independence. Image: Poppy Pix/Shutterstock.

for patients not accessing low vision services after being referred were concurrent major health problems.

Lack of referral/identification The same study also showed that patients’ perceptions were that either the service was not necessary or would not help them. Similarly, patients may have the misconception that low vison services are only for people who have severe visual impairment or are legally blind, and they may not be aware there are various visual aids and assistance available suited for earlier

IDENTIFYING AND ASSISTING PATIENTS IN YOUR PRACTICE The first step in visual rehabilitation is identifying that a problem exists. Taking an effective history is pivotal to an ocular health assessment, but if vision loss is identified, asking about how the patient is dealing with this is critical. While low vision-specific questionnaires exist (such as the ‘Impact of Vision Impairment’ and ‘Low Vision Quality of Life’ questionnaires), incorporating these and a full low vision history can be lengthy and goes beyond a standard optometric examination into areas such as understanding the patient’s specific visual challenges, remaining visual capabilities and identifying their functional needs. Questions, however, fall into three main areas of concern: activities of daily living, mobility,

Did you know? Up to 45% of people with low vision experience isolation and depression?* The faster clients get support, the less time they spend feeling alone. Refer a patient to Vision Australia at visionaustralia.org/healthcare-professionals/ refer-patient-form *Focus on Low Vision Research Paper, Center for Eye Research Australia 2007 - 2008.

and social and emotional concerns. As a result, asking three short questions covering each of these domains may identify a need for a more in-depth assessment or referral. For example: 1. Are you having any problems seeing everyday tasks like reading, seeing your phone or cooking? 2. Do you feel confident walking around indoors and outdoors, for example on uneven paths or up and down stairs? 3. Do you get upset or insecure because of your eyesight? (Figure 1) While management and referral of the underlying cause of the vision loss is paramount, managing the patient’s functional needs is also critical to holistic care. Questions about falls, reduced illumination conditions and driving tend to be overlooked in primary care optometry. In the case example at the start of the article, asking the patient these three questions may also identify a need for action in other aspects of their healthcare.

WHAT TO DO NEXT? There are a wide range of options for assisting patients who have vision loss. Some aspects of patients with low-to-moderate levels of vision loss can be managed effectively within primary care optometric practices with asking the right questions, assessment and simple interventions (for example: high reading adds and practical suggestions such as advice on enhancing

contrast). A wide range of digital technology now exists and can provide solutions to many related issues involving activities of daily living. However, comprehensive low vision rehabilitation service delivery often relies on an intricate interplay of numerous professions. The Vision 2020 Australia website 5 and the Deakin Low Vision Initiative14 both have a comprehensive list of providers of services and information relating to visual impairment including peer-support organisations and services specific to the various states and territories. There is some evidence patients are more likely to actually receive services when a direct referral is made on their behalf12 and engaging a range of providers and health professionals enables a holistic model of visual rehabilitation to address each of the four dimensions of quality of life: physical, functional, psychological and social factors. Relevant low vision services may include, but are not limited to: • Provision and training of low vision aids and equipment to enhance visual performance • Assistive technology, including smartphone apps designed for people with vision impairment • Occupational therapist assessment to identify any environmental adaptations that would support safe and independent functioning in the home, school or workplace • Orientation and mobility training, which includes training on the use of electronic canes, or guide dogs to help individuals navigate their way through their environment safely and independently • Counselling and psychology to support mental health and emotional wellbeing • Social workers and vocational rehabilitation specialists

was able to gradually build his confidence to walk to a park near his home independently to access the exercise equipment there, as well as to navigate to the local shopping centre via public transport. Several home modifications were made following assessment by an occupational therapist, including tactile markers for the microwave and stove, and improved lighting in the kitchen and dining areas in the home. Victor learned to use a liquid level indicator to measure milk for his coffee machine and obtained a talking meat thermometer. With these modifications, Victor has been able to prepare simple meals independently. Prior to his visual decline, Victor enjoyed reading for leisure and reported to be able to use his iPhone with reasonable confidence. With help from the Guide Dogs assistive technology team, Victor has learned how to access audiobooks, complete online purchases, access and reply to text messages and emails using technology that converts text to speech and vice-versa. Victor has been able to fully transition to using screen readers on his iPhone and Windows computer (Figure 2). Despite the many challenges faced by Victor due to his vision loss, with the help of necessary support and resources he has been able to regain his independence in many of his daily activities.

CONCLUSION This case is a good example of multidisciplinary care for severe vision loss. Mild vision loss is however much more common. As a result, it is critical that optometrists remember to not just manage the ocular disease, but also the visual consequences of it. This involves remembering to ask the relevant questions and arrange holistic care and/or referral for patients with any symptomatic impairment in vision that cannot be corrected with conventional methods.

A MULTIDISCIPLINARY APPROACH TO LOW VISION CARE

1. ORTHOPTIST

2. ORIENTATION & MOBILITY SPECIALIST

3. ASSISTIVE TECHNOLOGY SPECIALIST

4. OCCUPATIONAL THERAPIST

5. OPTOMETRIST

• Employment and education support

CASE STUDY  MULTIDISCIPLINARY CARE Victor* is a 66-year-old gentleman who was diagnosed with retinitis pigmentosa at the age of 40. He was made redundant from his job at age 55 and in his early 60s, he experienced a marked decline in his vision. Victor was seeing hand movements at 1m in each eye with approximately 3 degrees of central visual field remaining. He reported glare sensitivity and night blindness. Victor reported to be in good general health, and is under the care of a psychiatrist for depression. He approached Guide Dogs NSW/ACT initially for assistance and training with use of an electronic magnifying device that his son had purchased for him. Following several sessions of training with a Guide Dogs orthoptist, Victor was able to use his portable CCTV confidently to view his mail. Victor reported that he was increasingly reliant on his wife for assistance around the home and had become reluctant to leave the house without her. An orientation and mobility specialist was able to introduce Victor to the use of a long cane and he

NOTE: The authors would like to thank Dr Sharon Oberstein for reviewing and her input to this article. REFERENCES: 1. International Classification of Diseases, Eleventh Revision (ICD-11), World Health Organization (WHO) 2019/2021 https:// icd.who.int/browse11 2. Access Economics. The Economic Impact of Vision Loss in Australia in 2009. Access Economics. Report for Vision 2020 Australia by Access Economics. 3. Foreman J, Keel S, Xie J, van Wijngaarden P, Crowston J, Taylor HR, Dirani M. The National Eye Health Survey 2016 report. Melbourne: Vision 2020 Australia. 4. Taylor HR, Xie J, Fox S, Dunn RA, Arnold AL, Keeffe JE. The prevalence and causes of vision loss in Indigenous Australians: the National Indigenous Eye Health Survey. Med J Aust. 2010; 192: 312-318. 5. Adult referral pathway for blindness and low vision services [Internet]. 2023 [cited 2023 Nov 17]. Available from: https:// www.vision2020australia.org.au/resources/adult-referral-pathway/ 6. Taylor HR, Keeffe JE, Vu HT, Wang JJ, Rochtchina E, Pezzullo ML, Mitchell P. Vision loss in Australia. Med J Aust. 2005; 182 (11): 565-8. 7. Chiang PP, O’Connor P, Le Mesurier RT, Keeffe JE. A Global Survey of Low Vision Service Provision. Ophthalmic Epidemiol. 2011; 18: 109–21. 8. Chiang PP, Marella M, Ormsby G, Keeffe J. Critical issues in implementing low vision care in the Asia-Pacific region. Indian J Ophthalmol. 2012; 60 (5): 456-9. 9. O’Connor PM, Mu LC, Keefe JE. Access and utilization of a new low-vision rehabilitation service. Clin Exp Ophthalmol. 2008; 36: 547-552. 10. Bruce I, McKennell A, Walker E. The RNIB survey. Volume

Figure 2. A multidisciplinary approach to low vision care often involves a wide range of services, resources and service providers. Image: Centre For Eye Health.

1: Blind and partially sighted adults in Britain. London: Her Majesty’s Stationery Office. 1991. 11. Binns AM, Bunce C, Dickinson C, Harper R, Tudor-Edwards R, Woodhouse M, Linck P, Suttie A, Jackson J, Lindsay J, Wolffsohn J, Hughes L, Margrain TH. How effective is low vision service provision? A systematic review. Surv Ophthalmol. 2012; 57 (1): 34-65 12. Matti AI, Pesudovs K, Daly A, Brown M, Chen CS. Access to low-vision rehabilitation services: barriers and enablers. Clin Exp Optom. 2011; 94: 181-186. 13. Pollard TL, Simpson JA, Lamoureux EL, Keeffe JE. Barriers to accessing low vision services. Ophthal Physiol Optics, 2003; 23: 321-327. https://blogs.deakin.edu.au/low-vision-initiative/

NOTE: Insight readers can scan the QR code or visit insightnews.com.au/cpd/ to access a link to this article to include in their own CPD log book.

INSIGHT February 2024

ONCE-DAILY IKERVIS® IN THE PERSPECTIVE STUDY: REAL-WORLD EVIDENCE OF IMPROVEMENT OF SEVERE KERATITIS IN DED*1 *Significant improvements from baseline to Month 12

SPECT

REA

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in mean CFS score (Oxford Grading Scale, P<0.0001).1

ORLD S

Find out more about the PERSPECTIVE study and how Ikervis® can help your patients at eyehealth.com.au

Ikervis® is indicated for the treatment of severe keratitis in adult patients with dry eye disease which has not improved despite treatment with tear substitutes.

PBS Information: Authority Required. Refer to PBS Schedule for full information. Before prescribing IKERVIS®, please review the Approved Product Information available from Seqirus Medical Information (1800 642 865) or www.seqirus.com.au/products 

This medicinal product is subject to additional monitoring in Australia. This will allow quick identification of the new safety information. Healthcare professionals are asked to report any suspected adverse events www.tga.gov.au/reporting-problems.

MINIMUM PRODUCT INFORMATION: IKERVIS® (ciclosporin 0.1% ophthalmic emulsion). Indication: Treatment of severe keratitis in adult patients with dry eye disease which has not improved despite treatment with tear substitutes. Contraindications: Hypersensitivity to the active substance or any of the excipients; Ocular or peri-ocular malignancies or premalignant conditions; Active or suspected ocular or peri-ocular infection. Precautions: Any reversible underlying conditions, not associated with dry eye disease, should be treated prior to initiating IKERVIS®; History of ocular herpes; Contact lenses should be removed before instillation of eye drops and re-inserted at wake-up time and careful monitoring of severe keratitis is recommended; Glaucoma – limited experience with IKERVIS®. Exercise caution especially with concomitant betablockers; Co-administration with eye drops containing corticosteroids may potentiate effects of IKERVIS® on the immune system; May affect host defences against local infection and malignancies. Use in Pregnancy (Category C): No data available; Not recommended in pregnancy unless the potential benefit to mother outweighs the potential risk to fetus. Use in Lactation: Insufficient information on breastfed infants; it is unlikely that sufficient amounts are present in breast milk. A decision must be made to discontinue either IKERVIS® or breastfeeding during treatment. Use in Children: No data available. Interactions with other medicines: No data available. Adverse Effects: Common: erythema of eyelid; lacrimation increased; ocular hyperaemia; vision blurred; eyelid oedema; conjunctival hyperaemia; eye pruritus. Very common: eye pain, eye irritation. Dosage and administration: The recommended dose is one drop of IKERVIS® once daily to be applied to the affected eye(s) at bedtime. Abbreviation: DED: dry eye disease; CFS: corneal fluorescein staining; PBS: Pharmaceutical Benefits Scheme. References: 1. Geerling G, et al. Ophthalmol Ther 2022;11: 1101–1117. Seqirus (Australia) Pty Ltd. ABN 66 120 398 067. 63 Poplar Road, Parkville Australia 3052. Seqirus Medical Information: 1800 642 865. Seqirus is a trademark of Seqirus UK Limited or its affiliates. Ikervis® is a registered trademark of Santen S.A.S. and distributed by Seqirus (Australia) Pty Ltd under license from Santen Pharmaceutical Asia Pte Ltd. HSEQ781. Date of preparation: April 2023. AU-Iker-23-0030.

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DRY EYE

BUILDING THE

'BIG'PICTURE OF DRY EYE

A lack of understanding about treatment outcomes and natural history of dry eye in the real world – absent in data collected from clinical trials – led to the development of the Save Sight Institute Dry Eye Registry, which is tracking the clinical features and outcomes of dry eye disease in its growing cache of data.

he Save Sight Dry Eye Registry, launched in December 2020, is currently being used by 35 clinicians from 27 sites in seven countries – including Australia, Spain, United Kingdom, Germany and France – to monitor treatment effectiveness and patient outcomes. Those figures are only scratching at the surface of the potential trove of intel this registry could provide for dry eye management going forward. The web-based registry is free, accessible to optometrists and ophthalmologists – and anonymous, meaning data are encrypted and stored in a secure server. Only individual eyecare practitioners can see their own data. Practitioners can obtain CPD points from RANZCO and Optometry Australia for using the registry. The registry provides an interactive visual summary of each patient’s treatment journey, and anonymised reports allow users to compare their patient outcomes with their peers.

WHY WAS THE SAVE SIGHT DRY EYE REGISTRY ESTABLISHED? The Save Sight Dry Eye Registry was established by Professor Stephanie Watson OAM, head of the corneal research group at the Save Sight Institute, The University of Sydney and is based on the globally successful Fight Retinal Blindness! project led by Professor Mark Gillies. As Watson explains, registries address an unmet need in ophthalmology for real-world evidence; that is to understand treatment outcomes in everyday practice. For dry eye, randomised controlled trials have been providing evidence on treatments with patients enrolled using strict inclusion and exclusion criteria and conducted over the short term. Watson says that with optometrists managing many dry eye patients there was also a need to collaboratively collect data from both ophthalmology and optometry practices. “The Save Sight Dry Eye Registry is unique as it is the first collaborative registry, across ophthalmology and optometry to collect data from everyday clinical practice on dry eye treatment outcomes over the long-term. Patient-reported outcomes are also collected by the registry and will enable us to understand the impact of dry eye on quality-of-life and the benefit to patients of treatments in the real world. The ability to collect longitudinal data may also improve understanding of dry eye natural history,” Watson says. “Watching the registry grow globally will enable us to compare dry eye treatment outcomes and natural history across countries; with data collected on patient demographics and general health, our understanding of why dry eye prevalence varies across the globe may improve." The Save Sight Dry Eye Registry has also brought together a team of international experts on the steering committee. With Watson as chair, the steering

committee members include Dr Alberto Recchioni, Dr David Mingo, Dr Fanny Babeau, Scientia Professor Fiona Stapleton AO, Dr Francisco Arnalich-Montiel, Professor Gerd Geerling, Dr Himal Kandel, Professor Jennifer Craig, Associate Professor Laura Downie, Dr Ngozi Chidi-Egboka, Professor Saaeha Rauz, and Professor Vincent Daien. “Working with experts in the field on the steering committee has made the registry project an enjoyable and valuable experience. There is a significant amount of research that needs to be done to relieve suffering in dry eye. It is rewarding to know that with this registry and the team of experts supporting it, we may find knowledge that can be translated to improvements in dry eye care,” Watson explains. Save Sight Institute postdoctoral research associate Dr Ngozi Chidi-Egboka, who has been involved in the registry since March 2023, says the registry plugs a hole in dry eye research. She says at least one in four Australians have dry eye disease, resulting in considerable costs to the Australian health sector, and the burden is growing globally. “Given the increase in the use of digital devices and correlation with myopia control, dry eye is largely on the increase – not only in adults but kids as well. So, we need to understand the natural history, and treatment outcomes to know how to best manage the disease,” she says. ABOVE: Corneal erosions from dry eye visualised with fluorescein under a cobalt blue light on the slit lamp (left), and inferior corneal erosions in a patient with dry eye and corneal exposure due to nocturnal lagophthalmos (right). Images: Save Sight Institute.

“WITH THIS REGISTRY AND THE TEAM OF EXPERTS SUPPORTING IT, WE MAY FIND KNOWLEDGE THAT CAN BE TRANSLATED TO IMPROVEMENTS IN DRY EYE CARE.” PROF STEPHANIE WATSON OAM

INSIGHT February 2024

DRY EYE

Interactive visual tracking and analysis of visits, procedures and treatment outcomes using the Save Sight Dry Eye Registry. Image: Save Sight Institute.

“Data from the registry will inform the clinicians managing patients with dry eye in everyday practice and researchers developing dry eye treatments. That was the reason why the Dry Eye Registry was set up, so that we can collect the day-to-day data from normal clinical practice.” By encouraging optometrists and ophthalmologists to use the registry, to record the treatment journey of their patients, the Save Sight Institute is hoping the data Dr Himal Kandel. Image: Save Sight Institute. from the Dry Eye Registry will be able to inform researchers of evidence-based outcomes from dry eye treatment. “We collect data of all the medications the patient has ever used, not restricting them to only one medication, as we find in most clinical studies. We want to see the outcome of treatment as part of real-world practice,” Chidi-Egboka says. Data from the Dry Eye Registry can also be beneficial for benchmarking, allowing clinicians to compare their patient outcomes with their peers, and involving the patient in their treatment journey. “We have set the registry up so that clinicians can use the output data to explain to the patient what’s going on in a way they will understand – that’s number one. Also, the registry makes it easy for clinicians to track responses to quality-of-life questionnaires we use in assessing dry eye symptoms. It is easy for the clinician to simply email the questionnaire to the patient to complete in their own time or the patient can complete online during their clinic visit.”

INSIGHT February 2024

The registry uses validated questionnaires, the Ocular Surface Disease Index and Ocular Comfort Index, to assess the impact of dry eye on different aspects of the patient’s life, vision, environment, and everyday activities. Symptoms of anxiety and depression can be screened for using the Patient Health Questionnaire-4. Dr Himal Kandel, a senior researcher at the Fight Corneal Blindness project, of which Save Sight Dry Eye Registry is an integral component, has nearly a decade of experience in patient-reported outcome research. “Patient-reported outcomes have always remained a priority at the Save Sight Dry Eye Registry from its inception as we believe that improving the quality-of-life of dry eye patients is the ultimate goal of healthcare,” Kandel says. “We use validated tools and robust methods to collect and analyse these data which help us track and improve patient outcomes. Patient-reported outcomes give voice to the patients and reduce the disparity between clinicians’ and patients’ perspectives. They are a pivotal component of comprehensive outcome assessment. They are probably more important in dry eye than other health conditions as the evidence suggests that dry eye signs and symptoms (evaluated using patient-reported outcome measures) often do not correlate,” he says. Chidi-Egboka says the registry will also lead to greater transparency on the burden of treatment and impacts on quality-of-life. “We’ll be able to inform the government and the industries involved in policymaking on the effectiveness of certain treatments,” she says. Making the registry internationally accessible, allowing analysts to gather data from different locations, will help to track if dry eye treatment outcomes are noticeably different according to location, such as in Spain, compared to Australia. “It’s understood that people in different countries have different rates of dry eye prevalence, but we don’t have enough understanding of the predisposing factors,” Chidi-Egboka says.

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She hopes the registry will give researchers more insight into dry eye cause and effect, and potential adverse events of any treatment, which are recorded on the registry.

TRACKING OVER TIME The registry provides an interactive visual summary of every patient’s treatment journey, plotting each follow-up visit against the treatment, procedures and outcomes in their left and right eye separately. “The clinician can open the registry – easy to access online and quick to log-in to – and show/tell their patient, ‘On this visit you were treated with this medication or therapy’. A separate line tracks the procedures and outcomes including symptoms, signs and visual acuity in each eye at the time of treatment. The clinician can refer to any previous visit to see exactly what medications the patient was using,” Chidi-Egboka says. Lastly, as some dry eye risk factors are modifiable, such as time spent on devices, Chidi-Egboka says understanding exactly how to modify risk factors can potentially reduce the prevalence of dry eye disease. A paper Chidi-Egboka co-authored with colleagues from UNSW School of Optometry and Vision Science and published in Eye last year examined the effect of smartphone use on blinking, symptoms, and tear function in children. They found as little as one hour of smartphone use in children results in dry eye symptoms and immediate and sustained slowing of blinking, with no change in tear function evident up to one hour. The registry is now looking at screen time in adults to shed more light on this important issue. “Computer use, how can patients possibly avoid these risk factors? This registry is currently tracking screen use and may be able to link this to outcomes over a longer period of time, compared to randomised controlled clinical trials, which are normally short in duration and may not collect data such as screen time,” she says.

DR NGOZI CHIDIEGBOKA their dry eye and also general health. The long-term collection of data will help us understand dry eye natural history and its relation to health.”

OPPORTUNITIES FOR THE SAVE SIGHT DRY EYE REGISTRY Funding registries is always challenging. With the registry able to provide outcome data for most of the dry eye treatments on the market globally, the team at the Save Sight Institute are looking for funding partners interested in understanding treatment outcomes. “Data on treatment outcomes is hard to get from everyday practice and on a range of products. With the Save Sight Dry Eye Registry, there is an opportunity to improve dry eye treatment and understand which products are in use in the market along with their true benefit to patients,” Chidi-Egboka says. To join the registry, visit savesightregistries.org/fight-corneal-blindness/, or to find out more contact ssi.ssr@sydney.edu.au. Financial disclosures: The Save Sight Dry Eye Registry was supported by an unrestricted grant from Novartis and Seqirus.

Frame R7136 A

“The Dry Eye Registry tracks the same patient over years collecting data on

“THIS REGISTRY IS CURRENTLY TRACKING SCREEN USE AND MAY BE ABLE TO LINK THIS TO OUTCOMES OVER A LONGER PERIOD OF TIME, COMPARED TO RANDOMISED CONTROLLED CLINICAL TRIAL.”

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Viscotears

Viscotears® Gel PF improves the moistening of the ocular surface in the presence of dry eye sensations, burning or tiredness of the eyes, caused for instance: • by watching television for a long time • extensive computer work • dry air from air-conditioning or heating Preservative free Moistening and wetting effect1

Viscotears® Eye Gel provides soothing relief for sore, gritty dry eyes. Its long lasting gel formulation is suited for those who: • need extra protection • added nighttime support, or • prefer a heavier gel 6H

Maintains the tear film stability for a period of up to 6 hours2 Viscous gel for nighttime protection

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Material was prepared in February 2023 References: 1. Viscotears Gel PF IFU. 2. Viscotears Single Dose Unit 2.0mg/g Eye Gel, EMC, 5.1 pharmacodynamic properties https://www.medicines.org.uk/emc/product/2311/smpc - Accessed Feb 2023 © 2023 Bausch & Lomb Incorporated. ®/TM are trademarks of Bausch & Lomb Incorporated or its affiliates. Bausch & Lomb (Australia) Pty Ltd. ABN 88 000 222 408. Level 2, 12 Help Street, Chatswood NSW 2067 Australia. (Ph 1800 251 150) Vis.0001.AU.23

EVENT

Dr Ben Ashby on stage at SCC 2023. Image: Specsavers.

Hig hlig hts f rom

SPECSAVERS CLINICAL CONFERENCE 2023 Optometrists across Australia and New Zealand mark their calendars each year for the Specsavers Clinical Conference, considered one of the cornerstones of professional development in Australian primary eyecare.

pecsavers Clinical Conference (SCC), now in its 12th year, continued with the hybrid model of previous years and welcomed almost 1,000 delegates, including 300 in-person at Hotel Sofitel Sydney Darling Harbour and 700 online. The conference featured a prominent speaker line-up, with the experts imparting knowledge across the full scope of optometric practice from disease diagnosis, patient communication, rapport, and collaborative care. SCC commenced with newly titled Specsavers ANZ clinical services director Dr Ben Ashby welcoming delegates and commemorating notable milestones across the business. He celebrated highlights in Specsavers’ five-year plan to bolster its accessible and affordable eyecare model. He said that decreasing rates of avoidable blindness, increasing detection rates, and improving eyecare accessibility for the 10 million Australians and New Zealanders currently not accessing eyecare constituted part of the company’s long-term goals. “We set ourselves the ambitious goal to get to a 95% detection rate of avoidable blindness. And I’m very proud to congratulate all of our optometrists at this threeand-a-half-year mark of our five-year journey to now be at 90% detection for these conditions,” he said. Ashby said that among the reasons of a larger number of referrals to specialist services, is an increase in patients at Specsavers stores. “We have now provided care for 5.2 million people over the last 12 months with an additional one million people now accessing eyecare," he said. Around 500,000 of them are now in vision correction, living better lives with better sight and 70,000 have been referred to ophthalmologists for

treatments they wouldn’t have otherwise had. Key partnerships were also acknowledged, including KeepSight which Specsavers has supported since its 2018 inception. The Diabetes Australia-coordinated program is a national eye screening initiative for Australians living with diabetes. “Specsavers optometrists have now registered over 700,000 visits of their patients with diabetes. The reminders being sent out by KeepSight are increasing the return-rate of people with diabetes by 20%,” Ashby said. “What that means is that over the last year, where our optometrists have found 20,000 cases of advanced diabetic retinopathy that needed treatment by ophthalmologists, 4,000 of those cases would have been missed if it wasn’t for the KeepSight program.” Finally, Ashby discussed opportunities for Specsavers to elevate its accessible eyecare model. He said that expanding access to eyecare for patients in regional and remote locations is on the agenda for next year, which involves solving the maldistribution of optometrists through technology advancements. “Remote care is for those 100 stores across Australia and New Zealand that can’t get enough optometry cover to service their local communities,” he said. “We think this is a massive opportunity to improve access to eyecare in places that we can’t currently get optometrists. We’ve been piloting the model for a year already and next year we’re going to be taking it to an even more remote location to really put it through its rigours.”

EDUCATION  THE FIRST LINE OF MYOPIA TREATMENT Dr Rushmia Karim, ophthalmologist at the Vision Eye Institute in Sydney, kickstarted the conference by contrasting the evidence available on myopia to INSIGHT February 2024

EVENT

“When you start prescribing a contact lens to a child, you really have to counsel them properly. No foreign body in the eye is risk-free.” Ortho-keratology (ortho-k) generally receive good reception in rural communities due to the social stigma of wearing glasses among children, which is essentially non-existent in metropolitan communities, Karim says. However, again she noted the importance of communication regarding the potential risk of keratitis infections posed by ortho-k. “It’s really important for you to discuss adverse reactions with parents. Not every ortho-k patient is going to have an infection. But an infection can be catastrophic,” Karim stated. Moving on to basics in the clinic and diagnosing myopia, Karim said there was a prevalence of under correction, and when patients are referred to her, they tend to be more myopic than prescribed. SCC is also an ideal opportunity for optometrists from across Australia and New Zealand to reconnect and share clinical insights. Image: Specsavers.

Dr Shenton Chew delved into the RANZCO referral pathway for glaucoma treatment. Image: Specsavers.

However, above all, education is key in myopia management. “We really need to set expectations early in children and parents. It’s genetics plus lifestyle and we really have to hone in on the lifestyle part.”

REINFORCING OPTOMETRICOPHTHALMIC RELATIONSHIPS Dr Shenton Chew, a glaucoma surgeon at Auckland Eye, discussed how to optimise the glaucoma collaborative care model between optometrists and ophthalmologists. With glaucoma being the leading cause of preventable blindness, there is a substantial burden for the eye health sector to grapple with – and therefore a role for optometry to play. Chew emphasised the cumulative value each profession provides in glaucoma management and treatment. “Collaborative care is there to safeguard both the patient and optometrists,” he said. He defined collaborative care as the “delegation to optometrists some part of the regular monitoring of patients in stable glaucoma, or in glaucoma that is likely to develop that requires a specific plan created by the ophthalmologist, and as agreed to by both the patient and the clinicians”. Chew outlined different categories of candidates for collaborative care as per RANZCO’s glaucoma referral pathway.

its real-world realities. She explored the genetic and environmental components of the disease and the intersect between environmental and lifestyle factors that result in its progression. Karim began with data that demonstrated the benefits of outdoor exposure on slowing progression, and the challenges associated with communicating this with parents. These conversations can be more arduous relative to the simpler process of prescribing glasses, but she encouraged optometrists to discuss outdoor light exposure. “Going outside costs nothing. Yet it’s the most difficult conversation to have with parents,” Karim said. “As clinicians, it’s not just about bottom dollar, it’s about trying to provide holistic care, and changing this lifestyle that we’ve created as a society.” Karim recommends Hoya MiYOSMART myopia management lenses as a first line treatment for her patient cohort from ages eight to 12. She cites the prescription of Hoya MiYOSMART lenses as a lateral transfer for the child if they are already wearing glasses. Good tolerability, no associated risks, as well as a proven ability to slow progression, are among its most attractive features. “Generally, with Hoya MiYOSMART, a third of patients can have a reduction in their in myopia over two years,” Karim said. For the second line of treatment for myopia management, Karim recommends atropine with consideration of dose response. She advises beginning with EIKANCE 0.01%, to provide a lower dose and determine tolerance, and then progressing to 0.025% or 0.05% in order to tailor the treatment based on myopia progression and dose tolerance. CooperVision’s MiSIGHT lenses were also as a reasonable alternative to spectacle lens interventions, according to Karim. While the risk of use is relatively low, she recommends an emphasis on appropriate handling and hygiene when prescribing to children.

INSIGHT February 2024

The first cohort constitutes patients suspicious for glaucoma, either due to optic disc appearance and/or OCT scanning, or repeatable visual field loss in a glaucomatous pattern. Identification of glaucoma risk factors can help stratify these patients further to help workout the best timeframe for follow-up. One of these identifiers are disc haemorrhages, which can be easy to overlook. Although they can be associated with other conditions such as vitreous traction, posterior vascular disease, and diabetes, when they present in glaucoma, it represents a progressive issue. The next cohort in the collaborative care model are those with early-to-moderate glaucoma. Chew recommended striking a balance between prevention of visual disability and minimisation of treatment burden in this cohort of patients. He said shifting the lens towards treatment minimisation will circumvent compliance and convenience issues. “We certainly don’t want these patients to be on multiple classes of eye drops, just to get a lower pressure number to achieve the target IOP that was set, when the target might be a thing that needs to be shifted,” he said. “Severe side effects aside, there’s going to be issues with compliance and convenience, and this is why there’s been a paradigm shift in the ophthalmology world towards laser as first line treatment in the form of selective laser trabeculoplasty (SLT). As a first line treatment, there was less disease progression and better intraocular pressure control.” Further to this, the landmark Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial in the UK – that ultimately recommended SLT as a first-line glaucoma intervention – published six-year results in September 2022 further demonstrating the clinical effectiveness of the treatment. Chew himself cites SLT as a superior alternative to eye drops. However, fear among patients remains a barrier to uptake. Thus, it is necessary for optometrists to communicate it as a simple, office-based procedure that doesn’t hurt.

Dr Rushmia Karim discussed the importance of having conversations about myopia management with patients. Image: Specsavers.

“Compliance to the drops remains a big issue. Shockingly, one Australian study indicated that 50% of eye drop prescriptions remain unfilled by patients,” he said. Chew said communication can overcome these compliance issues, using an analogy to hammer home the message. “There are barriers: the therapy can have significant side effects, the disease is asymptomatic, so they get no positive reinforcement using the drops. But we can modify patient factors to improve compliance, such as improving their understanding,” he said. “I think they really get it when you explain to them that your eyes are the camera, your brain is like the TV screen, and glaucoma is the damaged HD cable that connects the two – you can’t switch it out at the local hardware store.” If lack of compliance can be attributed to memory issues, optometrists can recommend setting alarms on patients’ mobile phones or getting family members involved if it’s a dementia issue. “Instead of asking, ‘do you miss your drops?’, I might trick them a little and ask; ‘on a seven-day stretch, would you have missed your drops once or twice a day?’” The final cohort of patients encompass advanced to acute glaucoma. Chew said the most significant learning point for optometrists is when to designate patients to this category based on symptoms. For example, a patient who presents with an asymptomatic, but very high IOP reading does not need an acute assessment and can follow the routine referral pathway. The optometrist might choose to initiate eyedrop treatment as an interim measure and re-take the patient’s IOP in a week to ensure that they can safely wait for their ophthalmic assessment. Contrarily, if a patient presents with symptoms and with a relatively high IOP, this needs to be seen acutely after discussion with the local on-call ophthalmolog service.

DIET MODIFICATION IS THE NEW MEDICINE “As an eye specialist, I never want to see another patient, another Aussie, another fellow human go needlessly blind due to their type 2 diabetes.” Adelaide-based ophthalmologist and 2020 Australian of the Year, Dr James Muecke, used the stage to drive awareness of the intersect between poor diet and vision loss. Muecke is passionate about “de-medicating” patients, particularly those with type 2 diabetes, and reversing the vision loss associated with the disease through dietary adjustments. For context, Muecke used an anecdote of one his patients, Mr Neil Hansell, an everyday Aussie who constructs light machinery for a living and has a wife and

four kids. At the age of 50, Hansell woke up one morning blind in both eyes, with the realization that he’d spend the rest of his life in darkness as the result of his type 2 diabetes. Hansell lost his driving license, his independence and the ability to teach the javelin – a longstanding passion of his. “The thing that upsets him more than anything is that he can no longer see the beautiful smiles on the faces of his wife and grandkids,” Muecke said. Muecke said the consequences of the disease are very much avoidable. However, poor compliance with retinal screening protocols is a key driver of vision loss. “The problem is, of the roughly two million people in Australia and New Zealand with diabetes, well over half are not having their regular all-important sight-saving eye checks,” he said. He also pointed to a shift in global dietary advice after 1980, moving from a low carb healthy fat dietary recommendation to one which is high in carbs and infused with industrially produced seed oils. Rather than seeing a decline in chronic disease, there has been an upward trend of heart attacks since the implementation of these recommendations, and a four-fold increase in type 2 diabetes, with the most profound effects in some minority communities. “In our Indigenous population in Australia, we’ve seen more than an 80-fold increase in type 2 diabetes over the last half century,” Muecke said. Despite the steady increase in numbers, type 2 diabetes can be put into remission, a little-known fact amongst doctors and patients alike. “There are over 100 controlled clinical trials that show an improvement in metabolic health through avoiding added sugars, refined carbs, seed oils and ultra-processed substances. One of these studies reveals over 50% of participants are still in remission after a five-year period,” he said. “I’ve found a reduction in diabetic macular oedema in over 30 of my patients with type 2 diabetes who’ve embarked on therapeutic carbohydrate reduction.” Muecke also recommended optometrists ask the GP to request a fasting blood insulin level if they see a patient with retinal vein occlusion. It’s a strong indicator of metabolic dysfunction, and if needed, these patients can subsequently reduce their carbohydrate intake. “I looked at 45 of my patients who had retinal vein occlusion with macular edoema and who were receiving regular injections of anti-VEGF for at least two years. Over 50% of those patients had pre-diabetes or type 2 diabetes. Of the remaining patients, 60% had insulin resistance with a fasting insulin level of over 5.5mmol/L,” he said. INSIGHT February 2024

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can I find out about you as a primary care practitioner that I can help you with? And what is within our control?” Gidas emphasised the importance of asking open ended questions and following along closely to formulate tailored treatment options for patients’ lifestyles. He says that optometrists must listen with the intent to understand what is most important for the patient, if they want to achieve the best possible outcome. He supports this with a quote from Stephen Covey: “Most people do not listen with the intent to understand; they listen with the intent to reply.” Gidas added: “What does a day in the life of your eyes look like? So, we’re going to prescribe a solution that hopefully fits their lifestyle puzzle.”

Presenting the 2023 Doug Perkins Medal, (from left) Specsavers ANZ director of clinical services Dr Ben Ashby, Specsavers Beaudesert optometrist partner Millicent Healy (Australian recipient) and head of clinical performance Nick Gidas. Image: Specsavers.

THE BEDROCK OF GOOD CLINICAL PRACTICE Mr Nick Gidas, head of clinical performance at Specsavers, journeyed beyond clinical acumen and into the soft skill of patient communication. He described it as the gateway to making a difference in patients’ lives. “Communication, like any skill, unless we invest time to develop it, we won’t be able to continually improve our patient outcomes or the experiences we provide our patients,” Gidas said. He quoted American engineer and science communicator Bill Nye’s philosophy: “’Everyone you will ever meet knows something that you don’t’. “That’s the mindset you need to have, going into every consultation. What

He continued by stating that effective communication will prevent patients leaving the consultation feeling overwhelmed and confused. This entails eliminating jargon from conversations in patient interactions. “If we’re asking all these fantastic questions to understand how we can best help our patient, we have to be mindful of not using too many words that are familiar to us like ‘distance reading’, because our patients may not relate to them,” Gidas said. To elevate the personalisation of treatment, he recommended relating the objective back to the patient. That is, what do they want out of this and how does this impact their day-to-day? He cited the redundancy in relaying potential options to patients, without giving them supportive education and guidance on what best suits their lifestyle requirements. “We need to be empowering our patients and helping them make informed choices. If we leave them with just the options only and transfer that entire responsibility without some sort of supportive education, then we’re not actually prescribing a solution,” he stated.

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

Before prescribing please review Product Information available via www.aspenpharma.com.au/products or call 1300 659 646. Minimum Product Information: XALATAN® (Latanoprost 50 µg/mL) Eye Drops. Indication: Reduction of intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension. Contraindications: Hypersensitivity to ingredients. Precautions: Change in eye colour due to increased iris pigmentation; heterochromia; eyelid skin darkening; reversible eyelash and vellus hair changes; macular oedema often associated with aphakia / pseudoaphakia; other types of glaucoma; contact lenses; severe or brittle asthma; herpetic keratitis; driving or using machines – transient blurry vision; elderly: no data; children: do not use, no data; lactation- metabolites present in breast milk, risk / benefit. Pregnancy: Category (B3) Interactions: other prostaglandins, thiomersal. See PI for details. Adverse Effects: Eye Disorders: blurred vision, burning, conjunctivitis, excessive tearing, eye pain, foreign body sensation, hyperaemia, iris hyperpigmentation, itching, punctate epithelial erosions, grittiness, stinging, eyelash and vellus hair changes, punctate keratitis, blepharitis, eyelid oedema, localised skin reaction on eyelids; Systemic: bronchitis, upper respiratory tract infection, eczema, rash, urinary tract disorder, abnormal liver function, myalgia, arthralgia, dizziness, headache, rash, chest pain, asthma, dyspnoea . See PI for details and other AEs. Dosage and Administration: One eye drop in the affected eye(s) once daily. Other eye AT AUSTRALIAN VISION dropsOPTOS should be administered at least 5 minutes apart. CONVENTION

A first choice for glaucoma management1

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

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References: 1. Clinical Practice Guide for the Diagnosis and Management of Open Angle Glaucoma. Optometry Australia 2020 2. Australian Commission on Safety and Quality in Healthcare Active Ingredient Prescribing Guide - list of medicines for brand consideration December 2022 Aspen Australia includes Aspen Pharmacare Australia Pty Ltd (ABN 51 096 236 985) and Aspen Pharma Pty Ltd (ABN 88 004 118 594). All sales and marketing requests to: Aspen Pharmacare Pty Ltd, 34-36 Chandos Street, St Leonards NSW 2065. Tel: +61 2 8436 8300 Email: aspen@aspenpharmacare.com.au Web: www.aspenpharma.com.au Trademarks are owned by or licensed to the Aspen group of companies. © 2023 Aspen group of companies or its licensor. All rights reserved. Prepared: July 2023 AU-LAT-072023-07653

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Image: Hemi Retinal Vein Occlusion Autofluorescence optomap image 1. Tornambe, The Impact of Ultra-widefield Retinal Imaging on Practice Efficiency, US Ophthalmic Review 2017. 2. Successful interventions to improve efficiency and reduce patient visit duration in a retina practice, Retina. 2021. 3. Kehoe. Poster 19. Widefield Patient Care. EAOO 2016

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EVENT manager iao, senior Sephor a M ANZ. ns io at er op of eyecare a. tic ot ux rL lo Image: Essi

s Cheryn Goh’s experience as an optometrist is a familiar one. She finds immense fulfilment from her day-to-day duties, but sometimes it’d be nice to step away from patient-facing work and share clinical insights with her colleagues away from the consulting room. “As optometrist’s our days are usually focussed on our patients,” says Goh, a managing optometrist at OPSM Carindale who was recently promoted to area eyecare manager for QLD/NT/NSW for EssilorLuxottica.

QUT's Dr Roha n Hughes presented on my opia. Image: EssilorLu xottica.

“Even when we do work alongside our fellow colleagues, it is sometimes challenging to find the time to discuss the complexities of life, the latest research and the evidence-based best practice.” Her employer, EssilorLuxottica, has acknowledged that a fully engaged optometry team is one of the hallmarks of successful optometry networks today. With more than 430 stores and over 1,000 optometrists in the OPSM and Laubman & Pank network in Australia and New Zealand, the company does this through several channels, but during the past two years it has elevated this through a month-long roadshow across ANZ. The 2023 roadshow took place across August with another planned for mid-2024. It sees optometrists across the network flock to their nearest major centre for face-to-face events to hear key updates from leaders in the business, in addition to presentations from their peers, CPD sessions, dinner and an awards ceremony, plus more.

A NIGHT TO REMEMBER Through the EssilorLuxottica Eyecare Roadshow, OPSM and Laubman & Pank optometrists have had the chance to zoom out and understand the importance of their work on a macro scale. It’s also an opportunity to form tighter bonds with colleagues, celebrate achievements and hear from Australian and New Zealand optometry thought leaders.

All up, the roadshow visits six capital cities – Perth, Brisbane, Adelaide, Melbourne, Sydney and Auckland. Meanwhile, optometrists living in more remote locations meet at one of 11 regionally based satellite events that are beamed into their respective state event. This year Goh attended the Brisbane event where her OPSM Carindale team featured heavily in the state-based awards program recognising: • Early Career Optometrist of the Year • Regional Community Award • Mentor of the Year • Clinician of the Year • Patient Choice Award • Optometrist of the Year Goh herself was awarded Optometrist of the Year for the QLD/NT/NNSW division. “These events are of utmost importance as I believe that when we gather together, we can collaborate, learn from and inspire each other. It is wonderful that EssilorLuxottica sees the value in their optometrists and subsequently these roadshow events bring together the professional body to grow and develop,” she says. “We all enjoyed leaning in and learning from the leaders in our business, and also the optometry profession, so that collectively we can strive to lift the bar of clinical excellence and provide an amazing customer journey for our patients.” Goh says the awards ceremony always generates a buzz where individual optometrists in the business can be recognised and celebrated by their peers for their consistent hard work and dedication. “For me personally, there was some special moments where our Carindale optometry team rallied around to celebrate each other’s achievements,” she says.

Cheryn Goh (centre) and other eyecare award recipients at the Brisban e roadshow event. Image: EssilorLuxottica.

INSIGHT February 2024

“The roar of applause and cheers from the team when it was announced that Dorota Kuchcinska, one of our full time optometrists and pillars at our store, won the award for Clinician of the Year still gives me goose bumps. It was such a magical moment that demonstrated the strength and cohesiveness of the team.”

A TIME TO CONNECT, SHARE BEST PRACTICE Ms Sephora Miao, senior manager of eyecare operations at EssilorLuxottica ANZ, says the roadshow is a fresh concept first devised in 2022 when it was

OPSM and Laubman & Pank optometrists at the Brisbane roadshow event in 2023. Image: EssilorLuxottica.

dubbed the Next Level Eyecare Roadshow. In previous years, EssilorLuxottica ran smaller local cluster workshops of 20-30 optometrists. There was a clear appetite for more face-to-face and the business listened, making the important step of aiming to reach all optometrists within the network. The 2023 version – themed The Evolving Lens – was refined after feedback from the inaugural roadshow. Although it’s a significant undertaking sending the roadshow to so many centres within a short window, Miao says it provides an enriching experience for the OPSM and Laubman & Pank optometrists, so it will likely remain an annual fixture. “It’s important to bring all of our optometry colleagues together from across our ANZ network to connect and share best practice,” she says. In the 2023 roadshow, optometrists heard directly from key leaders in the business, with senior executives such as EssilorLuxottica’s general manager of ANZ retail Mr Matteo Accornero and senior vice president of ANZ store operations Mr Carl James attending the events. Optometry thought leaders Dr Kate Gifford and Dr Rohan Hughes capped off the events with sessions on myopia control, with attendees able to add this to their CPD portfolio. All up, the roadshow connected with more than 600 optometrists in 2023, presenting the majority of EssilorLuxottica ANZ’s permanent optometry workforce. Each year, Miao hopes to improve the roadshow user experience. Surveys are sent to attendees for feedback, which is factored in when drawing up the agenda for the upcoming year. After the 2022 roadshow, two recurring themes shone through. Firstly, optometrists were interested in their own professional development and wanted to know the steps EssilorLuxottica was taking to facilitate this. “So, as part of the roadshows in 2023, we incorporated a section on Leonardo, which is our global training platform, and looked at all of the new eyecare-related modules that are available to our optometrists,” she says. “The second theme that came through was our optometrists wanted to understand what’s in the pipeline for their talent development. It’s great to see all our optometrists invested in their own growth, so we spoke about the work we are doing with our HR team to better define the structure of our career progression pathways. We are building a new platform to facilitate those conversations with our optometrists while also increasing the number of opportunities for our high performing talent and our most engaged optometrists.” Another key component of the roadshow is the awards ceremony. First introduced in 2022, Miao says the feedback shows this is one of the most valued aspects. As voted by not only their optometry peers, but also store colleagues, the category winners within their region were recognised, in addition to three runners-up.

“A HUGE HIGHLIGHT OF THE NIGHT WAS HAVING AN INTERACTIVE MYOPIA CONTROL SEMINAR FROM DR KATE GIFFORD HERSELF, TO KEEP US UPDATED WITH THE CLINICALLY EVIDENCED MANAGEMENT OPTIONS.” NHAUYEN TRAN GRADUATE OPTOMETRIST

A new addition in 2023 featured sessions by key opinion leader optometrists within the network. “These are optometrists who practise in our stores day in, day out with expertise in a particular field. For example, we had one of our Myopia Leaders present on stage in each state and share their myopia control expertise,” Miao says. “We received a lot of great feedback about this; our optometrists loved seeing their colleagues on stage.”

THE GRADUATE EXPERIENCE For graduate optometrists still finding their feet, the roadshow has proved invaluable to learn from more experienced colleagues and become more ingrained in the company culture. This was the case for Ms Nha-Uyen Tran. She’s a graduate in the South Australia Metro Relief Team, a role covering for practices in the metro Adelaide region. She joined the ANZ National Relief Team in January 2024 to continue servicing EssilorLuxottica’s regional stores across Australia and New Zealand. To recognise her eyecare efforts in regional and remote communities, she was awarded the Regional Optometrist Award for South Australia at the Adelaide roadshow in 2023. “For me, a huge highlight of the night was having an interactive myopia control seminar from Dr Kate Gifford herself, to keep us updated with the clinically evidenced management options available to us currently, as well as those that are being researched and may be accessible in the near future,” she says. Tran believes collegiality built through events like the roadshow are a major aspect of efficient, evolving eyecare. “I’ve worked in both solo-consulting and multiple-consulting practices, and often find it is beneficial to learn from and share tips with my fellow colleagues, especially when coming across all the unique and wonderful things optometric care has to offer.” INSIGHT February 2024

WHY THIS ORTHOPTIST PURSUED HER CERT IV

Image: Lisa Raad.

DISPENSER DETAILS

Name: Lisa Raad Position: Orthoptist and optical dispenser Location: Pinpoint Vision (Earlwood, NSW) & Eyetreat (Norwest, NSW) Years in industry: 11

1. What initially attracted you to a career in optical dispensing? I started wearing glasses when I was 12 years old, so I always had an interest, but it wasn’t until I started working in an optometry practice – as an orthoptist – that I genuinely appreciated the role of optical dispensers. The finesse my colleagues brought to pairing frame shapes with prescriptions and facial features amazed me. I began referring to them (and then, optical dispensers in general) as the superheroes of the optometry practice. So, during COVID isolation periods I decided to use that time to get my qualification and join the superhero ranks.

2. What are your main career highlights? Being asked to present at the ODA Conference earlier this year and have such warm and positive feedback was incredible. I didn’t think it could get any better, only to have it topped a few hours later by receiving the ODA 2023 National Medal for Optical Dispensing Excellence. 3. What are your strengths as an optical dispenser, and what excites you about your job? My biggest strength lies in the dedicated time I invest with each patient, explaining their prescription and its implications for frame selection, lens designs, and coatings. It excites me when a patient says, ‘No one has ever told me that before’, because I know they are leaving my practice with a deeper understanding of their condition, and why certain designs or lens features were recommended.

process from start to finish. Visiting a lab helped me get a better understanding and visualise lens blanks, which impacted frame choices I would offer to patients.

The platform is so important for dispensers and all optical staff to learn from each other, recommend certain products/labs and share troubleshooting tips.

5. What do you see as the key opportunities and challenges facing the future of optical dispensing in Australia? I can see an opportunity for an increase in the number of qualified optical dispensers that play a slightly more clinical role within a practice. This would involve upskilling and being more confident with pre-testing – which could benefit several smaller optometry practices.

7. Why did you become a member of ODA, and what value do you see in the organisation? I became a member of ODA because the team behind it are some of the most passionate and dedicated professionals I know. Their enthusiasm for the profession is contagious and they are the kind of like-minded people I wanted to learn from and grow with.

I’m optimistic the challenges that have plagued optical dispensers historically are slowly disappearing as a direct result of more individuals getting their Cert IV, and having ODA looking out for the interests of the profession – thanks to many strong connections within the optical industry.

6. How do you ensure your skills and knowledge stay up to date in such a fast moving industry? Being a member of ODA definitely helps. The regular webinars are the best way to stay on top of different topics. I also try attend as many trade shows as possible to talk to different companies about changes in trends and materials being used for frames. I’m part of a couple of groups on social media where optical dispensers will often share their wins, and the occasional horror story.

The organisation is helping increase the reputation of optical dispensers by empowering us with information and resources, as well as being a point-of-contact to help with any concerns.

8. What did it mean to win the 2023 ODA National Medal for Optical Dispensing Excellence? To say I was speechless would be an understatement. Having the work I do and the love I have for the profession recognised by a group (and key individuals) that I have looked up to for a few years was so special. 9. What would you say to others thinking of joining ODA? Why haven’t you joined yet? Jump online right now and join before their next webinar and conference. You will not regret it.

Lisa Raad (right) being awarded the 2023 ODA National Medal for Optical Dispensing Excellence from ODA CEO April Petrusma. Image: ODA.

I also get excited to see the impact a pair of glasses can have on a person’s life – whether it’s by choosing colourful frames to express their creative side or having their symptoms disappear allowing them to enjoy their hobbies more.

4. If you could go back and provide advice to yourself at the beginning of your optical career, what would you say? I can’t stress enough how important hands-on experience is – so wherever and whenever it’s offered, jump at the opportunity. If you can learn a new skill inside your workplace, that’s great, otherwise I suggest visiting a lab (the earlier the better) for a better understanding of the entire Founded in 2022, OPTICAL DISPENSERS AUSTRALIA’S mission is to transform the optical dispensing industry by creating a community where optical dispensers and their associates can feel supported and inspired through education, events, networking, and employment advice, plus more. Visit: www.odamembers.com.au

INSIGHT February 2024

DISPENSING

HOW AI IS TRANSFORMING SPECTACLE LENS DESIGN Image: AAOO.

IN OPTICS, AI HAS NOT ONLY ANSWERED QUESTIONS SOUGHT OUT BY RESEARCHERS BUT HAS IDENTIFIED UNEXPECTED CORRELATIONS BETWEEN DIFFERENT EYE PARAMETERS. WHAT ARE THE IMPLICATIONS FOR FUTURE LENS DESIGN?

GRANT HANNAFORD "AI APPLICATIONS FOR LENS DESIGN ARE PRIMARILY USED TO PROCESS BULK DATA TO ADDRESS A SPECIFIC QUESTION POSED BY A DESIGN TEAM."

rtificial intelligence (AI) is easily one of the biggest buzzwords in the optical industry of late. The processes are significantly increasing the pace of development in lens design, however, a full discussion of AI is well beyond the scope of such a short article so we will cover the broad strokes here. There is a common misconception that AI is able to answer any question rapidly, but like any of us, the answer generated is only as good as the information available to it. In many cases, the information used is drawn from the internet, so the answers are subject to the general noise and misinformation present online. An easy example of this is to ask for definitions of simple optical conditions, such as hypermetropia. The answers, while close, miss the mark by just enough to show the answers aren’t being completely drawn from clinical sources. In the same way, for lens design we require a good database for generation of results (more on that later). The overall areas in which AI is currently providing advances in lens design, generally, are: • Best form optimisation, where the relationship between Rx and design are optimised on a per case basis. • Position of wear optimisation, using the full suite of positioning and power interactions to develop compensate designs. • Progressive addition lens (PAL) design, similar to best form where add, Rx and design interactions are optimised. • Behavioural modelling and biometric modelling, in which the specific biometric and behavioural requirements of a patient are used to modify lens designs and individualise layouts. All of these areas are providing significant patient improvements and are the subject of a presentation available via the Academy of Advanced Ophthalmic Optics. AI applications for lens design are primarily used to process bulk data to address a specific question posed by a design team. This facilitates searching large data sets with complex interactions for elements that may

INSIGHT February 2024

AI is accounting for biometric and behavioural requirements to modify lens designs and individualise layouts.

Image: Marco de Benedictis/Shutterstock.

influence the success or failure of a design. In a soon-to-be-published study, a series of environmental and lifestyle questions are related to biometric factors in the eye, with the total number of potential interactions between factors for one candidate alone in excess of 40,000. Across a cohort of individuals it is not possible to work through these data sets reliably, so AI provides iterative processes that can not only answer questions developed by the researcher, but also have been shown to identify unexpected relationships in the data sets as well. It would seem ideal to have every single individual set of Rx, behavioural and biometric conditions included in the data, however, a sufficiently strong outlier can skew the results significantly. For example, a model can be built relating refractive error to axial length which can inform personalised best form designs. If an eye deviates significantly from the model, for example very short but highly myopic, the determined axial length for that power will shift sufficiently. In a research sense, this informs our understanding of biometry, but for a practical applied design sense it is undesirable. The outlier can change the model being used, making the model inaccurate for the bulk of the other patients using the lens. In other words, we need to ‘clean’ the input data to ensure that the information being used to generate the designs is applicable to the largest

set of the population possible. This is also why it is not possible to allow an AI process to continually draw in new data ‘unsupervised’, as the models it generates can become skewed. Typically, teams will engage in a quality assurance program to assess the output of the AI data analysis prior to inclusion in a lens design, with data that is leading to a skewed output being diverted for alternative analysis. Iterative processes are not new in data management, but the ability of AI to isolate relationships previously hidden to researchers is allowing the pace of development for lens design to increase. The opportunities this affords our industry are significant to say the least. NOTE: For more detail on the processes themselves, Matlab has an excellent tutorial covering the basics, contact AAOO for the link.

GRANT HANNAFORD is a qualified lens designer, has completed an MSc (optometry) and is undertaking Doctoral Research in Ocular Biometry and Emmetropisation. He co-owns a private independent practice in the Southern Highlands of NSW and is the Director of the Academy of Advanced Ophthalmic Optics, is a Fellow of the ABDO and ADOA, and was the 2022 International Optician of the Year. He is also the Past Chairman of the NSW Optical Dispensers Education Trust and Past Vice President of ADOA (NSW) and a current appointee to the Australian Standards Committee for Spectacles.

MY JOURNEY INTO ALICE SPRINGS Image: Lina Li.

LINA LI HAS TRADED HER SYDNEY BEACH LIFE FOR THE RED SANDS AND EXPANSIVE SKIES OF ALICE SPRINGS. SHE EXPLORES THE UNIQUE CHALLENGES AND REWARDS AS AN ORTHOPTIST PRACTISING IN THE HEART OF AUSTRALIA.

LINA LI

“THE OFTEN TRANSIENT STAFFING IN ALICE SPRINGS PRESENTS A UNIQUE CHALLENGE: THE SERVICE AREA IS VAST, COVERING CENTRAL AUSTRALIA, AND THE RANGE OF EYE CONDITIONS I ENCOUNTER ARE BROAD.”

ife in Sydney consisted of a vibrant, concrete jungle-like CBD complemented nicely with the picturesque coastline of New South Wales. The dog beach visits every other Sunday were a routine, and the proximity to the beach was a luxury. Fast forward to my present life in Alice Springs, where the landscape is desert-like with red-orange sand, ranges, and beautiful clear blue skies. Waterholes substitute beaches, and the mantra seems to be “either three minutes driving distance, or three hours away”. The earthly colours of Alice Springs create a unique backdrop, and the work-life balance is exceptional, thanks to the close proximity of shops and the slower pace of life. But the real reason I’m here is for my orthoptic career. This journey began at Children’s Hospital Westmead, weaving through Sydney Eye Specialists before landing in Alice Springs Hospital. The decision to explore rural and interstate placements during my student days opened my eyes to the variety and experience of new territories. The transition from the bustling medical scene in Sydney to the smaller, close-knit community of Alice Springs was both challenging and rewarding. Having completed my orthoptic training at the University of Technology Sydney, I found myself in an environmental landscape vastly different from the city I had known. Alice Springs’ ophthalmology department is a small team with a long-term ophthalmologist (Dr Tim Henderson), rotating registrar, eye nurses, orthoptists, a booking officer, and reception staff. A locum ophthalmologist can come for any period from one week to one year, and throughout the year there will also be visiting medical officers with subspeciality skills for retinal, paediatric, corneal, uveitis and glaucoma conditions. The often-transient staffing in Alice Springs presents a unique challenge: the service area is vast, covering Central Australia, and the range of eye conditions I encounter are broad. Providing effective continuity of care requires a combination of resident and regular returning staff to ensure recurrent continuity. A typical week in Alice Springs involves community outreach visits once-a-week, pre-op workup and clinic on Tuesdays, surgery all day Wednesday and post-op

Moving to Alice Springs has paid off for Lina Li for her career and life outside of work. Image: Lina Li.

clinic and injection clinics Thursday, with an extra theatre afternoon and/or general clinic. On Fridays, post-ops and general patients are seen. On-call advice and consults are available 24/7. The ophthalmology department also provides a satellite service to Tennant Creek hospital every two months. As part of our regular work, to schedule outreach community visits or theatre days, we need to account for many moving parts. Some examples include cultural events and community visits which lead to last-minute cancellations, our outreach plane experiencing technical issues or the occasional stormy weather making flying conditions voided if possible. General hospital staffing can also affect the surgery days which may be added or cancelled at short notice. This flow on effect could mean clinics would be added on short notice. Orthoptics is a relatively new addition to the Alice Springs eye health ecosystem, but it has been a great asset to the ophthalmology department. We run orthoptic-only clinics every Wednesday; these can consist of vision checks for patching treatment, visual fields bookings to offload from diagnostic-heavy clinics and occasional cataract pre-assessment

clinic. The orthoptic skills and knowledge of the eye is also beneficial to help improve the knowledge of non-clinical staff or new staff members. What I enjoy most about practising in Alice Springs Hospital is the people. Every individual has a unique journey of how they landed in Alice Springs, adding to the richness of experiences. Exploring remote communities and witnessing the changes in the landscape, especially after rainfall when the scenery turns green, is truly spectacular. In the heart of the Australian outback, Alice Springs has proven to be more than just a desert – it’s a place of diverse beauty and remarkably cosmopolitan community spirit.

LINA LI is an Orthoptist at Sydney Eye Hospital and Norwest Eye clinic. She completed a Masters of Orthoptics at University of Technology. 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 February 2024

MANAGEMENT

WHEN A PATIENT COMPLAINS Image: Avant.

'RUDE STAFF IGNORED US FOR 20 MINUTES THEN TOLD MUM TO GO AWAY AND GET USED TO HER NEW GLASSES, IGNORING THE FACT THEY WERE GIVING HER HEADACHES. THEN CHARGED HER $150. NEVER VISIT THIS PRACTICE!' HOW TO HANDLE SUCH CASES.

GEORGIE HAYSOM “IT IS IMPORTANT THE ENTIRE PRACTICE TEAM PERCEIVES COMPLAINTS AND FEEDBACK AS VALUABLE OPPORTUNITIES FOR IMPROVEMENT.”

confrontation with an unhappy customer is probably the last thing you want, and usually comes at the worst possible time. However, as in the example above, many complaints involve elements of miscommunication, misunderstandings or customer service issues such as perceived rudeness, delays or billing processes. If you can manage these well at a practice level, you can often effectively resolve them and stop them escalating.

WHEN AND HOW TO RESPOND The following steps apply where a patient, carer or family member complains to you first. If they go to the regulator (Ahpra) or complain through a lawyer, you may not be able to contact them directly. Speak to your professional indemnity insurer and check whether you need legal advice before responding. If the comments were posted online, there are some additional issues to consider. See Avant’s guide to 'Responding to negative feedback online'. Ahpra and the Australian Commissioner on Safety and Quality in Healthcare have also produced a checklist for practitioners handling complaints which complements the steps listed below.

STRATEGIES TO ADDRESS COMPLAINTS 1. Have a clear and accessible feedback process If you encourage patients to share their experiences, they are more likely to raise concerns with you first and give you an opportunity to address them. Make sure someone senior in the practice team is responsible for responding. They should be experienced enough to address patient concerns sensitively and effectively. If the complaint is about a clinical matter, then it is important to make sure that a clinician is involved in responding to the complaint. Make sure all staff in the practice know the process and their role in it, including how to respond if they are the patient’s first point of contact. This ensures consistency in your complaint management process.

Practice staff should avoid being defensive and instead show empathy even if they don’t agree the complaint is warranted. Image: Fizkes/Shutterstock.

concerns raised. Where appropriate, you may also use this opportunity to ask for any additional information needed to investigate the complaint. 3. Acknowledge and seek to understand the patient’s concerns • For serious or complex complaints, you may need to set up a meeting. The patient may wish to bring a support person and/or you may need to arrange an independent interpreter. Allow plenty of time. • Try to speak directly with the patient if possible and appropriate, and encourage them to explain what happened in their own words. • Find out how they would like to resolve the issue. They may just want an apology. • Avoid being defensive. Try to show empathy for the patient’s experience even if you do not agree the complaint is warranted. • If a patient has experienced an unexpected or adverse outcome causing unintentional harm, follow an open disclosure process, and include an apology. You can apologise safely. See the Avant factsheet: 'Open disclosure: how to say sorry'. 4. Investigate complex complaints • Explain to the patient if the issue is not something you can resolve immediately and you need to investigate.

2. Respond as quickly as you can to direct complaints

• Keep them informed of the investigation’s progress and if there are any delays.

Never ignore a direct complaint. Some complaints may be straightforward and able to be resolved immediately. Where this is not possible it is important to acknowledge the complaint, ideally within a day of receiving it, and communicate to the patient your next steps while you consider the

5. Give as much information as you can

INSIGHT February 2024

• Patients who complain are often just looking for information – explain what happened and what it means. • Address and clarify any misunderstandings. • Explain any changes you have made to

avoid similar issues in future. • Check if the patient is satisfied their concerns have been addressed. • Explain what will happen next and make sure you follow up as needed. • Document any discussion you have with the patient. This does not form part of the clinical notes so should be documented in a separate location. 6. Make sure your processes do not make things worse Delay billing patients or pursuing payment until the complaint has been resolved. You may ultimately want to consider waiving or reducing fees as part of the resolution. Do not charge the patient for any meeting with them to discuss their complaint. 7. Look after yourself and your team It's never easy to be on the receiving end of a complaint and it can be stressful for all involved. While it is not really possible to welcome complaints, there are some important benefits for practices if they can encourage patients to provide feedback to them directly and respond to any dissatisfaction appropriately. It is important the entire practice team perceives complaints and feedback as valuable opportunities for improvement and that they are trained in the process of handling feedback and complaints. NOTE: The online version of this article contains links to additional resources and further reading.

ABOUT THE AUTHOR: GEORGIE HAYSOM BSc LLB (Hons) LLM (Bioethics) GAICD GradCert PsychBM, General Manager, Advocacy Education and Research at Avant.

SOAPBOX

AUSTRALIAN EYEWEAR TARIFF: HOW CAN WE ACCEPT THIS? we have an FTA. Unfortunately, most brands that manufacture in China (which is significant) consolidate the goods from the many suppliers in central warehouses located in Europe. The recent break-down in negotiations over an FTA with the EU means the tax still applies (it’s not where the goods are manufactured, it is where they are shipped from), and the government continues to collect its payments at the border.

Image: Safilo.

BY DAVID PEARSON The recent introduction of tariffs on spectacle frames has no effect on Australian manufacturing, highlights the weakness of the border force regulatory system and shows the damage that can be done to an industry by a single disgruntled entity. A quick recap: in mid-2022, an Australian eyewear company requested that a 5% tariff be imposed on the import of plastic spectacle frames. Further, this tax was then extended to cover metal spectacle frames in 2023. The motivation was that imposing a tax on spectacle imports would help Australian eyewear manufacturing. You would think that with extensive federal public service resources at hand, this type of request would garner detailed scrutiny to evaluate its effectiveness – that it couldn’t be possible to introduce a 5% tax on a majority of frame imports without some detailed explanation? Unfortunately not. A short submission from one company was all it took to introduce a tax costing the industry millions. It is correct that this tax only applies to imports from countries where Australia doesn’t have a free trade agreement (FTA) – China being one of the main manufacturers where

So who pays? A nuanced issue no doubt, and one that could be long-debated. But in reality, the price gets passed firstly on to retailers and then consumers. With all the talk of a government doing what it can to “lower the cost of living”, here is a concrete example of the opposite. However, a second, more regrettable outcome is that the tax gets paid by reduced investment in local businesses. Spectacle frame wholesaling is competitive, and while we all still see the Australian market as strong and stable with a good future, nothing dents confidence like the imposition of new/ unforeseen taxes with no basis. The large chains that purchase direct from China factories may have escaped this tax, while the locally owned distributors and subsidiaries are bearing the cost disproportionately along with independent retailers who purchase from local companies. These wholesalers are the companies that are the main employers of the spectacle supply industry – not Australian manufacturers. A 5% increase in the cost of goods, on top of inflationary pressures, is more than enough to reconsider the employment of the additional warehouse worker, the renewal of the office IT infrastructure, the advertising campaign spend or the practice point-of-sale creation. Thinking that this tax miraculously has no impact on investment decisions is a fantasy. And the outcome for Australian spectacle manufacturing? We didn’t see any presence at recent trade shows, no advertising in trade magazines or any recruitment for more reps to push the Australian

made frames. Even in the words of the company that prompted the imposition of the tax, the “tariff won’t make a monetary difference to my business” (Insight, June 2022). Please make no mistake, supporting Australian manufacturing is a great initiative. Safilo Australia has recently launched the FULL CIRCLE program and SMITH RX partnership with CR Labs, an Australian manufacturer which is a true success story of Australian made. Adam and his team at CR compete because they manufacture great quality product, bring innovation and support to optical practices, and do it locally with a highly skilled workforce at a competitive price. We are proud to be associated with CR Labs. In the end, the solution to this mess is for Australian Border Force, and the relevant federal minister (Clare O’Neil), to actually understand the impact of their decisions. A tax has been imposed that has no benefit to the Australian economy and no-one has asked “why?”. In our wonderful democracy, it’s fine for a company to try and make costs higher for everyone else, but it should be the role of the government who collects those taxes to at least check if it is a good idea. It is unacceptable that taxes can be imposed without any decent scrutiny, and even more unacceptable that the representations of our industry body have been ignored by those imposing the tax. In the overall federal budget, the revenue from this tax is an extremely small issue, it’s difficult to explain and affects an industry without much political power. However, the principal eats away at the credibility of government and the public service. Let’s not storm the capital, but as an industry we shouldn’t accept poor decisions.

Name: David Pearson Affiliations: Safilo, senior director APAC Location: Sydney

IT’S FINE FOR A COMPANY TO TRY AND MAKE COSTS HIGHER FOR EVERYONE ELSE, BUT IT SHOULD BE THE ROLE OF THE GOVERNMENT WHO COLLECTS THOSE TAXES TO AT LEAST CHECK IF IT IS A GOOD IDEA.

INSIGHT February 2024

CALENDAR EVENTS

To l i s t a n e v e n t i n o u r c a l e n d a r e m a i l : m y l e s . h u m e @ p r i m e c r e a t i v e . c o m . a u

ANZ CORNEA SOCIETY AND EYE BANK MEETING Melbourne, Australia 7 – 8 March ranzco.edu/events

WAVE 2024 Fremantle, Australia 16 – 17 March admin@optometrywa.org.au

APRIL 2024 AUSTRALIAN VISION CONVENTION (AVC) Gold Coast, Australia 6 – 7 April optometryqldnt.org.au CEO April Petrusma has announced the ODA Gala will be in Melbourne in March 2024. Image: ODA

FEBRUARY 2024 MIDO EYEWEAR SHOW Milan, Italy 3 – 5 February mido.com

ANZGS CONGRESS 23 Hobart, Australia 16 – 19 February anzgsconference.com

ASIAPACIFIC ACADEMY OF OPHTHALMOLOGY (APAO) CONGRESS Bali, Indonesia. 22 – 25 February 2024.apaophth.org

100% OPTICAL

Surgery simulation at GENEYE 2023. The event is returning to the Royal Victorian Eye and Ear Hospital in June 2024. Image: GENEYE.

SUPER SUNDAY 2024

SILMO SINGAPORE

Sydney, Australia 19 May (immediately after OSHOW24) vision@oaansw.com.au

Singapore 24 – 26 April silmosingapore.com/

JUNE 2024

MAY 2024 SQUINT CLUB MEETING 2024 Melbourne, Australia 3 – 4 May ranzco.edu/events

ARVO 2024 Washington, US 5 – 9 May arvo.org

AUSTRALIAN SOCIETY OF OPHTHALMOLOGISTS EXPO 2024 Sydney, Australia 1 – 2 June asoeye.org

GENEYE 2024 Melbourne, Australia 19 – 21 June geneye.org.au

JULY 2024

OSHOW24

AUSCRS 2024

Sydney, Australia 17 – 18 May o-show.com.au

Hamilton Island, Australia 27 – 27 July auscrs.org.au

London, UK 24 – 26 February 100percentoptical.com

MARCH 2024 OPTICAL DISPENSERS AUSTRALIA GALA Melbourne, Australia 1 March odamembers.com.au

SKI CONFERENCES FOR EYECARE PRACTITIONERS Furano, Japan 3 – 10 March skiconf.com

INSIGHT February 2024

OSHOW24 is returning to the Horden Pavillion in Sydney in May, purposely running on the same weekend as Optometry NSW/ACT’s Super Sunday event. Image: ODMA.

S P E C S AV E R S S T O R I E S : A M Y Y U HOW DID YOU ENTER THE OPTOMETRY PROFESSION?

CHANGING LIVES THROUGH BE T TER SIGHT AND HE ARING

When I was 7 years old, my parents discovered I was myopic. I was then put on orthokeratology lenses for 15 years and had regular three-month follow-ups at my local optometrist. The practice owner offered to host my Year 10 work experience and on the first day let me look through the slit lamp to view corneal staining with fluorescein. I still remember feeling fascinated at what I was seeing. In my final year at high school, I decided I wanted to work in the health industry to give back to the community, and with my exposure to the optical industry at such a young age, it was fitting that optometry was my passion.

WHAT ATTRACTED YOU TO SPECSAVERS?

SPECSAVERS STATS Name: Amy Yu Current position: Senior optometrist Location: Specsavers Wollongong Years within the business: 5

also newer research and treatments I wasn’t aware of during my studies. I plan on furthering my career growth with the Specsavers Early Career Optometrists (ECO) program next year with the support of my new store partners During COVID, I reached out as a volunteer to Glaucoma Australia, and with my current qualifications, I was fortunate to assist with patient education talks. Earlier this year, I did a live online webinar called ‘Understanding Glaucoma Tests’ where I discussed what is involved in the testing of glaucoma, how frequently these tests are conducted, and my own experience with clinically diagnosing and managing glaucoma. I also touched on the different options people with glaucoma have with their referral pathways and the associated costs. I am fortunate to be a member of the Optometry Australia Early Career Optometrists NSW/ACT (ECONA) Student Engagement subcommittee, and was recently appointed to be a co-chair for next year. Being an ECONA member has allowed me to connect with early and future career colleagues to improve the future of the profession.

This is a funny story: in 2017, I interviewed at Specsavers Hurstville for an optical assistant role to gain more industry experience. However, they weren’t hiring at the time and referred me to another Specsavers store 10 minutes away that was. I applied and got the job. I stayed and worked there as an optical assistant whilst studying, until the end of 2021, where I then interviewed back at Hurstville to be an optometrist. Specsavers is known for its unique marketing and I wanted to represent a well-known brand. What’s even better is that Specsavers has been recognised as a Great Place To Work, and I feel privileged to have worked for here for this long.

In 2023, I marked five years with Specsavers. To top the year off, I was selected as one of five finalists for my second year graduate project. It was humbling yet rewarding to see my efforts recognised.

SINCE THEN, WHAT GROWTH OPPORTUNITIES HAVE PRESENTED THEMSELVES?

WHAT EXCITES YOU MOST ABOUT TURNING UP FOR WORK EACH DAY?

In my second year as an optometrist at Specsavers Hurstville, I took on a mentorship role to support our two graduate optometrists and optometry students on university placement. I found this rewarding and it helped consolidate not only my clinical knowledge, but

Specsavers

WHAT ARE YOUR CAREER HIGHLIGHTS SINCE JOINING SPECSAVERS?

Knowing that I can make a positive impact on someone by addressing their visual concerns and meeting their visual needs is very rewarding, even if it’s just the simple things like updating their glasses prescription or monitoring their ocular health.

ALL SPECSAVERS STORES NOW WITH OCT

YOUR CAREER, NO LIMITS

Rare Optom Partnership Opportunity – Noosa, QLD Specsavers has a rare opportunity for an experienced Optometrist to join as a Joint Venture Partner in our profitable Noosa store. Are you looking to live in a beautiful and sunny region of Queensland, then this is for you? As a partner with Specsavers, you will have access to administrative support, including payroll, accounts payable and quarterly BAS along with Specsavers’ market-leading brand and a market-rate salary and superannuation in addition to your share of store profits.

LET’S TALK!

Optometrist opportunity – Specsavers Pukekohe, NZ Seeking a talented optometrist to join our extraordinary team at Specsavers Pukekohe. Located on the outskirts of Auckland, only 30 mins from CBD , yet away from the busy traffic. They offer cutting-edge technology, a friendly environment, and a commitment to professional growth. Embrace the relaxed pace of life and enjoy a perfect work-life balance. Don’t miss this incredible opportunity to be part of Specsavers Pukekohe.

In a few short years, Specsavers has achieved market leadership in Australia and New Zealand with more people choosing to have their eyes tested and buy their prescription eyewear from Specsavers than any other optometrist. To learn more about these roles, or to put your hand up for other roles as they emerge, please contact us today: Joint Venture Partnership opportunities enquiries: Carly Parkinson on 0478 201 057 or carly.parkinson@specsavers.com Australia Optometrist employment enquiries: Marie Stewart – Recruitment Consultant marie.stewart@specsavers.com or 0408 084 134 Locum employment enquiries: Matthew Cooney matthew.cooney@specsavers.com or 0447 276 483 New Zealand employment enquiries: Chris Rickard – Recruitment Consultant chris.rickard@specsavers.com or 0275 795 499 Graduate employment enquiries: apac.graduateteam@specsavers.com

Visit spectrum-anz.com

Optometrist opportunity – Specsavers Palmerston, NT The Specsavers Palmerston team is seeking a full-time experienced optometrist for a senior position with a focus on mentorship. The role offers a $150,000 base salary, a $40,000 sign-on bonus, relocation allowance, and super, along with 5 weeks of annual leave. This opportunity provides a chance to lead and mentor graduates in a 3-test room store with a mixed demographic. The store, located 20 minutes from Darwin, offers a vibrant community with access to natural wonders. Specsavers is committed to providing extensive support, development, and ongoing career growth, including pathway to partnership. Graduate Opportunities Are you moving into your final year of optometry study and starting to consider what company would be right for you as a graduate optomerist? Specsavers provides the support and mentorship to set you up for success, offering great graduate packages and extraordinary patient-focused environments. By joining Specsavers, you can be certain you will have everything at your disposal to cater to your diverse patient base. NSW/ACT Locum Work Available Specsavers across NSW & ACT are seeking locum support throughout December and ongoing into 2024. If you have gaps in your diary you need to fill look no further. Metro stores have both weekday and weekend dates available and will flexibly work with your availability. If you’re seeking block work our ACT stores, Armidale, Bathurst, Coffs Harbour, Port Macquarie can offer 1 week+ blocks with all travel and accommodation provided and great rates available. These vacancies won’t last long, please get in touch asap to book in now.

CAREER

People ON THE MOVE

Image: Vision 2020 Australia.

Image: ZEISS.

Insight's monthly bulletin to keep the Australian ophthalmic sector updated on new appointments and personnel changes, nationally and globally.

INDIGENOUS OPHTHALMOLOGIST JOINS VISION 2020 BOARD

Michelle Phung has joined the ZEISS MED team as Clinical Application Specialist, Lens Extraction. She will play a leading role in supporting clinical application and training across the lens extraction portfolio. Phung completed her Bachelor of Health Science and Master of Orthoptic at La Trobe University in 2017. During this time, she worked at Bupa Optical as an optical dispenser. Since 2018, she worked at Vision Eye Institute in Chatswood as an Orthoptic Assistant Team Leader responsible for assisting in cataract and refractive laser procedures and managing a fast-paced clinic.

ZEISS MED has introduced Arissra Kayunsumrutket as its Clinical Applications Specialist, Chronic Disease Management (CDM). Based on the Gold Coast, she will support the CDM business in Queensland from a clinical applications and partnership perspective. A graduate of Griffith University in Bachelor of Biomedical Science, Kayunsumrutket has 10 years’ ophthalmic experience. She has worked for Device Technologies as Product Specialist in Ophthalmic Diagnostic, responsible for account management of Queensland and Northern NSW. Prior, she worked at Queensland Eye Institute, Outlook Eye Specialists, Integrative Medical Clinics and The Vision Centre.

Dr Kris Rallah-Baker is one of two new appointments to the Vision 2020 Australia Board. He is Australia’s only Indigenous ophthalmologist, a proud Yuggera and Biri-Gubba man, and one of the founding members of the Australian Indigenous Doctors Association. The Vision 2020 Australia AGM was held in November, where five vacant board director positions were filled. Reappointed members included Mr Christopher Pyne, Ms Jane Schuller and Mr Dale Cleaver.

Image: CERA.

Image: Erika Siabatto.

EXPERIENCED FIGURE JOINS ZEISS CHRONIC DISEASE MANAGEMENT BUSINESS

Image: Vision 2020 Australia.

KEY APPOINTMENT FOR ZEISS LENS EXTRACTION PORTFOLIO

PEAK BOARD BOARD SHAKE UP; DEPARTING MEMBERS ACKNOWLEDGED

A NEW ERA DAWNS FOR LIONS EYE DONATION SERVICE

Mr Brandon Ah Tong was also appointed a new member of the Vision 2020 Australia Board. He has 20 years’ experience working in the eye health sector as an advocacy expert and is currently the Director of Policy & Advocacy with The Fred Hollows Foundation. “We would also like to give our thanks to outgoing directors whose terms have ended, Dr Jessica Gallagher, Jaki Adams and Shaun Tatipata. We appreciate their dedication to the organisation throughout their tenure and thank each of them for their commitment,” Vision 2020 Australia stated.

Dr Heather Machin is now leading the Lions Eye Donation Service (LEDS). She was appointed the new Head of LEDS, following Dr Graeme Pollock who retired in August 2023 after founding the eye bank in 1991. “It’s an exciting time around the world in eye banking with lots of opportunities, and I’m looking forward to helping bring the latest practices and technology to benefit Victorian patients and researchers. Dr Pollock has built a remarkable team here at LEDS. I’m honoured to continue his amazing work, support the excellent team here at LEDS and keep collaborating with CERA and the Victorian Eye and Ear Hospital,” she said.

OPTIQUE LINE LEVERAGES EXPERIENCED MARKETING SPECIALIST

Marking professional Erika Siabatto has brought her expertise to independent eyewear supplier Optique Line. Coming from the arts and entertainment industry, she has specialised in fashion art direction and, as a content creator, collaborated with renowned brands. “As a marketing professional, I craft and execute strategic campaigns to boost brand engagement and customer loyalty for Optique Line. I’m especially passionate about using my fashion expertise to champion sustainability and ethical practices within the industry while implementing top-tier retail strategies with beautiful and clean layouts to refresh the brand as well as supporting all the independent optometrists that stock our brands,” she said.

DO YOU HAVE CAREER NEWS TO SHARE? EMAIL EDITOR MYLES HUME AT MYLES.HUME@PRIMECREATIVE.COM.AU TO BE FEATURED. 66

INSIGHT February 2024

EFFICIENT INTEGRATED DIAGNOSTICS

Argos Biometer. Measures up better than the rest. 1–6

Connected surgical planning starts with the ARGOS® Biometer. Experience faster,†1-4 easier‡2 and better§1-2,5-6 optical biometry, even for dense cataracts. Combine with one touch planning and VERION™ image guidance for integrated workflow from the clinic to the operating suite.7,8 Ask Alcon for a demonstration today.

† Based on acquisition rates compared to IOLMaster* 700 (n=622; p<0.0001),1,4 IOLMaster* 500 (n=107-188; p-value not reported),2,3 LENSTAR* LS900 (n=107; p-value not reported).2 ‡Based on a higher success rate of acquiring the axial length (AL) measurement in eyes with dense cataract (96% of cases for ARGOS® compared with 77% for the IOLMaster* 500 and 79% with LENSTAR* LS900; p-value not reported).2 §ARGOS® Biometer has shown better acquisition rates in dense cataract compared to IOLMaster* 700 (n=622; p<0.0001),1 IOLMaster* 500 (n=107; p-value not reported)2 and LENSTAR* LS900 (n=107; p-value not reported).2 ARGOS® Biometer has shown better predictive accuracy in medium-long eyes

(n=23; p<0.001)5 and precise measurement (n=318; p-value not reported)6 than IOLMaster* 500. *Trademarks are the property of their respective owners. References: 1. Tamaoki A et al. Ophthal Res 2019;19:1–13. 2. Shammas HJ et al. J Cataract Refract Surg 2016;42:50– 61. 3. Hussaindeen JR et al. PLoS ONE 2018;13(12):e0209356. 4. ZEISS* IOLMaster* 700 510k Submission 2015. 5. Whang W et al. Sci Rep 2018;8(1):13732. 6. Shammas HJ. Accuracy of IOL power formulas with true axial length versus simulated axial length measurement in 318 eyes using an OCT biometer. 2019 ASCRS ASOA Annual Meeting. May 2019. 7. VERION™ Reference Unit User Manual 2019. 8. ARGOS® Biometer User Manual 2019.

Join OPSM, where our legacy of excellence spans 90 years. Become part of Australia’s leading optometry network, dedicated to providing patient centric eye care since 1932.

FEBRUARY 2024

YOUR JOURNEY TO SUCCESS BEGINS WITH OPSM

Accelerate your career aspirations with OPSM. Visit opsm.com.au/careers today.