Insight March 2021 by Prime Creative Media

INSIGHT MAR

2021

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AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

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It follows concerns that pay awards coverage would significantly drive down wages.

THE FIGHT FOR GLAUCOMA STENT TECHNOLOGY Why micro-bypass glaucoma surgery had to battle for recognition in Australia.

FAIR WORK DELIVERS OPTOMETRY RULING

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G L AUCOM A DRAINA GE D EV IC E

OVERHAULING THE MEDICARE SCHEDULE A look at the MBS Taskforce's final reports that are set to reshape the eyecare sector.

New stores. New opportunities. With growth comes opportunity and we’re now looking for the next generation of ambitious and dedicated optometrists to join us as partners. We’ve announced a number of new locations that form part of our ongoing plan to provide ever greater access to eye care services across both Australia and New Zealand. If business ownership is on your future career agenda, now is the time to position yourself for a role at Specsavers. To find out more about our new stores and partnership opportunities, contact Marie Stewart on 0408 084 134 or marie.stewart@specsavers.com or visit spectrum-anz.com.

INSIGHT MAR

2021

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

FAIR WORK REACHES DECISION ON LEGAL SAGA THAT THREATENED OPTOMETRY SALARIES

The Fair Work Commission has delivered an inconclusive decision regarding pay awards coverage for optometrists. However, Optometry Australia (OA) is encouraged by the ruling after initial fears it may drive down wages, particularly for graduates whose $80,000 salaries could have dropped to as low as $53,000 per year. For more than two years, OA has been working to protect the financial interests of optometrists after it discovered a note on the Fair Work Ombudsman (FWO) website stating the Health Professionals and Support Services (HPSS) Award was applicable to optometrists and staff such as optical dispensers and administration employees.

OA subsequently engaged the services of Industry Legal Group (ILG), initially flagging concerns over the risk of possible underpayment claims concerning front of house staff, with many employed under the General Retail Award. OA and ILG held meetings with the FWO in early 2019. Even though the FWO held firm in its position, it indicated practices would not be penalised over a staff member being employed under a different award (retail), as long as they passed the ‘better off overall test’ against what had suddenly been decided as the correct award (HPSS). Soon after, the FWO then announced the HPSS Award was

The Fair Work Commission effectively opted to maintain the status quo.

subject to a four-yearly review that may impact optometrists. Later, in December 2019, a provisional decision was published, but it did not expressly exclude optometrists from the HPSS Award. As a result, OA held concerns about how optometry inclusion under the HPSS Award could impact its members. The organisation stated this created

further uncertainty for optometrists who, it argued, have traditionally been award-free due to the nature and seniority of their role. With this in mind, OA said Fair Work’s provisional decision was not consistent with the aim of the award modernisation process. OA was particularly concerned about the financial ramifications for optometrists if they fell under the HPSS Award. A survey the organisation conducted in 2018 found the majority of Australian optometrists earned $130,000plus per year (excluding super), with the estimated average being $106,000 for employees and $110,000 for employers. continued page 8

AUSSIE DRY EYE DRUG TARGETS MAJOR MARKET GAP Two Australian ophthalmologists are repurposing a common cholesterollowering drug into a topical ocular therapy for dry eye and blepharitis, which was given to a patient as part of an initial trial who went 90 seconds without blinking. Dr Kenneth Ooi and Professor Stephanie Watson, from the University of Sydney’s Save Sight Institute, have completed a pilot study of their therapy called Atorvastatin, which they believe has the potential to treat both evaporative and aqueous deficient forms of the disease. Unlike other therapies on the market, the formulation has multiple mechanisms of action and, if successful, could fill a distinct gap

in a global market estimated to be worth up to $7.7 billion within the next five years. However, the research will need to overcome funding hurdles to reach the next phase of development. The tear film stabiliser has been repurposed from oral statins, which have well known cholesterollowering and immunomodulatory properties. Pfizer’s Lipitor is the gold standard statin and continues to generate roughly $2 billion per year in sales, despite its patent expiring eight years ago. Ooi and Watson’s use of statins as a topical ocular therapy for dry eye and blepharitis is novel. It is non-steroidal with no steroid-like related side effects. According

to Ooi, the Australian market is reflective of much of the western world, with treatment choices largely limited to LFA-1 inhibitor lifitegrast (Xiidra) and variants of cyclosporine (such as Restasis, Cequa and more recently Ikervis). There are also many over-the-counter therapies, some of which are wetting agents that don’t address the underlying mechanisms of dry eye. These have a place for minor dry eye but there remains an unmet need for cost-effective, side effect-free treatments for moderate to severe forms of the disease. “Atorvastatin is multi-modal in its mechanism of action compared to a number of competitors on the market or in the pipeline which continued page 8

ELECTIVE SURGERY IN THE POST-COVID ERA An elective surgery shutdown as part of the COVID-19 response wreaked havoc on an alreadystretched hospital system last year. So how is each state faring one year on? page 38

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IN THIS ISSUE MARCH 2021

EDITORIAL

FEATURES

LET'S END ‘ARBITRARY’ RULE The bureaucracy affecting ophthalmology services in Tamworth should be a cautionary tale for the government if it resists this important opportunity to change status quo.

VICTORIAN EYECARE New and exclusive data showing the impact of lockdowns on the eye health of Victorians.

STANDING OUT Eyes Right Optical has helped a practice find success in the premium market.

The NSW city faced an imminent shortage because an ophthalmologist wasn't allowed to stay due to his international medical graduate status requiring him to work in a District of Workforce Shortage (DWS). Because Tamworth technically doesn’t qualify – even though it ought to – it faced an ophthalmology care crisis until the health department’s eleventh-hour decision to extend his stay until July. It’s a glaring example of how the DWS system doesn’t work as it’s intended – to push specialists into areas of need. The problem is the government’s figures indicate Tamowrth's 2.5 ophthalmologists serve 83,443 people. But, the real number is 220,000 because many come from outside of its catchment, and aren’t counted in official figures. Thankfully the way DWS is calculated is being scrutinised by a Distribution Advisory Group (DAG) right now. Its communique in September noted specialties with more than three fulltime equivalents per 100,000 population aren't eligible for DWS classification, a threshold it labelled “arbitrary”.

GLAUCOMA STENTS Tracing the turbulent political journey of glaucoma stent surgery in Australia.

The DAG also noted because eye specialists are often co-located, it has a big impact on the size of the population considered in the calculation of specialist services.

MEDICARE UPHEAVAL A look at the proposals shaping the MBS Taskforce’s final report into ophthalmology.

EVERY ISSUE 07 UPFRONT

44 MANAGEMENT

09 NEWS THIS MONTH

45 CLASSIFIEDS

42 ORTHOPTICS AUSTRALIA

45 CALENDAR

43 DISPENSING

46 SOAPBOX

If too small, the DAG says too many services will be provided to patients outside of the catchment. This risks creating over-inflated figures where services are co-located and deflated everywhere else. If too large, risks like hiding localised problems can occur. Although Tamworth's problem isn’t resolved, at least there's acknowledgement of the issues with the system. Let’s hope the government listens so our regional specialists can get on with their important work. MYLES HUME Editor

INSIGHT March 2021 5

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UPFRONT Just as Insight went to print, the CENTRE FOR EYE RESEARCH AUSTRALIA launched a world-first survey for people with inherited retinal diseases (IRDs). Led by Associate Professor Heather Mack, it aims to help the sector understand information patients will need to navigate the rapidly evolving field. “Five years ago, someone diagnosed with an IRD would have been told that progressive, irreversible vision loss was inevitable,’’ she said. “Knowing how well people with IRDs understand the potential

WEIRD

of gene therapy, their expectations and the support and information they need is critical to helping them make informed decisions about participating in treatment or research.” IN OTHER NEWS, New regulations came into force last month requiring doctors to prescribe PBS drugs by their active ingredient. The new legislation prohibits prescribing software from automatically including brand names on prescriptions, with prescribers only allowed to include the brand name if they deem it clinically necessary. Handwritten scripts or drugs with four or more active ingredients will be exempt. The aim of the regulation is to improve patient understanding of the medications they take,

while increasing the use of generic and biosimilar drugs that will ultimately reduce of out-of-pocket costs for consumers. FINALLY, CooperVision released findings from a global myopia survey showing 82% of eyecare professionals worry their young patients will have significant eye health issues as they grow older, yet 54% of them believe parents don’t understand the future risks. The survey, which involved Australian participants, found once myopia was explained to parents, 87% were open to learning more about management solutions. The survey also revealed optometrists are comfortable with fitting children with contact lenses from age nine while for parents the average age is 12.

STAT

WACKY

Hudo, a Komodo dragon at Cincinnati Zoo & Botanical Garden in the US, has had his sight restored after undergoing bilateral cataract surgery. The reptiles are known to be highly visual creatures. “We noticed cloudiness in his left eye and less than two weeks later his right eye also became cloudy,” zookeeper Ryan Dumas said. “He stopped reacting to movement, and his behaviour changed dramatically.”

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WONDERFUL

Blind Sports NSW hosted a camp at the Sydney Academy of Sport in Narrabeen where NRL Game Development Officers ran programs for 30 athletes with low vision for the first time. Sound cues, like clicking of fingers, were used to aid the participants who learned to catch, pass, run with and kick a rugby league ball.

Published by:

Publisher Christine Clancy

A gaming equipment manufacturer has branched out to produce chewing gum to help gamers overcome fatigue. But the company, XPG, also claims the gum can be beneficial to eye health because it contains Lutein, an antioxidant it says can suppress inflammation and enhance sharpness of vision, among other benefits. n

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VICTORIAN EYECARE

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Due to extended lockdowns, Victoria represented more than half of all missed optometric Medicare services (approximately one million) from January to October last year. Full report page 23.

Art Director Blake Storey Graphic Design Jo De Bono

WHAT’S ON

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INSIGHT March 2021 7

NEWS

STATUS QUO DECISION POSITIVE FOR SECTOR continued from page 3

For graduates, a 2019 survey found over 55% were earning $80,000 or more, and more than 25% were earning more than $90,000. “Instead of acting as a safety net, the minimum rate of pay under the HPSS Award, if adopted, may significantly decrease the salaries currently being offered and paid which is particularly concerning for a profession where the highest pay rates for employee members are already not considered commensurate with the complexity and responsibility borne by practitioners,” OA warned. “For example, a graduate with a master’s degree entry would receive approximately $50,000 per annum under the HPSS Award. The minimum rates of pay under the HPSS Award are significantly less then members are currently receiving. As such, the HPSS Award is not required to provide a fair and relevant minimum safety net of terms and conditions relating to wages.” STATUS QUO MAINTAINED Recently, OA alerted members that a final hearing before the Full Bench of the Fair Work Commission concerning which health professional occupations should not be covered by the HPSS Award was held on 27 October 2020

and a decision issued on 24 November 2020. It effectively opted to maintain the status quo, meaning optometrists could continue to operate as they were. However, OA CEO Ms Lyn Brodie said the ultimate decision to “neither exclude these occupations [optometrists and dentists] from the coverage of the HPSS Award, nor include them on the List of Common Health Professionals in Schedule B of the Award” meant the position regarding award coverage for optometrists remained slightly unclear. “Whilst we would have preferred a more definitive outcome, we have also been preparing for such a decision and as the status quo has effectively been maintained we believe the news is overall positive for optometrists and the industry,” she said. “Given the earlier 2019 decision that the list of professionals in the HPSS Award is indicative, our legal advice has been that the prudent approach would be to at least benchmark optometrists against the HPSS Award to ensure they are no worse off. That is until there is a definite decision to the contrary such as the express exclusion of optometrists from the HPSS Award.

conditions or individual employment contracts. The most important aspect is that these contracts cannot leave an optometrist – or any practice staff – in a worse off position than if employed under award conditions.” "OUR LEGAL ADVICE HAS BEEN THAT THE PRUDENT APPROACH WOULD BE TO AT LEAST BENCHMARK OPTOMETRISTS AGAINST THE HPSS AWARD TO ENSURE THEY ARE NO WORSE OFF" LYN BRODIE, OPTOMETRY AUSTRALIA

Brodie said it was important to protect optometrists’ salaries. “Optometry Australia is run by optometrists for optometrists, and ensuring that working in the profession remains financially viable for our members is of course very important. We share similar concerns to other professional bodies such as the Australian Medical Association that inclusion in the HPSS Award may see wages driven down.” She added: “As with any organisation we don’t discuss operational finances but for clarity, very minimal funds were spent lodging the submission as the process was very straightforward with no court appearances necessary." If optometrists were still unsure about their employment obligations or rights, OA has urged members to contact its HR partner Industry Legal Group for free legal advice. Information on this service along with more information on the issue, templates, benchmarking assistance and award rates can be found on its website or optometrists can contact the OA office. n

“The Commission’s decision implies that individual employers can decide if optometrists are employed within award

NOVEL AUSSIE DRY EYE DRUG SEEKS FUNDING continued from page 3

stabilised to 15mm after one month of treatment,” he said.

have only one or predominantly one mechanism of action,” Ooi said.

“No local or systemic adverse effects were recorded and patients favourably rated acceptability and ease of use of topical statin therapy.”

In a recent pilot study of 10 patients with blepharitis and dry eye, which often co-exist, Ooi recorded positive results with reduced corneal fluorescein staining and conjunctival redness, improved tear break-up times (TBUT) and normalised Schirmer’s wetting. There was improved blepharitis, as well as dry eye symptom scores. “One patient in particular was able to keep her eyes open after treatment (without blinking) for 90 seconds. Her initial TBUT was four seconds and her Schirmer’s wetting, initially at 7mm,

INSIGHT March 2021

Ooi now has his sights set on obtaining further clinical data to optimise the dosing frequency. They are looking to offer the opportunity to the pharmaceutical industry and venture capitalists locally and overseas to fund the work. He hoped Atorvastatin may one day be used to treat evaporative dry eye, as well as the aqueous deficient form, including post-cataract and refractive surgery dry eye, post-intravitreal injection dry eye and Sjogren’s syndrome, as well

as allergic dry eye and ocular pain. The work stems from Ooi’s research into statins as a potential oral steroidsparing agent for uveitis at the Institute of Ophthalmology, University College London. Dr Kenneth Ooi, Save Sight Institute.

“Knowing that inflammation is associated with dry eye and that research indicates there may be an excess of free cholesterol in the lipid layer in meibomian gland dysfunction contributing to evaporative dry eye, statins came to me as being potentially ideally placed as repurposed novel tear film stabilisers," he said. They have secured patents for topical statins as a novel tear film stabiliser in Australia, Japan and Europe, and are filing in the US. There is the potential for novel spin-off patent generation as well. n

NEWS

STOPGAP SOLUTION FOR TAMWORTH OPHTHALMOLOGY SITUATION Tamworth and its surrounding region have narrowly avoided an ophthalmology care crisis after the health department granted a six-month extension for an ophthalmologist who was about to leave due to a “flawed policy” controlling workforce distribution. Dr Kayvan Arashvand, an ophthalmologist who completed his training in the UK and moved to Australia in 2014, has had his Medicare Provider Number (MPN) to practise in Tamworth extended until July 2021. Arashvand has been one of four eye doctors in Tamworth. However, the ophthalmologist he works under at North West Eyes, Dr David Moore, recently turned part time. The third works full time but is approaching retirement, and the fourth was a part time locum who recently returned to New Zealand. Arashvand’s original, temporary MPN was to expire in January. Because he’s an international medical graduate under health law, he is required to work in a District of Workforce Shortage (DWS) for at least 10 years, which excludes Tamworth – a point advocates say doesn’t match the reality. Because of this, he wouldn’t have been allowed to practise in Tamworth, which would have seen the city’s ophthalmology services fall from around 2.5 fulltime equivalent ophthalmologists to 1.5, to service 220,000 people. The city has also provided emergency after hours eyecare for 70 years, but this also faced uncertainty. Tamworth Regional councillor Ms Juanita Wilson told Insight the Department of Health recently extended Arashvand’s MPN after local MP Mr Barnaby Joyce discussed the matter with Federal Health Minister Mr Greg Hunt. She said RANZCO also intervened. “I am delighted and relieved for a couple of reasons. Firstly, that the region will retain an adequate level of ophthalmology services, despite it being a temporary extension. This has also allowed emergency services to remain locally rather than patients being transferred hours away to Newcastle or Sydney,” she said. “Secondly, it recognises the plight of both the specialist and this region. However, one hopes this will highlight to the Commonwealth Department of Health the inadequacy and inequity for regional Australia of the ‘postcode system’ in declaring a DWS.” At the heart of the issue is the

Dr David Moore (left) and Dr Kayvan Arashvand, North West Eyes in Tamworth.

government’s use of Medicare billing data and postcodes to assign MPNs and determine workforce distribution, which Wilson says disadvantages regional communities. For example, Arashvand could permanently practise in a metropolitan suburb near an eye hospital, but not in regional areas like Tamworth. This is because the government believes Tamworth isn’t a DWS because its ratio of ophthalmologists to population “is well above the national average”. In reality, Wilson said the Tamworth ophthalmologists treat a population more than 2.5 times the size of the official government figures – with 60% of patients coming from outside of the Tamworth postcode catchment. The government has established a Distribution Advisory Group to review whether the DWS system is appropriate. Wilson hoped the Tamworth situation could be rectified in the review, however it’s unclear if this would be completed before Arashvand’s temporary MPN expires in July. “A focus of the Commonwealth Department of Health should be how to attract and retain specialists in regional Australia,” she said. “It’s ridiculous in these times, for us to be expending time and energy trying to intercept a flawed health policy that removes specialists from where there they are needed most.” Moore said the region has advertised on and off for years to attract an ophthalmologist, but no one was prepared to stay permanently, except Arashvand. “They need to change the criteria for what’s an area of workforce shortage and allow country towns that service large areas outside the town to be deemed that, rather than just the postcode they service,” he said. “At the local level for us, we will try get a permanent exemption for Dr Arashvand to stay because we have been unable to attract anyone else.” n

IN BRIEF "IT’S RIDICULOUS IN THESE TIMES, FOR US TO BE EXPENDING TIME AND ENERGY TRYING TO INTERCEPT A FLAWED HEALTH POLICY" JUANITA WILSON, TAMWORTH REGIONAL COUNCIL

RETINAL RESEARCH

Retina Australia has awarded $160,000 in grants to some of the biggest names in Australian retinal research. The 2021 recipients are Dr Lauren Ayton from The University of Melbourne, Professor Alex Hewitt from The University of Tasmania, Dr Fred Chen from The University of Western Australia, Associate Professor Heather Mack from the Centre for Eye Research Australia and The University of Melbourne, and Dr Jennifer Thompson from Sir Charles Gairdner Hospital. Retina Australia funds world-leading research into treatments and cures for blindness caused by inherited retinal disease and cares for people and families through peer-to-peer services. It has invested more than $5.5 million in more than 40 research projects since 1983.

ARVO FELLOWSHIP

UNSW’s Professor Mark Willcox has been honoured with a Gold Fellowship from the Association for Research Vision and Ophthalmology (ARVO), an organisation he has been a member of since 1993. Willcox was honoured to be elected. “ARVO is our premier scientific society and its annual meeting is always a highlight in our calendars. The science at the meeting is always top notch – and it’s a great place to reconnect with friends and colleagues,” he said. “This year ARVO will be an online meeting, but I’m looking forward to it to learn new things and reconnect virtually.”

TRUMP PARDON

An ophthalmologist was among 140 people who were either pardoned or had their sentences commuted in the final hours of the Donald Trump presidency. Florida eye doctor Dr Salomon Melgen was offered clemency in January after he was jailed for defrauding Medicare out of at least $73 million by persuading elderly patients to undergo tests and treatment for diseases they didn’t have. He was convicted in April 2017 on 67 counts, with a judge sentencing Melgen, now 66, to 17 years in prison. Democratic senator Bob Menendez of New Jersey was credited with supporting the clemency, but he said he didn’t expect the decision. There’s also scant evidence of a relationship between Trump and Melgen.

INSIGHT March 2021 9

NEWS

DOCTOR WARNS CHANGES TO EYE INJECTION SCHEDULE WILL BE DISASTROUS FOR PUBLIC SYSTEM "THERE ARE NOT MANY PEOPLE OR PENSIONERS WHO CAN AFFORD MORE THAN $200 OUT-OF-POCKET EVERY FOUR OR SIX WEEKS" MARK CHEHADE, ROYAL ADELAIDE HOSPITAL

Dr Mark Chehade, from the Royal Adelaide Hospital, is concerned about an unmanagable rush of patients into the public hospital system.

The head of ophthalmic surgery at a major public hospital says the current Medicare fee for intravitreal injections only creates a slim profit and plans to slash it by two thirds would trigger a flood of patients into a public system that wouldn’t cope. Dr Mark Chehade, who commenced in his role as head of unit at the Royal Adelaide Hospital in January, also fears suitable patients for treat-and-extend regimens may not receive optimal care if non-ophthalmologists perform the procedure, potentially leading to unnecessary treatment burdens and ultimately costing the government more. The concerns follow the MBS Taskforce’s final report into ophthalmology items. Despite opposition from the sector, it proposes cutting the intravitreal injection MBS fee from $310 with a rebate of around $250, to $96 with a rebate of around $75 (a 69% reduction). It also raises the prospect of optometrists, nurse practitioners and GPs performing injections. Chehade said the current fee was “about right” once OCT scans – for which there is no item number – medicine acquisition, support staff, practice running costs and the surgeon’s time were accounted for. “The injection only represents the tip of

INSIGHT March 2021

what is a very involved process, and the MBS Taskforce is hellbent on slashing the fee and rebate,” he said. “It’s marginally profitable at best when you consider the entire event.” The MBS Taskforce did propose a new OCT item to be claimed up to six times a year for macular degeneration, which Chehade acknowledged would have some mitigating effect. In South Australia, Chehade said the ophthalmic public system was overwhelmed, despite only performing 5-10% of intravitreal injections. At the Royal Adelaide, the glaucoma clinic has made way for higher priority macular injections. This has meant patients waiting to be seen for non-urgent conditions like cataracts or glaucoma suspects are on a 1,500-person waiting list for outpatient appointments. About 1,100 of those have been waiting more than a year, with 350 more than three years. Chehade said this demonstrated the precarious position of the public system that, crucially, is being supported by private ophthalmologists seeing public injection patients without charging a gap (bulkbilling). This work could end under the proposed fee.

“I don’t charge a gap to around 30% of my injection patients because they can’t afford to pay a cent in private – that’s out of goodwill. If you look at just those patients who should – by right – be looked after in the public system but are being looked after privately, there would be another 1520% flooded into the public system and it would fail,” he said. “Then you’ve got people who were paying out-of-pocket costs who have been tipped over the edge because of the increased gap. They have gone from approximately $250 Medicare plus the $80 gap to the other way around; there are not many people or pensioners who can afford more than $200 out-of-pocket every four or six weeks, and yes there is a safety net but that doesn’t kick in until they have spent a lot of money already.” Without being able to bulkbill or see patients that can’t afford the new out-of-pocket costs, Chehade said ophthalmologists are worried about sending patients into public hospitals knowing they won’t get the required care. There's also concern about the impact of optometrists, GPs and nurse practitioners being involved in intravitreal injection care. Chehade said overseas models have shown nurse-driven injection services led to patients receiving a monthly dosing regimen, meaning patients suitable for treat-and-extend probably weren’t getting optimal care. “They go through this carrousel of frequent doses, because it’s only the specialist who understands the nature of the disease and can make the decision to extend,” he said. With treat-end-extend, Chedhade said patients could be getting four injections per year, instead of 13. “You’ve got to be careful when trying to reduce costs by taking the specialist out of it. The logic is wrong because if you’re calling on the government to provide the injection vials every four weeks – rather than four times a year for patients who are destined to be well controlled – you are not only subjecting them to a lot of treatment, inconvenience and clogging up clinics, but you’re also creating a considerable cost to the health system. I think the government aren't at all keen on seeing that happen.” n Turn to page to page 33 for a full breakdown of the MBS Taskforce’s final report into ophthalmology items.

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NEWS

MYOPIA-LOCKDOWN STUDY CONFIRMS FEARS "THE INCREASE IN DIOPTERS I WOULD NORMALLY SEE OVER THE COURSE OF A YEAR, I SAW IN SIX MONTHS"

A new phenomenon dubbed “quarantine myopia” is making waves in Australia in the wake of a Chinese study that found myopia prevalence was three times higher in six-year-olds during the COVID-19 pandemic. The cross-sectional study tested 123,535 children and found a substantial myopic shift (−0.3 diopters) for children aged six to eight years after home confinement due to coronavirus. The study and related editorial published in JAMA Ophthalmology noted the prevalence of myopia appeared to be approximately three times higher in 2020 than in other years for children aged six, two times higher for seven-year-olds, and 1.4 times higher for those aged 8. Such a substantial increase was not seen in older age groups (9-13 years), despite being offered more intense daily online learning courses. According to Optometry Australia (OA) chief clinical officer Mr Luke Arundel, the findings were important because children worldwide had done months of home schooling, including in Australia where schools were closed and sport cancelled. “Researchers have told us for many years now the importance of balancing screen time with green time for kids and that spending time outside in bright light

Susan Ang, Eyestore Bankstown and Kiama.

SUSAN ANG, SYDNEY OPTOMETRIST

is important to slow myopia development and progression,” Arundel said in an article on the OA website.

a result of the extended Stage 4 lockdowns in metropolitan Melbourne,” he said. Ms Susan Ang, owner of Eyestore with practices in Bankstown in Sydney, and Kiama, south of Wollongong, said she has noticed myopia progression accelerating amongst her predominantly Asian patient base. She said NSW had six weeks of school lockdown last year, and with parents working from home on devices up to 10 hours a day, kids followed suite. “I saw a child in February [2020] before the practice was closed during lockdown. We re-opened in May and the child came in for their three-month review. The increase in diopters I would normally see over the course of a year, I saw in six months,” she said.

“It will be interesting to see if Australian practitioners, particularly in Victoria – where an extended lockdown occurred with time outside limited to just one hour a day – will also see a similar increase in myopia.”

“For the patients under my care, those on atropine 0.05% fared the best in combination with orthokeratology, bifocal, or multifocal vision correction,” she said.

In an interview with Insight in December, Dr Philip Cheng, director of The Myopia Clinic in Melbourne, said he noticed a drastic rise in myopia during the final six months of 2020.

Ang said the “quarantine myopia” phenomenon was an emerging topic of discussion on Australian optometry forums, with practitioners raising concerns about the rate of change in dioptres among their myopia patients.

“I’m seeing more children diagnosed with myopia for the first time, young kids with high myopia who have progressed rapidly, and at-risk children with axial length increase. I’ve seen a discernible change, which I think is environmental, as

“It’s palpable, you can feel that increase,” she said. n

PUSH TO CHANGE GLAUCOMA SURGERY MEDICARE ITEM Nova Eye Medical is seeking a modification to the existing Medicare item for micro-bypass glaucoma surgery (MBGS) that only came into effect last year, stating the current wording has the unintended consequence of excluding microcatheter technology. The details were included in the Adelaide company’s publicly available application to the Medicare Services Advisory Committee (MSAC), which centres on its iTrack Surgical System, believed to be the only known microcatheter system in use in Australia. It is currently excluded from reimbursement via the Medicare Benefits Schedule (MBS) because item number 42504 – which was introduced in May 2020 – only mentions implantation of a micro-bypass surgery stent, also loosely known as minimally invasive glaucoma

INSIGHT March 2021

non-inferior to the use of micro stents in terms of clinical effectiveness and safety.”

surgery (MIGS). It is seeking modification to the existing item number wording to encompass the use of a microcatheter to decrease outflow resistance in the trabecular meshwork, Schlemm’s canal and distal outflow system. Assuming a population growth of 1.6% a year since 2016, the company estimated item number 42504 would be utilised up to 4,056 times in 2020/2021. “[Nova Eye] believes that the wording of the current item number has the unintended consequence of excluding currently used technology (microcatheters),” the MSAC application stated. “Incorporating the use of microcatheters in the wording of MBS item 42504 will not change the utilisation of the item number but will only offer an alternative choice of device used during the procedure. Use of a microcatheter is

The iTrack Surgical System.

MBGS has trod a turbulent path since arriving in Australia in 2014 when surgeons started performed the procedure under item 42758 (goniotomy). Its popularity soared, promoting the government to step in and effectively halt its use in many patients. The issue was partially addressed in 2018 with a new item number but its availability was limited to those simultaneously undergoing cataract surgery. Eventually, last year, the current item number 42504 was created, allowing standalone MBGS. Australia subsequently became the world’s first universal healthcare system to allow this. n Turn to page 26 to read about the political journey of MBGS in Australia.

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NEWS

MORE THAN 300 TO BE UPSKILLED AS PART OF OPTICAL DISPENSING WAGE SUBSIDY PROGRAM "THE RESULT HAS BEEN PHENOMENAL, AND WILL IMPACT OUR INDUSTRY PROFOUNDLY"

The Federal Government has confirmed more than 300 optical dispensing placements under a trainee wage subsidy program, as one training provider revealed it has employed four new teachers to cope with the surging demand. Optical dispensing was one of several industries to benefit from the government’s $1.2 billion Boosting Apprenticeship Commencements (BAC) initiative, which involves a wage subsidy of up to 50% for new or existing employees enrolled into appropriate courses. As of 14 January, a Department of Education, Skills and Employment spokesperson said more than 300 placements have been registered from employers with staff commencing optical dispensing training programs. However, Insight understands the actual number is likely to be much higher once more applications are finalised. Industry figures hope the scheme will encourage more employers to upskill their optical assistants and help address a shortage of qualified dispensers. With the BAC capped at 100,000 placements, the majority of registrations have come from the construction and building, retail and hospitality sectors. Following the scheme’s announcement

New ACOD teachers Kylie Prince, Lara Markham, Teresa Mackie and Elizabeth Sumner.

JAMES GIBBINS, ACOD

Instruments – the addition of more online materials, and most importantly the addition of four new teachers to the ACOD teaching team, bringing the total teaching team to 15.” ACOD’s new teachers include Ms Kylie Prince (Brisbane, Queensland), Ms Lara Markham (Shell Harbour, New South Wales), Ms Elizabeth Sumner (Geelong, Victoria) and Ms Teresa Mackie (Perth, Western Australia). “It has always been a policy of ACOD to induct new teachers gently, allowing them to grow and develop in a controlled fashion under the mentorship of the senior teachers,” Gibbins said.

in October’s Federal Budget, the Australasian College of Optical Dispensing (ACOD) – which is now in its fifth year of operation – has had hundreds of employees from around Australia enrol into its Certificate IV in Optical Dispensing (HLT47815), with many already commencing course work in preparation for their first workshops.

“However, in light of this huge enrolment, we hope to see these new teachers fast track their progress as much as possible. Fortunately, many of this year’s workshops will have up to 50 students at a time, with the one large group lecture in the mornings and smaller work groups in the afternoons, and the new teachers will be guided and overseen by the more experienced teachers.”

“The result has been phenomenal, and will impact our industry profoundly,” ACOD director and senior trainer Mr James Gibbins said. “In order to meet this sudden surge in demand for places, and to cope with the increase in both size and number of workshops, ACOD has responded immediately, including the purchase of new training equipment – like 24 focimeters through Tony Cosentino at BOC Ophthalmic

Previously, Gibbins has encouraged employers to enrol their staff promptly to ensure they are included in the program before it’s over-subscribed, and maximise the wage subsidy which is backdated to the date of registration. n

AUSSIES HAILED FOR CONTRIBUTIONS TO GLOBAL INITIATIVE Several Australians have been recognised for their contributions to global eye health during the past two decades as part of the International Agency for the Prevention of Blindness (IAPB)’s Vision 2020 agenda. The Vision Excellence Awards are the culmination of individual efforts towards the 'Vision 2020: The Right to Sight' initiative, launched in 1999 by the World Health Organization (WHO) and the IAPB to eliminate avoidable blindness by 2020. With the program over, the accolades acknowledge people who contributed significantly during the program’s 20-year journey. Adelaide-based Dr James Muecke and Professor Robert Casson were

INSIGHT March 2021

nominated for their work with social impact organisation Sight For All. Mr Brien Holden, the late founder-CEO of the Brien Holden Vision Institute and a Professor at the School of Optometry and Vision Science at UNSW, was hailed as the most influential optometrist of his generation, instrumental in ensuring Vision 2020 was more inclusive and grounded in evidence. Professor Hugh Taylor, who heads the Indigenous Eye Health Unit at the University of Melbourne, was recognised for multiple contributions, including his role helping to design the Vision 2020 program and attending its launch in Geneva and Beijing in 1999. The Fred Hollows Foundation also

Prof Hugh Taylor.

featured prominently. The organisation’s three recipients were Ms Anaseini Cama, the Pacific trachoma co-ordinator, Ms Virginia Sarah, global partnership executive, and Ms Jennifer Gersbeck, the foundation’s executive director of global advocacy, as well as the former CEO responsible for transforming Vision 2020 Australia into a highly respected body. Another local recipient was Ms Gillian Cochrane, a Fellow of the Australian College of Optometry, recognised for her public health work in Anglophone subSaharan Africa and commitment to Vision 2020. Dr Jill Keeffe, a technical advisor to the Lions Club International Foundation, also featured in the awards. n

NEWS

EYECARE PROFESSIONALS RECOGNISED IN AUSTRALIA DAY 2021 HONOURS LIST Nine people from the ophthalmic sector have featured in the Australia Day 2021 Honours List. Ophthalmologists Associate Professor Anne Brooks from East Melbourne, Dr John Crompton from North Adelaide, Dr Tom Playfair from Woollahra, Dr Richard Stawell from Hawthorn and Dr Kevin Vandeleur from Brisbane each became a member of the order (AM), along with former Orthoptics Australia president Mrs Marion Rivers from Gisborne South. Ophthalmologists Dr Henry Lew from Caulfield North, Dr John Willoughby from Gawler, and Mr Larry Kornhauser, a founding member of Keratoconus Australia and president since 2000, received a medal of the order of Australia (OAM). They were among 570 recipients in the General Division of the Order of Australia. Adelaide ophthalmologist Crompton had “no idea” who nominated

highlighting the plight of her late mother Dr Nancy Lewis: “She was an early pioneering ophthalmologist who achieved very much but was not recognised in this way."

him but was “surprised and humbled” when asked to accept the AM. He was recognised for his significant service to ophthalmology, and to the community of the Asia-Pacific region. “I’m most proud of teaching ophthalmology trainees at Royal Adelaide Hospital for 39 years and setting up neuro-ophthalmology training and in-country fellowships in South East Asia with Sight For All,” he said. Brooks is an Associate Professor at the University of Melbourne and is heavily involved at The Royal Victorian Eye and Ear Hospital as head of Special Eye Clinic 3, clinical lead of the Acute Ophthalmology Service, and an ophthalmologist to the Glaucoma Investigation and Research Unit and the Surgical Ophthalmology Service. She was happy to accept the honour but noted the under-representation of women,

A/Prof Anne Brooks.

Rivers, an orthoptist, said there had been many highlights in her career spanning more than 50 years. “Working as a paediatric orthoptist at Vision Australia where I could share all my knowledge with parents raising children and babies – perhaps facing a lifetime of vision impairment – and give them a way forward was some of the most rewarding work,” she said. “I've also loved the practical teaching of both orthoptic students and medical students over many years. I am proud of the reforms made at Orthoptics Australia while president to improve professional development and place the association on a sound financial and regulatory future.” n

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NEWS

TRACHOMA ELIMINATION DEADLINE GETS TWO-YEAR EXTENSION

PRESCRIPTION COULD LEAD POLICE TO FUGITIVE An Australian optometrist could hold the key to locating a fugitive wanted on two counts of conspiracy to murder, with Graham Potter. police offering a $100,000 reward for information leading to his capture. Graham Gene Potter was last seen in Tully, Queensland, in 2010 when he ordered and paid for a pair of glasses that he never collected. The Victorian Police Fugitive Task Force would like optometrists to search their records for clients with his script – or similar as it may have changed during the past 10 years – believing it could help lead them to the 63-yearold, born 17 October 1957. Potter, believed to be myopic, uses the aliases Jim Henderson, John Page and Peter Adams. His 2010 prescription was R -1.75 -0.75 x5, L -1.75 -0.50 x174. His pupillary distance was 64. His previous frames were Eschenbach model 820519 size 54-18 colour 30. Victorian police believe Potter will use any name and likely pay cash for a consultation and glasses. “Potter failed to appear on bail at Melbourne Magistrates Court on 1 February 2010 in relation to two charges of conspiracy to murder and has a prior conviction for murder,” police said. “[We are] appealing for assistance from optometrists to locate Graham Gene Potter and have offered a $100,000 reward for information leading to his capture. Optometrists are eligible for the reward.” When last sighted, Potter had dyed brown hair, a ginger beard and wore glasses, and was of medium to solid build and about 175 centimetres tall. Any information can be passed onto Crime stoppers phone 1800 333 000 or Detective Brendan Finn via email brendan.finn@police.vic.gov.au. n

Graham Potter's prescription in 2010.

INSIGHT March 2021

"THE PROBLEM IS THE INABILITY OF CHILDREN TO ACCESS SAFE AND FUNCTIONAL WASHING FACILITIES, AT HOME AND AT SCHOOL" HUGH TAYLOR, UNIVERSITY OF MELBOURNE

Australia has failed to meet its commitment to eliminate trachoma by 2020, setting a new deadline of 2022. The renewed date comes amid calls for greater access to adequate washing facilities in schools and homes in Australia’s remote Indigenous communities where families can sometimes wait up to six months for domestic repairs. Trachoma rates had fallen from 21% in 2008 to 4% in 2020 but plateaued in recent years, with the distribution of antibiotics and health promotion having been effective in lowering the rate. “But we need to address housing to get it across the line,” Professor Hugh Taylor, professor of Indigenous Eye Health at the University of Melbourne, told Insight. “Hygiene is fundamental. The problem is the inability of children to access safe and functional washing facilities, at home and at school.” Taylor said washing facilities in some schools in remote indigenous communities are locked, or damaged, making it impossible for children to wash their faces, and increasing the likelihood of infection or re-infection. At home, he said tenants were generally prohibited from performing repairs on a broken tap,

Australian trachoma rates fell from 21% in 2008 to 4% in 2020.

blocked drain or a leaky pipe. “They typically have to wait three to six months for a repairman. So families move in next door, which leads to overcrowding, and increases the risk of infection spreading,” he said. There are about 24 communities in Central Australia where more than 20% of children have the condition. According to Taylor, a housing maintenance officer in each community who could make prompt home repairs “would make a huge difference”. “COVID-19 has highlighted the importance of the power of the community-controlled sector, and we are advocating for a communitycontrolled approach to housing repairs and maintenance in Australia’s remote indigenous communities,” he said. n

GLAUCOMA SPECIALIST RECOGNISED AS FEMALE STEM LEADER Melbourne glaucoma researcher Dr Jennifer Fan Gaskin is one of 60 women selected for Science & Technology Australia’s Superstars of STEM program, which aims to challenge gender assumptions and increase female visibility in the relevant fields. Fan Gaskin, a Research Fellow at the Centre for Eye Research Australia (CERA) and glaucoma specialist at The Royal Victorian Eye and Ear Hospital, wants to use her newfound status to encourage women and girls to aspire to careers in science, technology, engineering and mathematics (STEM) and raise awareness about the importance of glaucoma research. Superstars of STEM was established in 2017 and aims to equip 150 women in STEM with advanced communication

Dr Jennifer Fan Gaskin, CERA.

skills and provide them with opportunities to use these skills – in the media, on the stage and in speaking with decision makers. “Together we can share our experiences to help young women overcome the obstacles that many of us experienced earlier in our careers,” Fan Gaskin said. n

NEWS

ENROLMENTS TO NEW WESTERN AUSTRALIA OPTOMETRY SCHOOL SURPASS EXPECTATIONS The University of Western Australia (UWA)’s new three-year postgraduate Doctor of Optometry program has enrolled 50 students, with 44 of those coming from the tertiary provider’s home state. Professor Garry Fitzpatrick, head of the university’s optometry division, told Insight the course had exceeded expectations as a new offering, receiving 188 applicants overall. With a possible intake of up to 60 students, the degree was open to people who have Bachelor of Biomedical Science or equivalent degree. In total, Fitzpatrick said 44 students were from WA, two from NSW, two Victorians, one Queenslander and a solitary international student already based in Perth. Approximately 75% are female, with five rural students and no Indigenous students. The new postgraduate degree, the first and only of its kind in WA and the seventh

in Australia, is part of a partnership between UWA, Lions Eye Institute (LEI), and optometry industry leaders. It has also divided the optometric community, with Specsavers and other corporate providers believing it will alleviate an escalating shortage of optometrists and reduce a reliance on the graduate supply from eastern states.

The new course began last month.

Optometry Australia (OA), however, asked the university to reconsider the course last year, stating it could fuel an oversupply of optometrists and potentially impact future employment prospects for many. Fitzpatrick said the degree officially commenced on 22 February. “It is designed specifically to tackle the increasing eye complications from chronic diseases and conditions suffered by millions of Australians,” he said.

“Previously Western Australians wishing to study optometry must relocate to the east coast of Australia at a considerable cost. Educating optometrists locally in WA will allow the university to develop leaders to serve our communities and reach those who live in rural and remote areas.” Fitzpatrick said there was an increasing demand for eyecare professionals across Australia due to the ageing population and the increasing workload of managing chronic diseases such as diabetes, macular degeneration, cataracts and glaucoma. UWA has applied to the Optometry Council of Australia and New Zealand for the Doctor of Optometry to be recognised as a qualification leading to registration as an optometrist in Australia or New Zealand. The course is currently not accredited. n

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NEWS

LOCAL STUDY FINDS KERATOCONUS ‘EXTREMELY COMMON’ IN DOWN SYNDROME A new study conducted in New Zealand has revealed keratoconus is prevalent in around a third of people with Down syndrome, suggesting that screening may be worthwhile for people with the genetic disorder. The cross-sectional study performed by optometrists and ophthalmologists within the University of Auckland’s Faculty of Medical and Health Sciences screened 110 athletes with Down syndrome who attended the 2017 New Zealand Special Olympics National Summer Games. It was the first study of its kind in Australasia.

IS A LOW CARB DIET AN ANTIDOTE TO TYPE 2 DIABETES? "THIS STUDY HAS GONE ONE STEP FURTHER IN SHOWING THE LOW CARB DIETARY APPROACH TO BE EFFECTIVE IN DRIVING TYPE 2 DIABETES INTO REMISSION" GRANT BRINKWORTH, CSIRO

“Building on existing research, this study underscores that a low carb diet can achieve greater weight loss and is more effective in reducing diabetes medication and improving blood glucose control,” he said.

The researchers used corneal topography to identify keratoconus and adopted two independent quantitative criteria. The first was keratoconus severity index ≥ 30%. The second, adapted from the literature, required at least four of eight topographic parameters to be abnormal.

“However, this study has gone one step further in showing the low carb dietary approach to be effective in driving type 2 diabetes into remission.”

According to the study, data from the worst eye were analysed. Diagnosis in each group was subsequently confirmed by three corneal fellowship trained ophthalmologists. Those with a definitive diagnosis were grouped into Keratoconus Confirmed Group 1 (KCC1) and Keratoconus Confirmed Group 2 (KCC2), respectively.

He added: “We know that lifestyle factors such as what we eat play a major part in determining our risk to type 2 diabetes. The good news is

INSIGHT March 2021

Lifestyle factors play a major part in determining type 2 diabetes risk.

these lifestyle choices are within our control to change.” Brinkworth said the study’s findings underlined the need for diet support tools for diabetics. “These results show low carb diets can be a really effective dietary approach for type 2 diabetes management, however, the challenge is to provide patients with easy-to-use support tools and convenient product solutions to help them adhere to it long-term to gain these greater health improvements,” he said. “In the future, having clearer a definition of type 2 diabetes remission and more rigorous studies examining the long-term safety and satisfaction of low carb diets will also help to confirm the strength of this therapeutic approach.” n

AUSSIE FIRM OVERCOMES BANDWIDTH ISSUES WITH SMART GLASSES

Using only topographic data, keratoconus was identified in 39.8% of athletes by quantitative topographic criteria one, and in 64.3% athletes by criteria two.

“We report keratoconus in 30.6% to 38.8% of athletes with Down syndrome; therefore, we believe keratoconus screening is indicated in Down syndrome for early management,” the researchers stated. n

Professor Grant Brinkworth, research scientist from Australia’s national science agency CSIRO, was part of the study that found after six months, patients who followed a low carb diet containing less than 26% of daily calories from carbohydrates, achieved greater rates of type 2 diabetes remission than those who followed other diets traditionally recommended for managing the disease. Brinkworth said the findings, published in the British Medical Journal (BMJ), showed those who better adhered to the low carb dietary approach had the greatest health improvements.

With keratoconus known to disproportionately affect people with Down syndrome, they wanted to investigate its prevalence, with the findings published in RANZCO’s official journal Clinical and Experimental Ophthalmology recently.

Keratoconus was then confirmed by qualitative sub specialist review in 30.6% (KCC1) and 38.8% (KCC2) athletes, respectively. The mean keratometry in groups KCC1 and KCC2 were 48.4 ± 3.2D and 48.2 ± 2.9D, respectively. Most were male and of European ethnicity.

An Australian researcher has contributed to a new study demonstrating that lower carbohydrate consumption can potentially put type 2 diabetes into remission.

Australian-operated company Harvest Technology Group has announced a new agreement to commence proof-ofconcept trials with the Belgian producer of industrial smart glasses. Video is transferred at as low as 32 kbps.

The ASX-listed company focuses on remote control, communication, automation and monitoring solutions. As part of the deal, Harvest Technology wants to integrate its Infinity Nodestream and Wearwolf technology into Iristick’s smart eyewear. The technology enables live secure point-to-point video and communications at ultra-low bandwidths and over poor quality or congested

networks. Video and audio can be transferred as low as 32 kilobits per second (kbps). Both companies completed prototype testing during December 2020 where the Wearwolf app was combined with the Iristick software development kit on a smartphone and worked with the cameras, microphone and screen on the Iristick smart glasses. Trial communications were successfully maintained between Perth, Australia, and Brussels, Belgium, at 128kbps. The final commercial product is expected to be launched in the first quarter of this year. n

RESEARCH

REPORT LINKS COVID-19 WITH PERMANENT VISION LOSS Ophthalmologists have documented the first reported case of permanent loss of visual acuity that may have been induced by SARS-CoV-2, the virus that causes COVID-19 disease. Researchers from the Metz-Thionville Regional Hospital Center, Lorraine University, Mercy Hospital, in the French city of Metz, say the virus has been found in tears, and known to cause conjunctivitis and asymptomatic nonneuropathic retinal lesions. But little was known about its ability to trigger serious ocular disease. “To our knowledge, this is the first reported case of inflammatory ocular neuropathy that was associated with uveitis, may have been induced by SARS-CoV-2, and resulted in permanent loss of visual acuity,” lead author Dr Jean Marc Perone wrote in the journal JAMA Ophthalmology. “In animals, other coronaviruses can cause conjunctivitis, anterior uveitis, retinitis, and disc neuritis. However, the

SARS-CoV-2's ability to induce serious ocular disease has remained largely unknown.

ability of SARS-CoV-2 to induce serious ocular disease has been unknown.” The case was diagnosed in a woman in her 50s hospitalised in intensive care in March 2020 for severe bilateral pneumonia before testing positive for the coronavirus. She developed blurred vision and redness in her right eye and temporary (eight-days) pain when mobilising the globe. Her best-corrected visual acuity was +2 logMAR (hand movement 6/600) in her right eye and 6/6 in her left. The right eye had a relative afferent pupil defect, central scotoma, and impaired colour and contrast vision.

THIS IS THE FIRST REPORTED CASE OF INFLAMMATORY OCULAR NEUROPATHY THAT WAS ASSOCIATED WITH UVEITIS [AND] MAY HAVE BEEN INDUCED BY SARS-COV-2" JEAN MARC PERONE, LEAD AUTHOR

The patient was treated with oral and topical corticosteroids for presumed non-infectious ocular inflammation. But 30 days after being admitted, fluorescein angiography revealed optic disc neuritis and inferior retinal vasculitis. Mild papillary edema was also observed. She was diagnosed with inflammationinduced ocular neuropathy associated with SARS-CoV-2–induced panuveitis. Perone said while central nervous system involvement (eg, meningo-encephalitis) had been reported in infected patients, it could not explain his findings because the cranial magnetic resonance imaging produced clear results. “This case suggests that COVID-19 manifestations may include isolated inflammatory optic neuritis that leads to permanent visual acuity loss. To limit the functional consequences of ocular neuropathy in patients infected by SARSCoV-2, it should be diagnosed and treated early," he said. n

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RESEARCH

ROCHE’S FARICIMAB MEETS PRIMARY ENDPOINT IN DME TRIAL

AIR POLLUTION MAY AFFECT AMD RISK Air pollution is linked to a heightened risk of agerelated macular degeneration (AMD), a major Fine particulate matter study published may affect AMD risk. online in the British Journal of Ophthalmology has revealed. Although it was an observational study – and as such, can’t establish cause – the researchers say the findings echo those found elsewhere in the world, and if confirmed, could pave the way for new treatment options.

"THESE POSITIVE RESULTS SHOW THAT FARICIMAB HAS THE POTENTIAL TO OFFER LASTING VISION IMPROVEMENTS FOR PEOPLE WITH DME" LEVI GARRAWAY, ROCHE

AMD is the leading cause of irreversible blindness among the over 50s in high-income countries, with the numbers of those affected projected to reach 300 million by 2040. Known risk factors include older age, smoking, and genetic make-up. But given that ambient air pollution is associated with heightened risks of heart and respiratory diseases, the researchers wanted to find out if it might also be associated with a heightened risk of AMD. “Overall, our findings suggest that ambient air pollution, especially fine [particulate matter] or those of combustion-related particles, may affect AMD risk,” they reported. “Our findings add to the growing evidence of the damaging effects of ambient air pollution, even in the setting of relative low exposure. If [they] are replicated, this would support the view that air pollution is an important modifiable risk factor for AMD."

INSIGHT March 2021

It's said to be the first time this level of durability has been achieved in a Phase 3 DME study.

factor-A (VEGF-A). The studies each had three treatment arms, with participants randomised to receive either faricimab or aflibercept at fixed eight-week intervals, or faricimab at personalised intervals of up to 16 weeks, following a loading phase.

According to Roche, more than half of participants in the faricimab personalised dosing arms had extended time between treatments of 16 weeks at year one – the first time this level of durability has been achieved in a Phase 3 DME study.

“These positive results show that faricimab has the potential to offer lasting vision improvements for people with diabetic macular edema, while also reducing the treatment burden associated with frequent eye injections,” Dr Levi Garraway, Roche’s chief medical officer and head of global product development, said.

The company claims faricimab is the first investigational bispecific antibody designed for the eye and targets two distinct pathways – via angiopoietin-2 (Ang-2) and vascular endothelial growth

“We look forward to discussions with global regulatory authorities, with the aim of bringing this potential new treatment option to people with this condition as soon as possible.” n

CALL TO REPLACE CONJUNCTIVITIS WITH 'SORE EYES' AS COVID SYMPTOM Sore eyes are the most significant vision-based indicator of COVID-19, according to new research published in the journal BMJ Open Ophthalmology.

The researchers drew on data from 115,954 UK Biobank study participants aged 40-69 with no eye problems at the start of this study in 2006.

The company’s Phase 3 Yosemite and Rhine studies met primary endpoints and showed faricimab given every eight weeks and at personalised dosing intervals of up to 16 weeks demonstrated non-inferior visual acuity gains compared to aflibercept (Eylea) given every eight weeks. Lessening the treatment burden on macular disease patients has become a key focus of pharmaceutical companies, with Novartis also focusing on extended treatment regimens with its drug Beovu for neovascular age-related macular degeneration (nAMD). Novartis recently announced positive findings from its the Phase 3 trial (Kestrel) assessing the efficacy and safety of Beovu in DME.

Ambient air pollution could plausibly be associated with AMD through oxidative stress or inflammation, they suggested.

Participants were asked to report any formal diagnosis of AMD by a doctor. Any structural changes in the thickness and/or numbers of light receptors in the retina – indicative of AMD – were assessed in 52,602 people for whom complete data were available in 2009 and 2012, using retinal imaging. n

Swiss drug giant Roche is poised to pursue regulatory clearance for its new faricimab antibody for diabetic macular edema (DME) after it produced a similar effect to Eylea in twin clinical trials, but with half the dosing regime in several patients.

Shahina Pardhan, Anglia Ruskin University.

Researchers at Anglia Ruskin University in Cambridge, England asked COVID-19 patients to complete a questionnaire about their symptoms, and how those compared to before testing positive. Of the 83 respondents, sore eyes was significantly more common when the participants had COVID-19, with 16% reporting the issue, according to

Science Daily. As few as 5% reported having had the condition beforehand. Lead author Professor Shahina Pardhan, director of the Vision and Eye Research Institute at the university, said: “While it is important that ocular symptoms are included in the list of possible COVID-19 symptoms, we argue that sore eyes should replace ‘conjunctivitis’ as it is important to differentiate from symptoms of other types of infections, such as bacterial infections, which manifest as mucous discharge or gritty eyes.” n

INTERNATIONAL

MAN REGAINS SIGHT AFTER WORLD-FIRST ARTIFICIAL CORNEA IMPLANTATION

The CorNet Kpro corneal implant.

It’s hoped the technology will transform global corneal therapy and provide, for the first time, a reliable and scalable synthetic substitute to the human cornea. “The surgical procedure was straightforward, and the result exceeded all of our expectations,” Bahar, the surgeon, said. “The moment we took off the bandages was an emotional and significant moment. Moments like these are the fulfillment of

“This is an extremely important milestone for CorNeat Vision, key in our journey to enable people around the world to fully enjoy their vision potential. I am grateful and honoured to work with an outstanding group of people whose hard work, diligence and creativity, made this moment possible." n

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“After years of hard work, seeing a colleague implant the CorNeat KPro with ease and witnessing a fellow human being regain his sight the following day was electrifying and emotionally moving, there were a lot of tears in the room,” he said.

According to the company, the in-vivo platform enables the bio-mechanical integration of the permanent implant with live tissue and doesn’t trigger an adverse immune response.

Dr Gilad Litvin, CorNeat Vision’s cofounder, chief medical officer and the inventor of the device, said unveiling the first implanted eye was a surreal moment.

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The implant is designed to replace deformed, scarred or opacified corneas and is expected to fully rehabilitate vision. CorNet’s platform is a 100% synthetic, nondegradable porous material, which mimics the micro-structure of the extracellular

When implanted, the material stimulates cellular proliferation, leading to progressive tissue integration.

The patient, legally blind man Mr Jamal Furani, suffered from edema and other diseases and, as a result, had a damaged cornea. The surgery lasted less than an hour and upon removal of bandages he could read text and recognise family members.

our calling as doctors. We are proud of being at the forefront of this exciting and meaningful project which will undoubtedly impact the lives of millions.”

The surgery using the CorNet Kpro – developed by Israeli startup CorNeat Vision – was performed at the Rabin Medical Center in Israel by Professor Irit Bahar in January.

matrix – the natural biological collagen mesh providing structural and biochemical support to surrounding cells.

A 78-year-old Israeli man has regained his sight after being implanted with what is reportedly the first artificial cornea that completely integrates with the eye wall with no reliance on donor tissue.

COMPANY

CLINICAL TRIAL RESULTS REINFORCE POTENTIAL NEW TREATMENT FOR DIABETIC MACULAR EDEMA Novartis has announced positive findings from its the Phase 3 trial assessing the efficacy and safety of Beovu (brolucizumab) to treat diabetic macular edema (DME). Kestrel is the second pivotal Phase 3 study of Beovu (3 mg and 6 mg) in DME. According to the company, the trial met its primary endpoint of non-inferiority in change in best corrected visual acuity (BCVA) from baseline of Beovu 6 mg to aflibercept (Eylea) 2 mg at year one. The trial also met its key secondary endpoint of non-inferiority in average change in BCVA of Beovu 6 mg to aflibercept 2 mg over week 40 through week 52. More than half of patients in the Beovu 6 mg arm were maintained on a threemonth dosing interval through year one, following the loading phase. Patients treated with Beovu 6 mg reportedly

experienced significant improvement in change of central subfield thickness (CST) from baseline over the period of week 40 through week 52. Meanwhile, in Australia, the Therapeutic Goods Administration (TGA) approved Beovu for neovascular age-related macular degeneration (nAMD) early in 2020, but it is not listed on the Pharmaceutical Benefits Scheme (PBS). In July, Novartis made its third submission to the Pharmaceutical Benefits Advisory Committee (PBAC) to request Beovu to be PBS-listed for the disease. The authority said that while Novartis’ claim of Beovu’s non-inferior effectiveness compared with aflibercept was reasonable, it did not accept the evidence supported less frequent dosing. “The PBAC considered [Beovu] is likely inferior to aflibercept in terms of comparative safety, based on the clinical

Novartis is trialling Beovu in DME.

trial evidence of a significant difference in serious adverse events between brolucizumab and aflibercept, and changes made to the approved Product Information to reflect an emerging safety signal of retinal vasculitis and/or retinal vascular occlusion.” Novartis disagreed with PBAC’s decision not to recommend it for listing. “Beovu has now been approved in more than 30 countries, including all major markets, and Novartis and Australian clinicians believe that Beovu represents an important treatment option for patients with wet AMD, with an overall favourable benefitrisk profile,” Novartis said in response. The company stated it would continue to work collaboratively with the PBAC, the Department of Health and the Federal Government to ensure Australians with wet AMD receive access to Beovu through the PBS at the earliest opportunity. n

BIG PLAYERS COMBINE FORCES TO COMBAT CHILDHOOD MYOPIA The parent companies of CooperVision and Essilor have announced a new joint venture to acquire a spectacle lens approved for myopia control in several countries. The partnership involving CooperCompanies and EssilorLuxottica – two giants of the ophthalmic sector – is expected to accelerate commercialisation of spectacle lenses produced by Californian firm SightGlass Vision. The joint venture, announced on 4 February, will take over SightGlass Vision from CooperCompanies, subject to regulatory approvals and other customary closing conditions. CooperCompanies previously held a minority stake in SightGlass Vision before fully acquiring it in January. The CooperCompanies-EssilorLuxottica deal will leverage their shared scientific and product development expertise, strengthening innovation opportunities and go-to-market capabilities. It builds on SightGlass Vision’s research, development, and clinical progress since its founding in 2016 to deliver science-based treatments to address the myopia epidemic.

INSIGHT March 2021

portfolio to treat the growing number of children impacted by myopia,” he said. SightGlass Vision Diffusion Optics Technology (DOT) lenses received CE Mark declaration in June 2020, allowing commercialisation across the European Union, UK, and other European Economic Area countries. The lenses are also approved for sale in Canada.

The lens has been shown to reduce myopia progression by 59% and 74%.

CooperVision president Mr Daniel McBride said the collaboration delivers on its promise to make myopia management accessible and the standard of care for treating childhood myopia. “With the SightGlass Vision technology from this collaboration, MiSight 1 day and orthokeratology contact lenses from CooperVision, and Stellest lenses from Essilor, eyecare practitioners can create a comprehensive optical intervention

A randomised, controlled study of the lenses in 2018 involved 256 children in the US and Canada aged six to 10, with myopia between -0.75D and -4.50D split into either two test lens groups or a control group. Both test groups demonstrated superiority for cycloplegic SER change from baseline, with a reduction in myopia progression of 59% and 74% at 12‑months. Both test arms also demonstrated superiority in terms of axial length change from baseline, with a reduction in axial length progression of 33% and 50% at 12 months. Dr Thomas Chalberg, founder and CEO of SightGlass Vision, said SightGlass and CooperVision have a shared commitment to advancing evidence-based myopia management technologies. n

OPTOMETRY

HOW OPTOMETRY IS BOUNCING BACK Specsavers data has quantified the impact of extended lockdowns on Victorian eye health for the first time. DR BEN ASHBY delves into the data, and explains why metropolitan Melbourne isn't out of the woods yet.

he optometric industry, like most others, was significantly affected by societal changes in response to COVID-19. At the start of 2020, Specsavers had strategies in place to deliver eyecare to 3.6 million patients; to detect and refer 51,000 cases of glaucoma; and to register 200,000 Australians living with diabetes to KeepSight, helping to protect their vision from diabetic retinopathy. By the end of March, the focus quickly changed to ensuring access to care and appropriate triaging of those with urgent and critical needs, while keeping staff members and customers safe. Insight’s August issue reported that in March and April there were 600,000 fewer Medicare-funded optometry services compared to the previous year. In the same two months, it is estimated 25,208 Specsavers patients who likely had eye conditions requiring specialist attention did not attend their appointments and 166,635 patients missed their routine eye test. OPTOMETRIC ATTENDANCE RATES Specsavers director of optometry Dr Ben Ashby says the resultant impact on eye health outcomes for patients became a topic of great focus for Specsavers. And as restrictions eased, the optical provider commenced prioritised recall of patients with existing conditions, which became a vital aspect of a data-driven strategy for recovery.

Little Collins St store partner Patrick Mac was among affected Victorian optometrists.

“Medicare data shows that from June onwards, optometry attendance rates have appeared to bounce back,” he says. “The resumption of routine optometric services as restrictions eased across the country is noticeable. When considering Medicare reported 600,000 less optometric services in March and April alone, it is obvious the industry has worked hard to recuperate patients and offer eyecare services, whilst adapting to delivery of these services in line with COVID-safe government protocols. We will continue to monitor the recovery of these patients to ensure we’re taking the appropriate measures to accommodate the demand for optometric services during this crucial time.” For the first time, Specsavers has been able to show the impact on Victoria’s second wave on eyecare services. The extended and significant lockdown period in Victoria skews January to October national data considerably. Medicare reports 564,074 less services in Victoria across this time compared to the same period in 2019, more than half of the national total of missed services (approximately one million), demonstrating the magnitude of impact on the eyecare system in Victoria. A comparison of Medicare item 10915 across the same timeframe shows there were 26,675 fewer services nationwide in 2020 (9,943 excluding Victoria), providing some insight into how many patients with diabetes have likely missed their annual dilation in 2020. “We recognised this trend within the Specsavers dataset as well and took steps to prioritise recall for patients with diabetes and existing eye conditions as restrictions eased. We are continuing to monitor this data to inform how we adjust our communication with patients to ensure we’re addressing at-risk patients appropriately,” Ashby says. DETECTION AND REFERRAL RATES National data shows that despite a significant reduction in routine attendance in April and May, the recovery has been relatively swift in terms of patients accessing eyecare once restrictions began to ease. Specsavers e-referral data shows a similar recovery for optometric disease detection and referral rates from May onwards.

Australia's 2020 optometric Medicare services compared with 2019, excluding Victoria, demonstrating a considerable rebound from June onwards.

“We monitored referrals for all eye conditions across 2020, concerned about the impact of the cessation of routine care due to COVID-19 restrictions,” Ashby explains. “One particular concern was around detection of glaucoma as we know this is closely tied to routine eye testing, often occurring as an incidental finding in asymptomatic patients. We knew if new detection rates dropped, our industry would face larger, ongoing ramifications.” According to Ashby, latest data shows this remains a risk for many patients in metropolitan Melbourne, where lifting restrictions have only recently enabled routine eyecare again. Here, Specsavers estimates more than 2,500 patients with undiagnosed glaucoma were unable to access routine care in lockdown. “With the recent return of patients for overdue reviews and routine care, a proportional increase in detections has been seen. In November and December alone, an additional 730 glaucoma referrals have been made across Specsavers’ metropolitan Melbourne practices compared to the same period in 2019. While these numbers are encouraging, they still only represent a third of the estimated patients missed, indicating a longer recovery ahead,” Ashby says. n INSIGHT March 2021 23

Eyes Right Optical's sibling owners Mark and Lisa Wymond.

OPTICAL

MAKING THE INDEPENDENT OPTOMETRIST Zacharia Naumann Optometry has made its frames range a defining feature of its practice. Practice manager BERNIE ZACHARIA explains how a 15-year partnership with Eyes Right Optical has helped the business flourish in the face of increasing competition.

ractice manager Ms Bernie Zacharia remembers simpler times when a listing in the optometry section of the Yellow Pages was enough to ensure a steady stream of customers for the year ahead.

Around that time, in 2003, her husband optometrist Mr Zac Zacharia and his business partner Ms Kathryn Naumann, also an optometrist, established Zacharia Naumann Optometry in the regional city of Wagga Wagga in southern New South Wales. The practice, which is part of the ProVision network, started out trying to be everything to everyone, but the arrival of the corporates forced independents like theirs to adapt and focus on untapped areas of the market. “Honestly, corporate optometry has been great for our business – without their consistent price focussed messaging we would still be trying to be all things to all people. We repositioned ourselves – shifting our focus to best visual solutions. Patients are happy and we have grown,” Bernie explains. “As an independent, one way to differentiate yourself is by offering something no one else can and we’re fortunate we can remain agile. For us, our frames range is a definitive part of our business and ultimately it led us to the premium end of the market. What you put on your shelf is how you communicate what sort of business you are. The real challenge of optometry is demonstrating the value of a premium lens, but you can showcase your commitment to quality through your frame display and investment in technology. Our range sets the scene for their premium journey.” Establishing a unique frames range with a reliable supplier can be a challenge for any independent, but Zacharia Naumann found a trusted distributor in Melbourne-based Eyes Right Optical. Founded in 1992 by Ms

INSIGHT March 2021

Gaye and Mr David Wymond, the family-owned business was taken over by their son and daughter Mr Mark Wymond, managing director, and Ms Lisa Wymond, national brands manager, in 2018. Eyes Right is a wholesaler of high quality, designed-focused and fashionable eyewear targeting the mid to high end of the eyewear market. The Wymonds also operate Modstyle, which supplies quality Australiandesigned eyewear for more price-conscious consumers after the latest look; and Sunglass Collective, a pure sunglass company launched last year with exclusive rights to the Bollé, Serengeti and Morel Azur collections in Australia and New Zealand. Zacharia Naumann stocks frames from all three Wymond businesses, with collections from Eyes Right – such as best sellers ProDesign, WOOW, Marius Morel, Koali and Face à Face. Together, with Sunglass Collective and Modstyle brands – featuring Avanti, Eclipse, Nifities and Inface, among others – the Wymond relationship is worth up to 40% of total revenue for the practice. Bernie says the partnership dates back 15 years when they saw the Face à Face collection at the Eyes Right stand at the ODMA Fair. The decision to stock the label helped to elevate their frames range and initiated their premium journey. “But what impressed me most as a buyer and practice manager was the after sales service and a real desire to help us out,” she says. “When the sales reps visit, they see what we’re selling and suggest other ranges based upon what’s worked. It has never been a cookie cutter approach, it’s been a customised relationship from the start and over the years we’ve grown together. I was excited to learn they had acquired Modstyle and more

recently Sunglass Collective. These acquisitions have helped us streamline our suppliers, which meant overall less downtime from sales rep visits.” Mark Wymond says a major part of the Eyes Right mantra is making the optometrist look good whether it be stocking the latest designs, next day delivery or immediate warranty replacements. Importantly, Eyes Right and the associated companies stock all collections at their warehouse in Scoresby. Up against the vertically-integrated supply chains of the corporates, Mark says there’s never been more pressure on independents to deliver on the fundamental aspects of running an optical business. “Spectacle sales account for 35% to 40% of the total revenue of the practice. Apart from awesome practice staff and shop fit out, spectacle frames are the most visibly different part of the practice that the end consumer sees. It is vital to get the product mix right to differentiate your practice in the market,” he explains. “It’s also fundamentally important for independent practices and suppliers to be able to provide excellence in customer service by providing a more personal touch, we also need to react quickly to changing fashion trends. When two businesses closely align in their values, like they do with Zacharia Naumann Optometry, it creates an excellent platform for success.” FUTURE BRIGHT FOR INDEPENDENTS Eyes Right Optical is the powerhouse of the three Wymond businesses. It is built on long term alliances with Design Eyewear Group in Denmark (ProDesign, Face à Face, WOOW), French eyewear manufacturer Morel (Koali, Oga, Lightec, Nomad and Marius Morel) and Kenmark Eyewear from the US (Vera Wang, Zac Posen, Kensie). The company has also embedded leading IT capabilities backed by award-winning products, sales teams and customer service. It always represents as an easy-to-deal-with business model focusing on excellent delivery rates and marketing capabilities. But, like many businesses, particularly in the frames segment, it had to contend with a tumultuous 2020. “We are very lucky to have the suppliers in Design Eyewear Group, Morel and Kenmark who do the creative and design work. They never took their foot off the pedal and didn’t reduce their ordering and manufacturing capacity, so we have plenty of new product coming through, there are new releases at the start of this year and more in the pipeline,” Mark says. “Those relationships were formed from 1992 to 2003 and are vital in times where we haven’t been able to go overseas. These strong relationships have meant that we’ve still been able to get things done. They know us and our capabilities and share our ease of doing business philosophy.” Overseas travel restrictions posed another challenge for Mark who helps design the Avanti and Eclipse collections with Modstyle sales representative Mr Peter Bienvenu. “We are hands on in the creating and design of these collections, when we are face-to-face with the supplier, we can change aspects quicker and explain design element clearer.” The Wymond companies battled through March, April and May in 2020, but as Australia re-opened from lockdowns, sales surged. Although Victoria was plunged into Stage 4 restrictions from August to October, they swiftly recouped lost sales and set a new fourth quarter record for Victoria. They also expanded their footprint at the end of 2020 with the acquisition of Morel New Zealand, which held licences for several Morel collections across the Tasman. Eyes Right now supplies all Morel product between Australia and New Zealand. “One of the big learnings from 2020 was the resilience of our team. That’s something I have admired. We asked a lot of them and they put that trust in me and the management team

Bernie Zacharia, practice manager at Zacharia Naumann Optometry in Wagga Wagga.

to get them through it, and today our bond has never been stronger.” he says. “To our amazement the industry as a whole recovered quickly, which allowed us to get everything back to normal much sooner than we forecasted. For me it shows how robust the industry is and gives me great confidence for the future.” In terms of future of independent optometry, Mark says he is “a glass half full kind of guy” and believes they are winning the battle against the corporates. COVID-19 has tipped market forces further in the independents’ favour. For example, he says it prompted consumers to adopt a ‘shop local’ mindset, while also avoiding major shopping centres where larger crowds increase the likelihood of viral transmission. With overseas travel cancelled along with major events, people have had more discretionary spend. “Optical frames fit in a nice category of a retail under $1,000 spend that can dramatically alter your look. I also think consumers have become savvier as to what optical quality actually is, and the independent optometrists can capitalise on this point while also providing an exceptional service.” There were other interesting quirks that emerged. For example, Mark explains independents noticed spectacle wearers wanting to restyle their look after becoming conscious of their appearance on video calls. Independents in coastal towns also experienced an uptick in new patients who spent their lockdowns at beach houses. With gyms closed, cycle sales soared, seeing a spike in cycle-specific Bollé eyewear sold through Sunglass Collective. “When you put it all together there has been a sizable shift in consumer behaviours which has been great for the optometrist on the local shopping strip,” he says. STRIVING FOR AUTHENTICITY For independents to succeed, Bernie Zacharia says practices should avoid playing their competitor’s game and focus on providing a service that is authentic and unique. Reliable and trusted suppliers play a key role in this. “We are constantly trying to differentiate ourselves. When considering a new direction, we always ask ourselves: ‘Is it unique? Do we believe in it?’. For example, about five years ago we introduced lens-first dispensing. Interestingly, our average frame price increased alongside the average lens sale as patients started to appreciate the value of premium lenses and recognise that a quality lens deserves a quality frame,” she says. “Do what feels right and interests you. In turn, you’ll be authentic and have confidence in what you stock and the way you want to practice. We are genuine and upfront in the way we operate and Eyes Right are exactly the same – that’s why we work so well together. After that, everything else falls into place.” n

ProDesign Denmak model 3633 9245.

INSIGHT March 2021 25

GLAUCOMA

FOR MBGS UNDER MEDICARE Advances in glaucoma stent technology far outstripped the Medicare schedule early on, creating a disconnect that had far-reaching consequences. As Australia marks World Glaucoma Week this 7-13 March, Insight traces the turbulent MBGS journey that’s now considered an ophthalmology success story.

growing list of trans-trabecular stents available for glaucoma patients are revolutionising the way the disease is being treated. These tiny devices provide the means by which aqueous can bypass areas of outflow limitation with less tissue manipulation and fewer severe complications than traditional trabeculectomy. Due to these perceived benefits, general ophthalmologists and glaucoma subspecialists are increasingly making use of micro-bypass glaucoma surgery (MBGS) techniques for stent implantation. However, these glaucoma stents, which also fall under the looser umbrella term minimally invasive glaucoma surgery (MIGS), have had a troubled run with the Medicare Benefits Schedule (MBS) since being introduced in Australia seven years ago.

INSIGHT March 2021

Australian Society of Ophthalmologists (ASO) president Associate Professor Ashish Agar has been instrumental in advocating for MBS inclusion of MBGS from the start. As he puts it: “Securing funding for MBGS under Medicare has been a long, tortuous journey. It has been one of the more challenging episodes in ophthalmology in recent history.” Generally, he says the introduction of new technology into the operating theatre for eye surgeons has been met with increasing surveillance and a heightened need to justify its use in terms of health economics – and MBGS is no exception. “From a health economics perspective, technology makes assessment easier, and puts a sharper, stronger focus on evidencebased medicine,” Agar explains. At Agar’s side has been Associate Professor Paul Healey who has also been involved in

ophthalmology’s advocacy efforts to recognise MBGS as a safe and effective treatment for glaucoma patients.

“We still need to perform trabeculectomy and tube shunt surgery, but it’s not the only option at our disposal now.”

A Sydney-based ophthalmic surgeon and academic, Healey is secretary of the Australian and New Zealand Glaucoma Society (ANZGS), and chair of the organisation’s New Devices and Procedures Panel. He also holds a degree in epidemiology and has been a key link in the chain to successfully gain MBS approval for MBGS.

According to Healey, MBGS’s popularity increased exponentially in the three years after its arrival in Australia. In 2013/14, MBS item 42758 (goniotomy) was claimed 138 times; in 2016/17 it was claimed 3,809 times, an increase of 2660%.

“My strong belief is that all effective health treatments should be funded by both the MBS and the public hospital system. I want to live in a country where your access to medical care is based on your clinical need, not your ability to pay.” 2014 – THE ARRIVAL OF MBGS MBGS arrived in Australia in 2014, heralding a new era in interventional glaucoma therapies. A MBGS inserted via a small goniotomy (iStent) was approved for use in Australia first, with other types (Hydrus and Cypass) following soon after. “Australia was the first country outside the US to have early access to MBGS technology,” Agar says. “This is because Australia is, in effect, a testing ground, a proving ground, for such technology because we have a well-regulated medical environment; if Australian ophthalmologists have confidence in a device or technique, that carries weight internationally.” A market share approach was used to estimate the financial implications of listing MBGS on the MBS in 2014. The expected size of the MBGS market was based on projections of data from MBS goniotomy item 42758 to estimate uptake of MBGS stent implantation when it was used in clinical practice. Between 2014 and 2017, surgeons used the item 42758 (goniotomy) when inserting the device, mostly in conjunction with cataract surgery, but occasionally as a stand-alone procedure. Agar says MBGS initially soared to popularity because it filled a gap in treatment, offering a middle-ground option. “Ophthalmologists had been using the same trabeculectomy operation for 50 years. For a quarter of a century, we were hanging out for something new,” he says.

“The ANZGS drafted a White Paper in 2017, looking at MBS item 42758’s use, and we concluded that it was appropriate for surgeons to continue to perform MBGS procedures under MBS item 42758,” Healey says. Professor Graham Lee, Professor of Ophthalmology at University of Queensland and a consultant at City Eye Centre in Brisbane, agrees that MBGS filled a niche for surgeons specialising in glaucoma. “Although MBS item 42758 was established for paediatric glaucoma, the wording of the descriptor did not specifically limit it to only paediatric glaucoma use, as it was for making a goniotomy, ie a hole in the trabecular meshwork. At the time, the Medicare descriptor wording was appropriate, but it wasn’t designed for implanting an MBGS device – it was for congenital-type glaucoma, and seldom used. When MBGS arrived in Australia, that item number use took off,” Lee says. While MBGS uptake offered great hope for glaucoma surgeons and patients in Australia, its meteoric rise in use alarmed the government. Subsequently, publicly funded access to some glaucoma stents was virtually eliminated overnight following the health department’s decision to place limitations on MBS item 42758. 2017 – MBS EXCLUSION To the dismay of ophthalmologists, in 2017 Medicare altered the item descriptor for item 42758 (goniotomy) to explicitly exclude any such prostheses and to exclude its use for anything other than primary congenital glaucoma. Thousands of patients about to receive the iStent platform (Glaukos) or Hydrus (Ivantis) stent for glaucoma – who could previously access subsidised treatment under an MBS item for goniotomy – lost access. “Overnight, the government pulled the rug out from under us and our patients, when all MBGS lost funding,” Agar says.

“The problem was, there was a gap between first-line treatment – eye drops, or laser therapy – and last-line treatment – trabeculectomy or tube shunt surgery. It is a significant operation, a big leap of faith for patient and surgeon. Surgery has higher morbidity, and longer recovery. It’s a huge psychological barrier.

But, he adds, the government was merely doing its job and reacting to the information at hand. The problem was that information didn’t paint the full picture.

The iStent inject W is Glaukos's latest Trabecular Micro-Bypass System.

Featuring a wide flange at its base, the iStent inject W optimises stent visualisation and placement, enhances procedural predictability and increased confidence for surgeons.

“The government saw a large increase in MBS item 42758 (goniotomy), from a few dozen cases to a few thousand cases,

INSIGHT March 2021 27

GLAUCOMA

which rang alarm bells so it pulled the plug on funding,” Agar says. That sudden change lit a fuse among Australia’s foremost glaucoma surgeons. The ASO led the advocacy effort and made a submission to the Medicare Services Advisory Committee (MSAC) with support from industry and organisations including the Australian and New Zealand Glaucoma Society (ANZGS), RANZCO and Glaucoma Australia. According to Healey: “MSAC threw the challenge back to clinicians to justify our use of MBS item 42758 for glaucoma stent procedures. They set the bar high and the subsequent internal review was detailed and time-consuming.”

private health funds wouldn’t cover it. It became the province of the rich for 18 months,” Agar says. Healey agrees this was one of the issues with the government’s decision to pull funding for MBGS procedures. “One of the unintended consequences of restricting MBGS on the MBS was it also halted private health fund rebates. If the MBS completely pulls out of funding an item number, not only do private health funds also stop paying on that item, they also all stop paying the very high ancillary and hospital costs associated with the procedure,” Healey says. “The decision to stop public funding for MBGS suddenly made the surgery unaffordable for almost all privately insured Australians as well.”

2018 – A REPRIEVE

2020 – STANDALONE APPROVED

After extensive lobbying, there was some respite in 2018 when the government announced the permanent listing of MBS item 42705 for MBGS in conjunction with cataract surgery, to take effect from 1 November.

Although it was a step in the right direction, ophthalmologists believed the 2018 permanent listing of MBS item 42705 for MBGS didn’t go far enough because it was only available to those simultaneously undergoing cataract surgery.

This also included the listing of a new MBS item for the removal and replacement of trans-trabecular drainage devices due to device related complications (item 42505).

There was a belief this would create two classes of glaucoma patients, because those not needing cataract surgery – or who had already had the operation – weren’t eligible.

“When the unique MBGS Hydrus (Ivantis) device was introduced to Australia in 2014, every case was audited and data analysed,” Agar recalls. “And as part of that initial process, surgeons who implanted Hydrus had to record each case on the Spectrum Registry. This built up a strong evidence-base and developed more confidence and certainty in its efficacy over three years.”

This prompted the ASO to lodge another MSAC submission in 2019 for standalone use of MBGS.

The ASO drew on this data as part of its 2017 submission to MSAC to show the technology is safe and effective.

When MSAC reviewed the data, he says they formed a view that the evidence was strong for a combined MBS item number for MBGS in conjunction with cataract surgery but funding a standalone item wasn’t justified.

“We worked through the MSAC system, and we got a good hearing without needing to make a political or public campaign. Our case was based on scientific, clinical evidence, and supported by ANZGS, RANZCO, Glaucoma Australia, and individual ophthalmologists,” Agar says. In hindsight, he notes the introduction of MBGS in Australia in 2014 was not closely guarded in a clinical sense. “The use of MBGS devices initially was not well-supported clinically. It was pushed out to general ophthalmologists and marketed as an optional extra for cataract surgery – and this muddied the water,” he says. “We paid the price for unregulated and unscientific use. And when funding was pulled, it became a social justice issue. Patients were effectively left ‘high and dry’. If you had money, you could still buy it, but

INSIGHT March 2021

Originally, MSAC assessed the application but advised the Minister of Health against it because, as Healey explains: “MSAC considered that patient population and eligibility criteria were poorly defined with uncertain comparative safety, clinical effectiveness and cost-effectiveness.”

“The ANZGS felt strongly that the safety profile of MBGS was much better than the alternative of trabeculectomy. The reported outcomes for standalone stents actually appeared better than combined stent with cataract surgery. We felt strongly there was a place for this technology,” he says. “We argued to MSAC that if standalone surgery reduces complications, even if it works only in a small percentage of patients, then it will be worthwhile. In a narrow group of patients, standalone MBGS surgery would be appropriate.” In 2019, the chair of MSAC convened a stakeholder meeting

PROF GRAHAM LEE

A/PROF ASHISH AGAR

A/PROF PAUL HEALEY

"THE MBS DOESN’T ALWAYS KEEP PACE WITH TECHNOLOGICAL DEVELOPMENTS"

"IT HAS BEEN ONE OF THE MORE CHALLENGING EPISODES IN OPHTHALMOLOGY"

"THE SAFETY PROFILE OF MBGS WAS MUCH BETTER THAN THE ALTERNATIVE"

about the submission, which Agar and Healey attended. “After much discussion we forged a path that we thought could lead to a successful re-submission,” Healey says. He anticipated this would be “ethically, politically and epidemiologically challenging but essential if we are to have publicly funded access to those who really need it”. Then, in the 2019-20 Mid-Year Economic and Fiscal Outlook, the Federal Government announced it would support an MSAC recommendation to list a new item for the insertion of micro-bypass glaucoma stent as a standalone procedure. New MBS item 42504 commenced on 1 May 2020 and is available to patients with open angle glaucoma for whom conservative treatment has failed or is contraindicated. Lee, the education chair of the ANZGS alongside Healey, was involved in the advocacy push. “Paul [Healey] and I wrote updates for RANZCO members as we wanted to avoid confusion before MBS item 42504 for standalone MBGS became active, with the aim of appropriate usage of the number,” Lee says. THE DEVICE LANDSCAPE Agar says the green-light for standalone MBGS has been encouraging, with some devices cementing their popularity while others are still finding their place. “The iStent platform (Glaukos) is the most widely used MBGS device; Hydrus (Ivantis) is the second most widely used. Both are TGA-approved and MBS-funded in Australia,” he says. “iTrack (Nova Eye Medical) is a different technology altogether. It is currently undergoing the approval process for funding under the MBS. It has to go through a new process, with limited use in Australia, and most of the clinical evidence is from the USA – iTrack is still finding its feet." Further to this, Insight reported in December that Nova Eye had lodged an application with MSAC to modify the existing item number 42504, stating the current wording has the unintended consequence of excluding its microcatheter technology (iTrack). At present, the descriptor only mentions implantation of a micro-bypass surgery stent system. Assuming population growth of 1.6% a year since 2016, the company estimates item number 42504 would be utilised up to 4,056 times in 2020/2021. Incorporating the use of microcatheters in the wording, it states, will not change utilisation of the item number but will only offer an alternative choice of device. With the rapid development of glaucoma implants, Lee believes technology is outpacing the Medicare process. “The MBS doesn’t always keep pace with technological developments. MBGS is a niche area, performed by a small group of surgeons, whereas the MBS covers a lot of ground, it’s wide-ranging. In an ideal world, MBS descriptors and item numbers would keep pace with changing technology,” Lee says. For Agar, the motivation to advocate for the MBS listing was never personal. “It was never about what I earned for the operation. Surgery is only a small fee; the biggest cost is the facility fee – accessing hospital infrastructure, nurses, an anaesthetist, and getting in an operating theatre. Without an MBS item code, hospitals can’t raise a charge, they can’t pay staff." When it approved the item number last year, MSAC compared MBGS alongside trabeculectomy and concluded that although MBGS was less effective, it was safer and may allow some patients to delay or avoid trabeculectomy. Other analysis shows MBGS generally costs less than trabeculectomy and is projected to save the MBS approximately $500,000 per annum by the fourth year of listing. This saving is driven by fewer initial and revision

Nova Eye Medical’s iTrack Surgical System is the only known microcatheter system in use in Australia.

trabeculectomy services, however the true financial impact will depend on the efficacy of MBGS in reducing trabeculectomies, which is uncertain. “MSAC will review the use of standalone MBGS after two years to see what effect it has on the number of trabeculectomies being done and make sure it is still cost-effective,” the committee stated. Throughout the advocacy process, Agar says he and his colleagues presented their case grounded on the importance of evidence-based medicine. “We continue to encourage surgeons to collect and collate data from MBGS procedures and add them to the Fight Glaucoma Blindness! Registry, which is a free service and not specific to any MBGS device,” Agar says. This will help ensure history doesn’t repeat and when MSAC reviews the use of MBGS in two years, the ASO will have ready-made data to present. 2021 – ACCESS With new devices in the pipeline for approval, Agar says he only wants devices included under the MBS if they work. “Some devices come and go. It’s like the iPhone effect – we don’t want updates just for the sake of it,” he says. “What we hope is that the patient should have access to the technology available. Access should not be dictated by their ability to pay.” Agar, who also practises at Prince of Wales public hospital, wants to see MBGS available in the public system and in private setting. Aside from the financial gap, he says MBS funding for MBGS is also invaluable in closing another gap; the tyranny of distance. “I travel to Broken Hill and Bourke and remote towns as part of the Prince of Wales outback eye service. Because of the geography and accessibility, I have to plan surgeries meticulously, or schedule a patient for an operation in Adelaide or Sydney,” he says. “Access to affordable MBGS has made a huge difference to these patients in particular; it’s safe and requires less follow-up. The accessibility gap is huge and MBGS is the only treatment that allows us to fill this gap.” Healey says government funding for glaucoma stent procedures is in everyone’s interest if the procedures and associated devices have a useful role. “In the history of glaucoma surgery, there’s been some interesting ideas that haven’t panned out. The government is interested in health-economic benefits and a reduction in health costs overall,” he says. “All the studies of MBGS show a reduction in medicine use. If MBGS is more cost-effective than using drops it may actually be cheaper in the long run.” n

INSIGHT March 2021 29

GLAUCOMA

FOR GLAUCOMA SUSPECTS The pathway for glaucoma suspects isn’t always clear cut with many maintaining this classification for prolonged periods. A major eyecare provider outlines its efforts to keep on top of this group, underpinned by a robust communications strategy.

hen Specsavers optometrists electronically refer patients for specialist glaucoma assessment, the referral contains a mandatory classification into one of three categories.

These comprise: ‘new assessment’ for patients who are newly diagnosed by the optometrist and have never been seen by an ophthalmologist; ‘glaucoma review’ for patients with existing confirmed glaucoma; and ‘suspect review’ for those who have seen an ophthalmologist before due to high risk factors, but haven’t been diagnosed with the condition. The optical company – which has more than 350 practices in Australia – implemented the classification system in 2018 to align with the RANZCO Referral Pathway for Glaucoma Management. It works by encouraging its optometrists to be clear with their rationale for referrals, specify urgency judiciously and promote clear patient communication relating to the referral. This data also provides valuable insight into clinical assessments that occur for patients before the point of diagnosis – which the company says is a critical period in terms of clinical decision making and optometric management plans. Glaucoma referral data collected since 2018 shows approximately 50% of patients are referred as a ‘new assessment’, 30% ‘glaucoma review’ and 20% ‘suspect review’.

In 2020, 8,355 referrals were made for ‘suspect review’ patients across Australia. This is a group of patients who have enough clinical risk factors (or progression of risk factors) to lead an optometrist

INSIGHT March 2021

to recommend an ophthalmologist assessment for glaucoma. Here, Specsavers outlines observations specific to ‘suspect review’ patients, including feedback from ophthalmology, optometric attendance and recall response rates. FALSE POSITIVES Since 2019, Specsavers has been working with e-referral platform Oculo and many ophthalmologists in Australia to obtain feedback on glaucoma referrals and identify the rate of false positives following specialist assessment. According to the company, the feedback can be linked to the referral classifications mentioned above and adds further context to referrals for ‘suspect review’ glaucoma patients. From a subset of 784 referrals reviewed from 2019-2020, ophthalmologists gave patients one of three diagnoses: ‘glaucoma’; ‘glaucoma suspect’ for patients in whom glaucoma was probable but progression had not been confirmed; or ‘no glaucoma’ which indicated the referral was false positive. Of the referrals classified by optometrists as ‘suspect review’, 87% were confirmed to have definite or probable glaucoma with the remaining 13% deemed false positive (Figure 1). This, according to Specsavers, is a strong indication of alignment between optometry and ophthalmology when it comes to the index of suspicion for glaucoma, but also highlights that a formal diagnosis is not the predestined outcome for all suspects. In fact, 42% of ‘suspect review’ referrals remained ‘glaucoma suspects’ after ophthalmological review. The company says collaborative care is often discussed in the context of diagnosed patients but this feedback data exemplifies the joint role of optometry and ophthalmology in monitoring suspects and that the lead up to a glaucoma diagnosis is not always clear cut, with every scheduled review playing an important role in determining and adjusting the management plan for the individual. OPTOMETRIC MONITORING OF GLAUCOMA SUSPECTS Analysis of retrospective data from 2018 until the end of 2020 shows 81% of patients referred with a ‘suspect review’ classification in 2020 had

visited an optometrist at least once in the two-year period leading up to their referral. Of these patients, nearly half (46%) had attended consecutive annual appointments in the preceding two years. According to Specsavers, this reveals that the vast majority of glaucoma suspects were being closely monitored by an optometrist prior to their point of referral, which aligns with the recommendations in the RANZCO Referral Pathway for Glaucoma Management.

Figure 1 – Ophthalmology feedback on

referred glaucoma suspects. Further to this, 43% of the glaucoma referrals classified ‘suspect review’ in 2020 were issued as part of continued collaborative care. This means they were repeat referrals for patients already referred as ‘suspect reviews’ in the preceding two years.

Additionally, 74% of referred ‘suspect review’ patients in 2020 were recommended to return for ongoing care in a timeframe between six to 12 months from their eye test date. The company says this figure indicates the degree of caution that optometrists exercise for a sightthreatening disease that has potential to progress at varying rates, with little to no symptoms. RECALL COMMUNICATIONS Clear recall communication is considered crucial to ensuring patients are informed of their need to return for assessment and the reasons for their recommended appointment. This is particularly important for patients where a diagnosis is not yet confirmed as they might not understand the potential risks of missing an optometrist visit. Specsavers states that other considerations such as timing and frequency of reminders, format, communication channel and language, are all reported to have an influence on patient engagement and return rates. The company’s recall communication system gives optometrists the opportunity to sign patients up to a specific glaucoma recall at their appointment. Patients receive a series of relevant glaucomarelated reminder notices, the first arriving in time for the optometrist’s recommended follow up date. This function is used for any patient who requires an ocular health follow up due to risk of or confirmed glaucoma. A combination of email, SMS and letters are used based on patient preference, available contact details and appropriateness. The personalised messaging clearly identifies the reason for the recall and, as the notices continue, whether the patient’s assessment is due or overdue. This personalised, condition-specific messaging continues to be a point of focus for Specsavers, which has found through ongoing testing that there is more effective engagement when the messaging is specific to a patient’s needs, as compared to standardised communications. On 30 March 2020, Specsavers began operating under an urgent and essential care model, following government guidelines brought about by the national spread of COVID-19. As part of this, all recall communications paused, including glaucoma recall. While practices were available to assist patients with glaucoma who proactively requested an assessment, routine reviews were not undertaken. This, of course, had ramifications for those being monitored for risk of glaucoma. In May, after receiving advice from health department guidelines and reopening in a modified COVID-safe practice environment, the company began a gradual re-establishment of the recall system. Modifications were required to prioritise patients with heightened risk of eye disease, including those who had been designated a glaucoma or diabetes recall by their optometrist.

Figure 2 – Of the patients who recieved glaucoma recalls, those in younger age brackets returned quicker, but older patients eventually returned in much higher numbers.

Figure 2 shows return attendance rates across 2020 for patients who received a glaucoma recall. There was a relatively quick recovery to preCOVID recall response rates for younger patients. Interestingly, the data shows those over the age of 65 responded at a slower pace initially but ended up returning in significantly higher numbers as 2020 progressed. A year-on-year response rate comparison against the same dataset in 2019 showed that while responses for those aged under 39 remained steady, increases in return rates for those between 40-64 and over 65 increased. Most notably, return attendance rates increased by 5% for those over the age of 65. While there could be many explanations for this change in behaviour, Specsavers believes this could be attributed to a combination of increased health awareness post-pandemic lockdowns, pent-up demand, and an increasing sense of trust and security as COVID-safe environments became normalised, particularly for this vulnerable population. Communication regarding COVID-safe optometry protocols have become a crucial part of patient communication for practices and something that can help to provide comfort to patients and enhance compliance. The recovery, and in some cases improved appointment attendance rates for glaucoma patients, has demonstrated the importance of timely reminders and a considered approach to recalling those at risk of progressive eye conditions. The trends revealed by this analysis are said to provide some visibility of the less linear aspects of glaucoma detection and management. As the data shows, many glaucoma suspects enter into collaborative care after a period of close monitoring by an optometrist. However, their outcome is not predetermined. A significant proportion remain as glaucoma suspects for prolonged periods of time and rely on a robust system of communication and collaborative care for timely intervention. Despite significant improvements in response rates in the past few years as evidenced by continued measurement of recall response rates, Specsavers believes there is still a way to go to ensuring all patients obtain the care they require. It says an example of a communications solution that offers inspiration for this challenge is the KeepSight reminder system in place for people living with diabetes, run by Diabetes Australia in partnership with Vision 2020 Australia, Centre for Eye Research Australia (CERA) and Oculo. It has been co-funded by the Australian Government, Specsavers, Bayer, Novartis and Mylan, and works as a secondary recall reminder system to Specsavers’ optometrist recall communications, giving third-party endorsement to patients, resulting in higher adherence rates to follow up appointments recommended by optometrists. The early trends concerning patient adherence to recommended appointments for those on the KeepSight database will be described in more detail in future issues of Insight. n

INSIGHT March 2021 31

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MBS TASKFORCE

THE OPHTHALMOLOGY SCHEDULE

IS IT WORTH IT? The MBS Taskforce has published its final report into ophthalmology items containing recommendations that have come under intense scrutiny from the sector. But it wasn’t all bad news. Insight examines what the future ophthalmology care model may look like under Medicare.

ith the MBS Taskforce’s final report into ophthalmology items now before the Federal Government, much of the spotlight has focused on dramatic changes to the way intravitreal injections could be billed and administered in future.

committees should conduct the detailed review. The 15 members of the Ophthalmology Clinical Committee, chaired by Queensland ophthalmologist Dr Bradley Horsburgh, reviewed 189 items and recommended some level of revision to 31.

But, among the 19 recommendations to modernise ophthalmological Medicare services, there are many other interesting pieces of information, data and proposals that ophthalmologists across all subspecialities ought to know.

With the taskforce ultimately deciding the recommendations put before Federal Health Minister Mr Greg Hunt, it broadly supported the ophthalmology committee’s recommendations. But the taskforce and committee didn’t agree on everything.

For example, a raft of new Medicare items appear to be on the horizon to align glaucoma management with modern best practice. A new OCT item that can be claimed up to six times a year for macular degeneration has also been floated. And to tackle eyecare shortages in rural and remote communities, ophthalmologists could soon be offered incentives.

EYE INJECTIONS Since the release of the draft report in 2019, recommendations 18 and 19 have received the most attention for the way in which they would reshape intravitreal injection services.

Unlike intravitreal injections, the taskforce resisted the temptation to change the cataract surgery item – whose fee has been reduced three times since Medicare was introduced in 1984. But questions were raised as to why its rebate/fee is higher on a time basis than other equivalent schedule items.

Recommendation 18 proposes reducing the intravitreal injection MBS fee from $310.15 to $96.55 (-69%), so that it aligns with “the more complex” peri/retrobulbar injections, item 18240. Recommendation 19 then raises the prospect of optometrists and nurse practitioners performing intravitreal injections.

It’s no surprise eye injections and cataract surgery have been under the microscope. Together, they account for 42% of total ophthalmology services and 67% of benefits paid.

RANZCO and the Australian Society of Ophthalmologists (ASO) voiced concerns over these recommendations at the draft phase, but the MBS Taskforce forged ahead with the plan in its final report.

In total, in FY2016/17, ophthalmology’s items accounted for approximately 1.45 million Medicare services in Australia at a cost of $346 million. And during the past five years, service volumes for these items have grown at 5.5% per year, and benefits have increased by 6% annually. This growth is largely explained by an increase in the number of services per capita.

Those opposed to dropping the patient rebate/fee believe the measure will double or triple out-of-pocket costs for private patients, or drive them from a well-run private system, into an already struggling public system. RANZCO has previously said the proposed new fee is below the actual cost of providing the service, which would make it difficult for practitioners who provide bulkbilled injections to continue offering the service.

Modernising the entire MBS – which has more than 5,700 items – is a major undertaking, so the taskforce decided that specialised clinical

In reaching this final recommendation, the taskforce noted that in comparing the “relatively simpler” intravitreal injection procedure to peri/

INSIGHT March 2021 33

MBS TASKFORCE

retrobulbar and other injections, the present rebates do not reflect the relative complexities of the procedures. The taskforce even kept this recommendation in the final report despite the Ophthalmology Clinical Committee chair Dr Horsburgh stating the committee wasn’t prepared to endorse it. Interestingly, the taskforce did consult with the ophthalmology committee as to whether the intravitreal injection fee could be justified, to which the committee responded: "[We] consider the current eye injection schedule fee to be justified. The schedule fee underpins service delivery, particularly for patients initially treated in the overburdened public system then transferred to private ophthalmologists, and those treated in ‘privatised’ clinics associated with public hospitals.” The MBS Review is said to be clinician-led, with no targets for savings attached. But ASO vice president Dr Peter Sumich believed the recommendations were the work of technical experts who were clearly investigating ways to make MBS cost savings, rather than deliver clinical services. He said cutting the intravitreal injection rebate didn’t translate into the real world. It failed to recognise the cost to the private sector in delivering the sight-saving treatments; particularly with an under-resourced public sector that was non-existent in many areas. “The important thing to note is that this is a report to the government, not by or from the government. Australia has the best clinical outcomes in the world because the current system works,” Sumich noted. OPTOMETRISTS AND EYE INJECTIONS The committee also set out its rationale for recommending appropriately trained optometrists and nurse practitioners be considered for administering intravitreal injections. The ASO has stated previously this would amount to “task substitution” and was simply a cost cutting mechanism that could threaten patient safety. If approved, the organisation says it could struggle to stand up in

court – much like the glaucoma scope-of-practice case in 2013. In its rationale, the taskforce said the recommendation was in response to evidence of clinical need, maldistribution of clinicians and constraints on overall supply. “The Department of Health Workforce Report (2018) found there were 990 accredited ophthalmology specialists with current medical registration in 2016. The large majority were clinicians and, of those, 83% were located in [major cities],” the taskforce report stated.

“THE [INTRAVITREAL INJECTION] FEE UNDERPINS SERVICE DELIVERY, PARTICULARLY FOR PATIENTS INITIALLY TREATED IN THE OVERBURDENED PUBLIC SYSTEM THEN TRANSFERRED TO PRIVATE OPHTHALMOLOGISTS" - OPHTHALMOLOGY CLINICAL COMMITTEE “[The report] also noted that the demand for ophthalmology services is estimated to grow at 2.8% per year to 2030, and that projections reveal an undersupply of ophthalmology specialists throughout this projection period. International eye health workforce rates indicate Australia has 36 surgical ophthalmologists per million people, ranking it in the bottom three for OECD countries with available data. Optometry rates are reasonably high, at 184 per million.” According to the taskforce, international evidence from published, peerreviewed clinical studies demonstrates that – with the correct training and protocols in place – nurse practitioner-administered intravitreal injections are as safe as ophthalmologist-delivered services. It said nurse administration of intravitreal injections was most established

NEW OCT ITEM ATTACHED TO EYE INJECTIONS In other eye injection-related issues, the committee noted that almost all intravitreal injection events include an OCT service and consultation, but the majority of these couldn’t be billed because the MBS only has an initial OCT item.

treatment frequency, and that this would be too difficult to monitor. Concerns were also raised over the number of in-hospital intravitreal eye injections, which should occur in fewer than 3% of patients, but currently occur in 18% – with this number is increasing.

As a result, the taskforce recommended the creation of a new OCT item number that can be claimed up to six times per year, per patient, for macular degeneration.

There was also a recommendation for creating two separate items for eye injections that define which eye was injected (left or right). Searchable per-eye Medicare data is non-existent, which is crucial to determine and monitor treatment frequency and identify low-value care.

received 24 or more injections in FY2016/17.

According to the report, more than 24 injections per year for both eyes can exceed the recommended frequency supported by drug information and randomised clinical trials, but 0.4% of patients (247)

Additionally, fewer than three injections per year most likely indicates low-value care. In FY2016/17, 31% of patients (21,222) received three or fewer injections. The committee noted there were several valid reasons for low

INSIGHT March 2021

There is no Medicare data that distinguishes between right and left eyes that have received injections.

The ophthalmology committee believes this is largely unnecessary and may be due to financial incentives, prompting it to recommend that item 42738 be reclassified as a Type C procedure, which requires clinicians to fill out a form to justify in-hospital use. “Various studies have compared injections given in an outpatient setting with those performed in an operating theatre and found no significant difference in endophthalmitis rates,” the report stated. “Performing these injections in a hospital or day surgery adds significant cost to the procedure with no apparent clinical benefit.”

in the UK National Health Service, where the care delivery model has been recognised and codified by the Royal College of Ophthalmologists. In the US, the state of Georgia passed legislation to enable optometrists to perform eye injections once they had completed a specialised 30-hour injectables training program, supervised by an approved ophthalmologist. “The MBS Taskforce notes in particular that intravitreal injections have been performed by specially trained nurses at the Auckland District Health Board since 2012. These clinics have been expanded over time to become standalone injection clinics run by Nurse Practitioners (NPs). The NPs assess patients, make decisions on the need for intravitreal injections and arrange for follow up. These clinics run autonomously with collaboration of Senior Medical Officers rather than ophthalmologists,” the taskforce report said. “Further, nurse-delivered intravitreal injection services have been studied (and results published in the medical literature) in Denmark and New Zealand, and reported in Spain, Australia, Scandinavia, Singapore, and elsewhere.” THE COST OF CATARACTS The ophthalmology committee recommended no change to cataract surgery item 42702, stating that both the volume and service growth were in line with expectations. Although the taskforce indicated it didn’t want to override this, it did ask the committee to explain why the MBS rebate/schedule fee for cataract surgery is higher on a time basis than other schedule items. Notably, the taskforce pointed out the average time to perform cataract surgery has decreased from approximately 60 minutes 20 years ago, to 30 minutes today; and the rebate per hour of $1,140 is 1.7 times greater, or $481 per hour greater, than the rebate per hour for the next comparable procedure (prostatectomy); and 2.3 times greater, or $639 per hour greater, than the average of comparable procedures. In response, the committee said it believed the cataract surgery schedule fee is justified, and had already been reduced three times in 1987, 1996 and 2009, and frozen since 2010. “There has been no material change in the time efficiency of cataract surgery since the late 1990s. The introduction of new technology, such as toric intraocular lenses, has also increased patient expectations. Responding to these expectations requires enhanced preoperative technical measurement and additional staff, equipment and infrastructure,” the committee stated. Interestingly, the report stated that occasionally educated patients request clear lens exchange surgery to be billed as a cataract surgery. Although this is rare and explicitly excluded in the item descriptor, the committee said it may explain the 0.2% of total services provided to patients below 40 years of age. As such, it recommended MBS Compliance investigate these cases, noting there are legitimate uses of 42702 under age 40, such as premature cataract due to other ocular or systemic conditions. High out-of-pocket costs for cataract surgery and a low number of bulkbilled services for the procedure (just 3.5% on average) were also raised in the report. It also noted that the bulkbilling rate only varies slightly across socioeconomic groups, ranging from 2% in the least disadvantaged group to 5.9% in the most disadvantaged group in FY2015/16. The committee agreed this low bulkbilling rate may be driven by additional costs of cataract surgery that are not covered by the MBS. These costs are usually covered by private health insurance. (For example, the cost of intraocular lenses and theatre fees, which are typically $1,800–$2,200, must be paid by an uninsured patient, irrespective of what fee is charged by the ophthalmologist). Additionally, the committee recognised that several jurisdictions include

Ophthalmology Medicare items costed the government $346 million in FY2016/17.

visual acuity in cataract surgery referral guidelines, including in Victoria, New Zealand and Sweden. But it believed Snellen visual acuity was a “rationing mechanism” that doesn’t adequately represent visual function and important criteria such as contrast sensitivity and glare. It considered the UK’s National Institute for Health and Care Excellence guidelines to be more reflective of modern practice which could be adopted more widely in Australia. These guidelines do not include Snellen visual acuity and emphasise the effects of cataract on the patient’s ability to perform day-to-day activities. MODERNISING THE GLAUCOMA SCHEDULE Advances in glaucoma care has far outstripped the MBS over the decades and, as a result, many procedures that reflect current best practice don’t have an item number. In its final report, the taskforce backed the recommendation for several new items covering at least nine procedures, such as repair of cyclodialysis cleft, glaucoma drainage device removal or insertion of intraluminal stent or tying off of lumen, and OCT diagnosis/monitoring of glaucoma, optic disc photographs. The committee recognised these procedures require ongoing assessment of clinical efficacy and nominated Associate Professor Paul Healey and Professor Stephanie Watson to work with the health department and RANZCO, with the latter agreeing to sponsor Medical Services Advisory Committee (MSAC) applications for these items and provide supporting evidence. OTHER RECOMMENDATIONS Focusing on eye injections and cataracts, it was noted that out-of-pocket costs were high for these procedures, and the public system needed greater capacity and efficiency to allow uninsured patients to seek timely access to cataract surgery within public hospitals. To address this, it was recommended the government allocate more funding to ophthalmology staff specialists in the public system, with these positions only available to ophthalmologists who participate in the training and supervision of registrars. The higher prevalence of eye disease in rural Australians compared to their urban counterparts – particularly among the Aboriginal and Torres Strait Islander population – also prompted a new recommendation to entice more ophthalmologists to these areas. Current outreach funds focus on assisting patients in accessing available health services, rather than incentivising clinicians to provide services, so the taskforce recommended a mechanism to cover the additional costs of rural and remote ophthalmology service provision. n

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MBS TASKFORCE

THE OPTOMETRIC SCHEDULE With optometrists performing three-quarters of all eye exams in Australia, the optometric Medicare schedule has a major bearing on the quality of eye health in this country. Insight dives into the MBS Taskforce's edorsed report that could reshape primary eyecare for decades to come.

desire to reduce red tape for optometrists and a raft of measures affecting computerised perimetry – where concerns have been raised over potential misuse as a screening tool – are among the key Medicare reforms likely to impact optometrists. In its endorsed report to the Federal Government published late last year, the MBS Taskforce backed 11 of 14 recommendations by the Optometry Clinical Committee, with the most notable exclusion being its decision not to support more frequent eye exams for middle-aged Australians. During the course of its work, the committee – chaired by Adjunct Associate Professor Phil Anderton from UNSW – reviewed 32 MBS items. These items related to consultations, contact lenses, domiciliary services, removal of embedded foreign body and telehealth. In the financial year 2017-18 these items accounted for approximately 9.4 million services at a cost of $438 million. In the period 2012/13 to 2017/18, compounded annual growth for optometric service volumes remained at 4.6% and total cost of benefits at 3.6%. The population increased at a lower 1.6% annually, but the ageing population is likely to be behind costs increasing at a higher rate than rate of population growth. In keeping with the purpose of the review, the taskforce and committee signalled their intent to streamline and simplify the optometric schedule. This included joining the similar ametropic (contact lens) items and amalgamating the change of visual function and new symptoms items and removing a ‘same practice’ restriction. With the rise of online contact lens retailers, the Federal Government has 36

INSIGHT March 2021

also been asked to sign off on rewording the explanatory notes for all 10 contact lens prescription and fitting items, removing the requirement for the optometrist to deliver the lens. COMPUTERISED PERIMETRY An intriguing point to emerge from both the optometry and ophthalmology taskforce reports was the apparent excess use of computerised perimetry among Australian optometrists. Computerised perimetry has reportedly become the standard of care in optometric and ophthalmic practice to monitor glaucoma-related visual field defects. These tests, however, aren’t intended for screening purposes via the MBS. The optometry committee, along with the ophthalmology committee, was concerned about variation in service provision across the ophthalmic and optometric items, particularly the variation in services per capita by age group. Figures show service growth for item 10940 in optometry are double the rate of comparable ophthalmology items (8% and 4% per year, respectively). In its investigation, the committee found computerised perimetry services performed by ophthalmologists appear to be in line with expectations, with the rate of servicing increasing exponentially with age. This is in a similar way to glaucoma prevalence rates. However, service rates by age and growth for optometric item 10940 haven’t aligned with expectations. It also didn’t increase exponentially with age; instead, dropping off for patients aged 80 years and above, and higher than expected for those aged 50 and below.

The committee felt this may indicate that computerised perimetry is being used as a screening tool. This concern was also the basis for the taskforce ultimately rejecting one of the committee’s original proposals to create a new item for a brief consultation (not more than 15 minutes) to be co-claimed with computerised perimetry (items 10940 and 10941).

the taskforce’s final review into ophthalmology items recommended consideration of appropriately trained nurse practitioners, optometrists and GPs to perform the procedure. While this is opposed by ophthalmic bodies, OA stated it had been advocating for pilot initiatives for optometrists to support ophthalmologists with intravitreal injections, as a mechanism for better patient access.

It was proposed the item would only be claimed when monitoring suspected or diagnosed glaucoma, with elements of a short consultation – such as intraocular pressure measurement or slit lamp examination – often necessary at the same visits as a visual field examination.

“We were most pleased to see this recommendation as we believe that optometry working with ophthalmology can help support better access to treatment via intravitreal injection which can be critical to saving people’s sight,” Cappuccio said.

The taskforce rescinded this recommendation because of concern for misuse of computerised perimetry as a screening tool without a clear rationale. To avoid unnecessary screening, it then endorsed a separate proposal to reword the explanatory notes for these items to emphasise the need for practitioners to document their rationale for performing a computerised perimetry test.

“We will continue to seek RANZCO’s support to work collaboratively on models of care that utilise appropriately trained optometrists in the provision of this treatment.”

The optometry committee was asked to explain why perimetry usage was higher than expected among optometrists. It attributed the rise, among other things, to greater patient awareness of the asymptomatic nature of eye diseases and the importance of early detection. It stated optometrists are primary eyecare practitioners who use visual fields as part of a diagnostic test regime on indication as per the schedule. They conduct more than 75% of all eye exams in Australia and need to differentiate the normal and healthy against conditions and diseases of the eye and visual pathway. There’s also an increasing number of therapeutic optometrists skilled at detecting, monitoring and treating various eye diseases. More than 62% of all optometrists are therapeutically qualified, and each year 350 optometrists qualify while 150 older non-therapeutic optometrists retire. The current trend indicates 85% will be therapeutic qualified and managing more complex cases by 2029.

CONTACT LENSES The emergence of online retailers has led to a seismic shift in the way consumers purchase optical products, including contact lenses. To align with this market trend and simplify the schedule, the endorsed report recommended rewording the explanatory notes for all 10 contact lens prescription and fitting items. Specifically, removing the requirement to deliver the lens (10921 to 10930). This would allow for situations where patients purchase their contact lenses from a different point-of-sale. However, the clinical service of contact lens fitting, patient education and trialling of the lenses remains unchanged. To further reduce red tape, the report also recommended combining the similar and low usage ametropic schedule fee items (10921, 10922, 10923 and 10925) into one item. The committee considered this would continue to cover all contact lens fittings situations and simplify claiming processes. DOMICILIARY VISITS

In another recommendation, however, the taskforce did recognise an additional, third visual field test in a 12-month period may be required in some circumstances to establish a reliable baseline estimate for future glaucoma progression or determine progression over a shorter period.

With fewer than 21,000 services provided under items 10931 and 10933 with a spend of only $176,000, the report proposed introducing a single flag fall for domiciliary visits and replace both items with a single item covering all domiciliary visits.

As a result, the endorsed report supported the formation of a cross professional departmental working group, including ophthalmologists, to develop a rationale and cost effective implementation model for this, with eligibility restricted to glaucoma patients at high risk of progression.

It also recommended removing co-claiming restrictions by; allowing the billing of a short consultation (10916 and 10918) at domiciliary visits; and allowing billing of computerised perimetry (10940 and 10941) with an attendance.

Another notable inclusion affecting computerised perimetry is the amendment of items 10940 and 10941 to allow the service to be performed by a suitably qualified person “on behalf of” the billing optometrist. The committee recommended a cross professional working group be convened to develop appropriate training guidelines, but the taskforce went further and also requested a credentialing process that defines who is suitably qualified. EYE EXAMS FOR MIDDLE-AGED AUSTRALIANS While the optometric community was largely positive about the outcomes of the report, there was disappointment over the taskforce’s refusal to support increasing the frequency for comprehensive eye exams from three to two years for people aged between 50 and 64. The taskforce found “there was no clear justification” for this, despite the optometry committee laying out a detailed rationale, while accepting there would be “costs involved”. Optometry Australia (OA) general manager of policy Ms Skye Cappuccio said: “We did provide a comprehensive review of the evidence and we felt that it made a strong case for this change but this evidence does not seem to have been recognised by the taskforce.” PERFORMING INTRAVITREAL INJECTIONS Although intravitreal injections weren’t mentioned in the optometry review,

The optometry committee stated there were many scenarios where a short domiciliary consultation is appropriate – such as the removal of ingrown eyelashes, dry eye management and dilated fundus examinations. But current restrictions for visits to nursing homes disadvantaged this atrisk population, given the availability of modern portable visual field analysers. “The change would support improved access for those at home or in residential aged care facilities, promoting the principle of appropriate and timely assessment, and improving outcomes for people where timely assessment can be crucial in early intervention,” the committee stated. TELEHEALTH ENDORSED According to OA, the taskforce endorsed all recommendations from the ophthalmology committee, including the establishment of two new telehealth items. This included an item for a patient-only consult on referral from optometry only; and one for providing management advice via report to optometrist and patient. OA CEO Ms Lyn Brodie added: “Optometry Australia has been advocating for the latter as an important support for optometrists and ophthalmologists to work collaboratively to ensure patients can have ready access to the care they need.” n INSIGHT March 2021 37

ELECTIVE SURGERY

ELECTIVE POST-COVID An elective surgery shutdown as part of the COVID-19 response wreaked havoc on an already-stretched hospital system last year. Insight checks in on how each state is faring one year on.

his month marks one year since the Federal Government took the unprecedented step to suspend non-urgent elective surgeries in public and private health systems across Australia due to the COVID-19 pandemic. The National Cabinet’s directive affecting all states and territories was designed to free up bed space to manage COVID-19 hospitalisations, preserve personal protective equipment (PPE) for the most urgent use and to protect patients from infection. Twelve months on, Insight reviews the ophthalmic surgery landscape and the lingering impact of the shutdown. Leading figures also discuss the merit of elective surgery ‘blitzes’ announced in certain states, and the role of the private sector in helping whittle down public waiting lists.

INSIGHT March 2021

QUEENSLAND

with cancers and tumours often face adverse implications from elective surgery, but cataract patients, by comparison, have some of the best access to intraocular implants, are often able to have “walk-in, walk-out” day surgery, and achieve consistently good visual outcomes. Queensland's DR BILL GLASSON believes treating public ophthalmology patients in the private system to improve efficiency and outcomes is the way of the future.

After the initial shutdown, Queensland Health started re-introducing non-urgent procedures across its hospitals from late-April and May, with private hospitals able to return to 100% of normal activity, subject to availability of PPE. With modelling indicating Queensland could have more than 7,000 people waiting longer than clinically recommended by 1 July 2020, the state government swiftly announced $250 million in new spending for hospitals to provide non-urgent procedures outside of regular hours. Six months later, the Queensland Government claimed the ‘blitz’ had been a “resounding success in managing waiting lists”, according to the latest health data. Dr Bill Glasson, former president of the Australian Medical Association (AMA) and the Australian Society of Ophthalmologists (ASO), said Queensland hospitals were “in a pretty good position”. “There is no difference in waiting lists between pre and post COVID,” he said. “Waiting lists are never-ending, and it’s hard to measure ‘hidden’ waiting lists – those waiting to be seen to then go on to an elective surgery waiting list – but most hospitals keep to targets.” The median waiting times for ophthalmology patients from July to September 2019 was 0 days for Category 1, 129 days for Category 2, and 333 days for Category 3. Compared with the 2020 figures over the same period, Category 2 patients are now waiting 100 days longer on average, and Category 3 38 days longer.

“There is always going to be a waiting time for ophthalmic elective surgery. Public patients will be diverted to private hospitals more in the future, but we don’t want to undermine the value of private health insurance and the benefit of choice for patients paying to be treated in the private system. How we do this is important,” Glasson said. “State Governments want to ‘bundle’ elective surgery services, such as the costs associated with theatre, anaesthetist and so on – but we need to be very careful that they don’t screw down the price so its unsustainable. The state government needs to be mindful of not affecting quality.” Glasson warns that if public patients are going to be treated in the private system as a means to reduce the public backlog, then registrars must follow. “We need a mechanism which registrars can operate in private settings. We need to teach future generations to operate in private facilities, in addition to the public system,” he said.

NEW SOUTH WALES

A/PROF ASHISH AGAR is concerned about what impact the outsourcing of elective surgery to the private sector is having on teaching the next generation of specialists in NSW.

After the initial shutdown in March, hospitals in New South Wales were given the green light in April to increase elective surgery from 25% of pre-pandemic levels to 50% by May 31, then 75% by June 30, 2020.

Several years ago, the Queensland Department of Health introduced Surgery Connect, a program to ease elective surgery waiting lists in public hospitals.

Associate Professor Ashish Agar, glaucoma specialist at the Prince of Wales Hospital and Sydney Eye Hospital and partner at Marsden Eye Specialists, said the elective surgery scene in New South Wales has not changed since November, when the latest healthcare data revealed ophthalmic patients were waiting 330 days on average – a 98 day increase on the same period in 2019 and the largest rise among all medical specialties.

The patient-centred program coordinates and contracts with the private sector to deliver elective surgical services for patients where there is insufficient capacity to provide treatment within clinically recommended timeframes within Queensland public hospitals.

Despite the lengthy wait, Agar commended the nation’s healthcare leaders, acknowledging the restrictions and gradual return to capacity had proven to be a successful strategy compared to the failures evident in healthcare systems overseas.

Glasson said the Queensland Government’s decision to treat public patients in the private system, to reduce backlog, was “the way of the future”.

“Australia has demonstrated good leadership, and healthcare providers and patients have complied for the common good, and now we’re reaping the benefits. Our elective surgery capacity is a pipedream for those overseas, and in that context, it’s important to acknowledge Australia’s leadership and successful campaign to manage the pandemic,” Agar, who is also president of the Australian Society of Ophthalmologists (ASO), said.

At 1 October 2020, the percentage of ophthalmology patients waiting within the clinically recommended time was 65% (Category 1), 33% (Category 2), and 67% (Category 3).

“Surgery Connect utilises efficiencies of the private system. It’s far cheaper to have cataract surgery in the private system, than the public system,” he said. “The public system has a limited budget but unlimited demand. Ophthalmology is a highly sought-after type of surgery, and it’s an expanding field of medicine, supported by good technology and good patient outcomes. Its success rate is putting huge pressure on the public purse. Waiting lists control demand in the public system, whereas price controls demand in the private system,” he said. Glasson, who sits on Cancer Australia’s Advisory Council, said patients

“A year down the track [since elective surgery restrictions were introduced], Australia is in one of the best positions of developed nations, and there’s an expectation in our health system that things are heading back to normal. The private sector is going ahead as usual, but the public sector is a mixed bag.” Agar said there was a minimum three-month wait for ophthalmic

INSIGHT March 2021 39

ELECTIVE SURGERY

patients, and up to one year maximum, which is having a severe impact on outpatient clinics in public hospitals. The latest Bureau of Health Information Healthcare Quarterly report reveals from July to September last year in NSW, ophthalmologists performed 10,298 procedures in the public system, with just 66% of those on time. This is a 32% drop from the same quarter in 2019 when 98% were delivered within the recommended timeframe. Of the 8,426 cataract procedures performed in the September quarter, the median wait time was 343 days – 71 days longer than in 2019. “The data reflect who has come through the system, but it doesn’t capture the backlog of patients who remain unseen,” Agar said. “The unknown patients are a bigger concern. As Dr Bill Glasson was saying, there has been some outsourcing to the private sector – which can work well in terms of efficiencies and the like – but our concern is that outsourcing has a significant impact on teaching hospitals. If cataract surgery is done in private hospitals, what impact does that have on teaching?” Agar said his colleagues who taught in public hospitals have told him how registrar’s caseloads are impacted by public patients being siphoned into the private system. “The temptation for public hospitals is for a cost-saving aim, rather than a patient-outcome aim,” he said. “The established infrastructure and staff in the public system is rundown. In NSW, there are some major teaching hospitals where ophthalmic surgery has not resumed to pre-COVID levels. This means a loss of training and a loss of skills in the public sector. Ophthalmic surgery is not being done.” Agar said his colleagues are raising concerns that COVID may be used as an argument to cut costs and services in public ophthalmology surgery, thereby cutting patient’s visual prospects.

SOUTH AUSTRALIA

DR MARK CHEHADE says South Australia was fortunate to suffer no adverse eye health outcomes for patients as a result of COVIDrelated surgical suspensions.

At the Royal Adelaide Hospital, 520 patients were on the waiting list, with 45 overdue; 306 were waiting for a lens extraction, with 18 overdue. For those classed Category 3, 109 patients were waiting between 121 and 240 days. When Insight spoke with Chehade in January, he estimated there were 546 patients on the ophthalmology waiting list for surgery at the Royal Adelaide Hospital. “I’d estimate 95% would be Category 3. After 12 months, they’re targeted. A few dozen have gone beyond the target of a 12-month wait for surgery.” Chehade said three specialists volunteered to treat public patients in private hospitals as part of South Australia’s blitz. “We had a blitz at Royal Adelaide Hospital, but we have had them intermittently over the years. Fortunately, there have been no adverse eye health outcomes for patients as a result of COVID-related surgical suspensions, but as I said, we were only shutdown for three months.”

VICTORIA

DR ANTON VAN HEERDEN believes overall wait times have not been catastrophic, but there remains an unknown number of people whose pathology has not been assessed in Victoria.

Before elective surgery could gain any meaningful momentum in Victoria, the state was plunged into a second lockdown in July that led to a second shutdown of non-urgent surgery. By September, Premier Daniel Andrews announced a phased restart of elective procedures in public and private hospitals. Regional Victoria eventually returned to 85% of usual elective surgery activity from September 28, while for metropolitan Melbourne this occurred from October 26. A return to full capacity across the state was slated for November 23, 2020. Insight recently spoke with Dr Anton van Heerden, head of surgical ophthalmology services at Royal Victorian Eye and Ear Hospital (RVEEH), about the elective surgery landscape in Victoria. He said the RVEEH was still only operating at about 80% of usual elective surgery activity.

Following the elective surgery suspension in March, South Australia was the first state to fully restore all elective procedure capacity by early-tomid-June 2020.

“We’ve gradually increased our activity as per the Department of Health and Human Services guidelines. Waiting times between an appointment and surgery are about the same as pre-COVID,” van Heerden said.

Dr Mark Chehade, who commenced in the role of head of the ophthalmic surgery unit at the Royal Adelaide Hospital in January 2021, said the state was fortunate to be only shutdown for three months.

Elective surgery rates at RVEEH were “not going backwards” and while he had received a number of new patients through referrals from optometrists, there “hasn’t been a mad rush”.

“COVID’s effect on elective surgery waiting times in South Australia were minimal,” he said. “I’d estimate it increased the number of Category 3 patients who reached the target 12-month wait by 15%.”

“There hasn’t been a massive deluge of patients, contrary to expectations,” he said.

He said surgeons did not fall too far behind. “South Australia did very well with respect to COVID. We had immediate cessation of all surgery except Category 1 [in March] and returned to Category 2 and urgent Category 3 by mid-year. The problem is waiting lists are endemic, not from the pandemic.” According to SA Health’s Elective Surgery Dashboard [last updated 5 April 2020], 3,475 ophthalmology patients statewide were on the waiting list and ready for surgery at the first opportunity, with 201 patients overdue.

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The median waiting time for ophthalmology patients in Victoria from July to September last year was 30 days (compared to 330 days in NSW), and similar to 32 days for the same period in 2019. The median waiting time for ophthalmology patients in Victoria peaked at 87 days from April to June 2020. From July to September, ophthalmologists treated 2,240 patients in the public system statewide, compared to 6,463 patients from the same quarter in 2019. In Victoria in 2020, the median waiting time for cataract patients nearly doubled from 56 days (January to March quarter), to 101 days (April to

June quarter), then fell back to 54 days (July to September quarter). Van Heerden said he noticed that patient’s pathology was much worse because of lockdown. “I’ve seen quite a few cataract patients who had treatment deferred for six months due to lockdown, and their vision has suffered as a result of that,” he said. “Overall, there hasn’t been a catastrophic wait, but there is an unknown number of people whose pathology has not been assessed.” In December, the state government – having driven COVID cases numbers down – announced a $300 million elective surgery blitz to ensure Victorians can access surgery. “The Victorian government has been threatening a blitz for a while – it was on the radar even before COVID started. But there’s no real point until we’re at 100% capacity. Based on our [RVEEH] waiting list, there is no urgency for a blitz at the moment,” van Heerden said. However, he is concerned about a third wave outbreak, especially after the NSW Northern Beaches cluster in late December and Greater Brisbane’s three-day snap lockdown in January to stop the spread of the UK COVID-19 variant. “When Victoria had a few confirmed cases in early January, it prompted discussion at RVEEH of re-introducing COVID testing for each patient, as per in the lockdown.” According to van Heerden, one of the main issues of re-introducing COVID testing for each patient is the administrative burden. “It takes a lot of work to book and un-book patients. It’s a very inefficient use of time and it can be frustrating, but we anticipate there’ll be another lockdown and must be cautious,” he said. “The boat turns a lot slower in the public system than the private system, and that poses a real challenge, but the RVEEH has done a remarkable job of managing patients and staff during the pandemic. I was expecting progress to be a lot slower, and more difficult, but the communication between the Department of Health and Human Services and the RVEEH has been exceptional, especially given there a lot of cogs in the wheel.”

WESTERN AUSTRALIA

DR TOM CUNNEEN says Western Australia should be commended for eliminating COVID from the community which has allowed minimal interruption to ophthalmic care.

January 2021 – six-months later – Cunneen said elective surgery, in both the public and private system, has been “back to normal” for several months. “WA has been fortunate not to have community spread of COVID for several months and as such our elective surgery has been running at full capacity for the majority of 2020,” he said. Last year, amid the frustration of reduced elective surgical activity, Cunneen said he felt that, based on the number of positive COVID cases, the state government could use their discretion and lift the capacity restrictions. His initial frustration has since subsided. “The state government, and the people of WA, should be commended for eliminating COVID from the community which has allowed very little interruption to ophthalmic care,” Cunneen said. At the end of November 2020, Sir Charles Gairdner Hospital, where Cunneen holds a consultant position, had eight Category 1 cases with five days median waiting time, 68 Category 2 cases with 27 days median waiting time, and 304 Category 3 cases with 83 days median waiting time.

TASMANIA

PROF NITIN VERMA says waitlist numbers differ across Tasmania and are the result of many, often complex, interrelated factors.

Tasmania deployed a gradual and progressive restart to elective surgery at the discretion of medical professionals, following the National Cabinet’s recommended suspension last year. Current RANZCO president Professor Nitin Verma practises privately at Hobart Eye Surgeons and publicly at the Royal Hobart Hospital. “Tasmania has had around 230 cases who tested positive to the COVID virus since early 2020,” he said. “During the initial restrictions that resulted from the COVID pandemic, we followed the directives of the Federal and Tasmanian health departments as well as those of the local hospitals in our management of patients with eye problems. “In particular, the guidelines specifically developed by RANZCO for this period were used to triage and prioritise treatment for patients with new and pre-existing eye problems.” Verma said the surgical treatment of Category 1 and urgent Category 2 cases, in general, continued uninterrupted during the pandemic.

Perth-based surgeon Dr Tom Cunneen specialises in cataract, laser, and eyelid surgery. He operates privately at St John of God Subiaco Hospital and the Perth Eye Hospital and holds a consultant position at Sir Charles Gairdner Hospital. When he spoke to Insight in May last year, ophthalmologists in Western Australia were restricted to operating at 50% of all normal elective surgical activity, despite only two active COVID cases at the time. As a result, they were consulting at full capacity but operating surgically at just 50% of their previous through-put. This created friction because patients were being diagnosed but unable to have surgery in a timely manner. Surgical capacity was reinstated 100% in WA on 15 June and in

According to Tasmanian Health Service outpatient clinic data, as at 28 October 2020 in the Southern Region (which includes Royal Hobart Hospital), ophthalmology patients were waiting 71 days in urgent cases, 147 days in semi-urgent cases, and 383 days in non-urgent cases. “As the leaders in collaborative care, we continue to work with the Tasmanian Government, our local hospitals and health facilities to ensure that eye patients on waiting lists are seen as soon as feasible,” Verma said. “Overall waitlist numbers differ across Tasmania and are the result of many, often complex, interrelated factors. Although COVID-19 has affected waiting lists in some areas, as long as there are no major problems around the corner, we anticipate a speedy return to normal in the delivery of eyecare.” n

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CARING FOR STROKE OR BRAIN INJURY PATIENTS ORTHOPTISTS ARE UNIQUELY POSITIONED TO ASSESS AND MANAGE THE VISUAL NEEDS OF ACQUIRED BRAIN INJURY AND REHABILITATION PATIENTS, WRITES ORTHOPTIST AND ACADEMIC MICHELLE COURTNEY-HARRIS.

MICHELLE COURTNEYHARRIS

"THE ORTHOPTIST HAS A STRONG EDUCATIONAL ROLE, INCLUDING LIAISING WITH HOSPITAL STAFF, THE PATIENT’S FAMILY, AND THE PROVISION OF COUNSELLING"

isual problems in patients admitted to hospital for acute care, such as an acquired brain injury (ABI), including stroke, often go unrecognised. Deficits to sensory and motor functions because of an ABI can vary from subtle to debilitating with the most reported defect being that of disruption to one’s peripheral field of view. It is also important to remember that while a larger proportion of hospital and rehabilitation admissions are of older people, the likelihood of pre-existing ocular conditions co-existing with any newly acquired visual problems will be greater, with up to 73% of stroke survivors found to have some form of visual impairment. Changes to a patient’s level of visual function can add a level of complication to patient care, individual mobility and interfere with prescribed rehabilitation tasks. With our specialist training in ocular motility, ocular pathology and low vision, orthoptists are in the unique position of being able to triage, assess and manage individual visual needs of stroke or brain injury survivors. Assessment performed by an orthoptist may be while the patient is an admitted inpatient or once discharged. In addition, orthoptists provide feedback and guidance to other health professionals for the adaptation of their services based again on the individual visual needs of the patient. The role of the orthoptist in the care of stroke or brain injury survivors includes the identification and management of pre-existing pathology and newly acquired ocular misalignments, which may include gaze or nerve palsies. Patients may experience disturbances to vision and contrast, diplopia or loss of their peripheral vision that can affect simple tasks such as reading, feeding, dressing and safe navigation for general mobility in non-familiar environments. When looking after stroke or brain injury survivors a typical day for the orthoptist may consist firstly around

INSIGHT March 2021

triaging patients within hospital stroke and rehabilitation units and assessing those most likely to have a visual deficit. Further assessment involves ocular motor orthoptic and ocular neurological examination including visual field and visual neglect testing. On identification of a visual deficit, the orthoptist will determine if the ocular condition is preexisting or newly acquired secondary to stroke or brain injury. Orthoptic treatment provided includes fitting of Fresnel prisms for diplopia, training in adapting to a visual field loss and/or visual neglect and orthoptic exercises. The orthoptist has a strong educational role, including liaising with hospital staff, the patient’s family, and the provision of counselling regarding their visual deficit and any impact it may have on their activities of daily living. Recommendations made may involve review with an ophthalmologist, optometrist, or an assessment at a low vision clinic such as Vision Australia or Guide Dogs Australia. All patients discharged from stroke and rehabilitation units receive follow-up, particularly in relation to their ability to meet visual driving requirements. Orthoptic assessment of these patients is instrumental to prompt application of appropriate intervention and management strategies. While not all hospitals or rehabilitation units currently have direct access to orthoptic services, in the absence of this service, the Vision Defect in Stroke Screening Tool (S-ViST) and the accompanying online Vision Defect in Stroke Education Module is available to all NSW Health-employed professionals. The Vision Defect in Stroke Screening tool is a clinically validated compact document that targets a patient’s eye health history, prompts for simple observations and assessment of ocular misalignment and tests vision. The online case-based education module is a simple interactive platform with the purpose of improving knowledge on both common age-

Orthoptists can play a key role in the care of stroke or brain injury survivors.

related ocular conditions and visual problems caused by stroke. Both resources provide non-eyecare health professionals with the ability to, at the very least, identify and refer on patients who are experiencing visual changes. Access to both resources by those outside of NSW Health, especially for the screening tool itself, can be made by contacting the Agency for Clinical Innovation (ACI) Ophthalmology Network directly or via the ACI website (online education module). n A full list of references can be found in the online version of this article at www.insightnews.com

ABOUT THE AUTHOR: MICHELLE COURTNEYHARRIS is an experienced orthoptist, lecturer at the Discipline of Orthoptics, UTS and PhD candidate under examination. Contributions were also made by Kathryn Thomson and Susanne Brunner, both experienced orthoptists in the assessment and management of stroke survivors. ORTHOPTICS AUSTRALIA strives for excellence in eye health care by promoting and advancing the discipline of orthoptics and by improving eye health care for patients in public hospitals, ophthalmology practices, and the wider community. Visit: orthoptics.org.au

DISPENSING

VERTEX DISTANCE, EVERY MILLIMETRE COUNTS HIGH-POWERED LENSES STILL REQUIRE THE BACK VERTEX DISTANCE TO BE MEASURED OTHERWISE THE WEARER MAY NOT GET THE BEST OUT OF THEIR LENSES. STEVEN DARAS DISECTS THIS UNDERUSED DISPENSING MEASUREMENT.

ertex distance is a vital but oftenunderutilised measurement in dispensing spectacles. It is the distance from the back of the correcting lens surface to the apex of the cornea and is often called the back vertex distance (BVD) for this reason.

STEVEN DARAS

"A STRONGER LENS HAS A DIFFERENT EFFECT ON LIGHT WHEN IT SITS AT DIFFERENT DISTANCES FROM THE EYE. THIS CAN CAUSE GREATER OR LESSER BENDING OF LIGHT AT THE CORNEAL PLANE"

In the past BVD measurements were routinely used when dispensing high powered post-cataract aphakic corrections. When correcting aphakia, prescribers included the test BVD on the prescription due to the high plus powers being prescribed. This allowed whoever dispensed the prescription to compensate for any changes required to the lens power due to the spectacle frame sitting at a different plane or BVD. A stronger lens has a different effect on light when it sits at different distances from the eye. This can cause greater or lesser bending of light at the corneal plane affecting the eye’s ability to refract the light. Thus, compensating the lens power allows the wearer to see the same with the new lenses sitting in the new plane (frame BVD) as they originally saw in the original plane (test BVD). This allows the wearer to get the same visual effect with their new spectacles as they did during their eye test. As aphakic prescriptions declined, so did recording BVD measurements at test and during dispensing. However, all highpowered lenses including high minus still require the BVD to be measured and be considered in both instances. Otherwise, the wearer may not get the best visual performance from their lenses. Recently I assisted a colleague with a client who had purchased glasses elsewhere but was still having trouble despite having her glasses remade. Her original prescription read R -8.75/1.50 90 L -7.75/-1.50 90. The onsite optometrist confirmed the refraction and measured the test BVD, then her fitted frame BVD was measured and her prescription was compensated. The lenses were reordered as R -9.25/-1.50 90 L -8.00/-1.50 90. She was extremely happy with the result. The 6mm change in vertex distance had been compensated and she now has the same vision through

Both phoropters were aligned by the same practitioner. The patient on the left has a test BVD of 14mm while the patient on the right has a test BVD of 26mm.

her spectacles as when tested, so every millimetre counts. When ordering ‘as worn’ progressive powered lenses (PPL) lens laboratories require the frame BVD as well as other specific measurements. These allow optimisation of their lenses to perform in the actual plane of wear. Knowing how far away from the eye the lens sits is important. If this measurement isn’t given, the lab will apply a set of pre-set values (averages) that allows them to complete the order but may not allow the lens to work as the lens designers had planned. Thus, BVD’s should be measured for: all ‘position of wear’ PPL designs; on all highpowered lenses especially greater than ± 8.00 D (British standards recommend ≥ ± 5.00 D); when matching previous spectacles; and when the test vertex distance is written on the prescription as this is an instruction from the prescriber to create the same effect in the new frame plane as their test BVD during refraction. Test and frame BVD’s will vary as there is no average BVD due to head and facial features differing from person to person. The trial frames or phoropters sit differently on different faces so test BVDs vary. American Optical (AO) stated that an average for their phoropter’s test BVD is 13.75 mm and suggested 14 mm be used.

In a study of 189 of their patients, a group of ophthalmologists specialising in refractive surgery and refractions (Weiss et al, 2002) found quite a difference to this advice. Using the AO phoropter, they found that the range of actual test BVDs measured on their patients varied between 10mm and 34mm with the test BVD ‘average’ being 20.4mm (see image).

Some prescribers use their own ‘standard’ test BVD figures of 16mm, 14mm, while some use 12mm, so who is correct? Whilst low powered spectacle prescriptions may explain why we don’t see test BVDs written on these, there is a need in stronger Rxs. Unfortunately, in practise there are very few test BVDs written on higher-powered spectacle prescriptions. This means that unless the fitted spectacle frame sits at the same BVD as the test lens, then there is little or no chance of the wearer seeing as well as when tested. Research would tend to suggest that where applicable every test and frame BVD should be measured, recorded and compensated to achieve best practice. n

STEVEN DARAS is Course Coordinator of Optical Dispensing TAFE Digital, co-author of the Practical Optical Dispensing and Practical Optical Workshop textbooks, a popular conference speaker and a director and secretary of ADOA.

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MANAGEMENT

CHANGE AS INEVITABLE AS DEATH AND TAXES WHETHER IT’S AN UNFORESEEN DISASTER OR SELF-IMPOSED PROJECT, CHANGE CAN BE IMPOSED ON BUSINESSES IN A MYRIAD OF WAYS. KAREN CROUCH EXPLAINS HOW TO HANDLE CHANGE AND ITS IMPACT ON THE PRACTICE AND STAFF.

021 is expected to be another year of change. The ongoing effects of the coronavirus continue to hamper world economies and cause political instability, creating waves of uncertainty that individual businesses, including health practices, aren’t immune from.

KAREN CROUCH

"INEVITABLY, IMPLEMENTATION OF CHANGES MAY REQUIRE EFFECTIVE COMMUNICATION TO CLIENTS, TRADESMEN AND OTHER VISITORS"

Consequently, ‘change management’ capability to deal with situations, planned or otherwise, is critical as reflected in the learned statement “change is as inevitable as death and taxes”. Apart from operational aspects, the need to understand and manage human behaviour is equally vital in implementing changes. Additionally, the COVIDinfluenced environment has emphasised the need for innovation and flexibility as regulatory conditions evolve. The basic forms of potential change, and relevance of change management in each, are: Predictable – self-imposed, managed in orderly fashion – for example, a commissioned project. External pressures such as regulatory requirements (see below) should be expected too and, in the current environment, are rolling targets. Change management should be an essential component of overall project management, detailed further below. While change may be managed efficiently, impact on budgets and completion deadlines is vital so business owners are aware of likely outcomes, particularly where a mission critical project must be completed within specified timeframes. Unpredictable – a result of business disruption or disaster which impacts normal operations of the practice, such as the loss of access to premises or technology. However, all unpredictable changes may not be totally unforeseeable. For instance, a need to expand capacity to meet increasing patient demand or to amend a vital procedure may be identified reactively or proactively. Generally, these are unexpected but, unless triggered by a disaster, they should be manageable. Many businesses lack a comprehensive recovery plan (business continuity) or do not appreciate the value of one until

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a disaster threatens them. In health practices, potential negative impacts on patients is a significant concern. Apart from preparing and reviewing contents and applicability of the plan, there will be the element of change management which efficient implementation will inevitably require. Comprehensive contingency plans will usually address sudden changes like a loss of premises access or vital services – power, transport, unexpected high patient/ customer demand, and other situations requiring recovery action. Externally imposed – regulatory, environmental or economic changes e.g. to the national health system. This change falls between the two aforementioned types – not always self-imposed but generally known ahead of time, preceded by political and social debate.

COVID-19 has emphasised the need for flexibility as regulatory conditions evolve.

repetitive in nature, requiring execution at regular intervals;

Once required change is announced, or relevant legislation promulgated, a state of readiness should be assessed, including the cost of achieving compliance. Practices with sound project management skills handle these situations well.

•R esponsible person/s who will oversee delivery of each identified action; and

Human element – a common thread running through all changes is they invariably impact staff. People react differently to change, some requiring coaching to adjust to a new environment. A typical example is technology where some embrace new functionality, while others resist or take longer to adapt, resulting in a need for additional training or education.

Through “scope creep” or need for improvement, plans may deserve reconsideration. Consequently, it will require a disciplined process to assess the essential or desirable nature of the proposed changes and, if benefit justified, modifications should be integrated into the overall project plan.

Overall project management – regardless of change being introduced, the very first step should be a structured project plan comprising the following elements: •A ctivities to be undertaken, expressed in a clearly enunciated manner, including brief description of the targeted objectives; •D escription of each action item to ensure details are fully understood and, most importantly, how specifically targeted objectives are expected to be achieved; •T imeframes in which each action should be performed. Some may be

•P ost-implementation, or in certain cases ongoing review, is a vital step in confirming satisfactory completion of each action element.

Regular discussion at staff meetings will ensure employees appreciate the importance of the particular change being implemented, including potential negative impacts of unsatisfactory performance. In situations such as compliance with latest COVID-19 regulations, failure to comply may expose the practice to fines. Inevitably, implementation of changes may require effective communication to clients, tradesmen and other visitors. n

ABOUT THE AUTHOR: KAREN CROUCH is Managing Director of Health Practice Creations Group, a company that assists with practice set ups, administrative, business, legal and financial management of practices. Email kcrouch@ hpcnsw.com.au or visit www.hpcgroup.com.au.

2021 CALENDAR silmobangkok.com

MARCH 2021

WORLD GLAUCOMA WEEK International 7 – 13 March wga.one

RANZCO NZ BRANCH ANNUAL SCIENTIFIC MEETING Christchurch, New Zealand 19 – 20 March ranzco.edu

WAVE 2021 HYBRID CONFERENCE Fremantle, Australia 20 – 21 March optometry.org.au

ANZSS (SQUINT CLUB) Christchurch, New Zealand 21 March kathpoon@bigpond.com

RANZCO VIC BRANCH SCIENTIFIC MEETING Melbourne, Australia 27 March ranzco.edu

OA VIC BRANCH JULY SCIENTIFIC MEETING Victoria, Australia 27 March orthoptics.org.au

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

APRIL 2021

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

NATIONAL ABORIGINAL AND TORRES STRAIT ISLANDER EYE HEALTH CONFERENCE Australia (virtual) 20 – 22 April mspgh.unimelb.edu.au

MAY 2021

JUNE 2021 MIDO EYEWEAR SHOW Milan, Italy 5 – 7 June mido.com

JULY 2021

100% OPTICAL London, UK 8 – 10 May 100percentoptical.com

VISION EXPO EAST New York, USA 25 – 28 May east.visionexpo.com

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

VISION 2021 Dublin, Ireland 11 – 15 July vision2020dublin.com

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

SPECSAVERS – YOUR CAREER, NO LIMITS A

ll Specsavers Recruitment Services (SRS) - Who are we? Specsa ve stores rs SRS are an in-house recruitment team who specialize in attracting and recruiting talented optical and retail now w it h OCT professionals for our Specsavers stores across Australia and New Zealand. We have dedicated permanent and locum recruitment consultants that focus on specific geographic locations across ANZ. Your SRS consultant is on hand to support you through all your recruitment needs and will take excellent care of you and your future career. For any locum opportunities, please contact Maddy Curran at madeleine.curran@specsavers.com or 0437 840 749.

The Specsavers Graduate Recruitment team are currently recruiting for a number of vacancies in Perth, WA. If you’re looking to make a genuine impact, and deliver patient-centric, evidence-based preventative eye care and work collaboratively to manage health outcomes, then we urge you to talk to us about how you can join our mission to transform eye health. At Specsavers you will have access to cutting edge technology and be part of the driving force bringing Optometry into the forefront of the healthcare industry.

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

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

Optometrist opportunities, regional QLD We are currently seeking Australia’s most dedicated and driven Optometrists to join our Specsavers family in regional QLD. We will give you access to the latest technology and equipment (including OCT) to assist you with your career progression, provide you with a host of professional development opportunities – from our annual clinical conference to ophthalmology-led education programs and offer a competitive salary – including PII, AHPRA, CPD allowance and bonuses and incentives. Full-time, part time and contract roles available across the State.

marie.stewart@specsavers.com or 0408 084 134

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

cindy.marshall@specsavers.com or 0450 609 872

Joint Venture Partnership Opportunities – Specsavers Port Pirie Specsavers is on the lookout for experienced optometrists to join us as Joint Venture Partners in Port Pirie. We have various opportunities available – with high growth potential and affordable buy in – these are opportunities not to be missed! As a Specsavers JVP, you will have access to back-office administrative support from our Support Office, the power of Specsavers’ market-leading brand driving customers to your store and an annual combined marketing fund of more than $60 million. Receive a guaranteed market-rate salary in addition to your share of store profits along with guaranteed annual leave and access to exclusive wellbeing workshops.

Australia Employment enquiries: Madeleine Curran – Recruitment Consultant

madeleine.curran@specsavers.com or 0437 840 749 Locum employment enquiries: Cindy Marshall – Locum Team Leader New Zealand employment enquiries: Chris Rickard – Recruitment Consultant

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

SOAPBOX

THE WORLD OF NEURO-OPHTHALMOLOGY OCT. It must be remembered that visual acuity and visual field tests are purely subjective and depend on the will, whim and intelligence of the patient. Testing for a relative afferent pupillary defect (RAPD) was the only objective test available to us. Now, an OCT test gives us objective evidence of damage to the retinal nerve fibre layer and ganglion cell layer which precedes detection by our much less sensitive computerised field tests.

euro-ophthalmology (N/O) is an interesting subspecialty because it crosses boundaries. Almost exclusively a ‘medical–type’ specialty rather than ‘surgical’, about half of its practitioners in Australia and New Zealand are neurologists and the other half are ophthalmologists. In fact, the only surgical procedure that is regarded as principally in our domain is optic nerve sheath fenestration: creating a hopefully permanent drain of cerebrospinal fluid from within the optic nerve sheath and thus protect the optic nerve from progressive ganglion cell and nerve fibre loss in chronic papilloedema (much like a trabeculectomy that drains aqueous from the anterior chamber). Most ophthalmic members of the Neuro-Ophthalmology Society of Australia (NOSA) run busy N/O clinics in the larger public hospital eye departments. There are no full-time N/Os in Australia or New Zealand compared with other countries with much larger populations. Thus, we usually subspecialise in combinations of ocular-motility, medical retina, oculoplastics and general ophthalmology, while our neurological colleagues also deal with strokes, migraines, headaches and epilepsy, among others.

Because many of our patients have chronic conditions with interesting clinical signs, they often feature in trial practice and final FRANZCO exams; this is when our expertise is particularly valued by trainees. A large proportion of our work involves

INSIGHT March 2021

victims of trauma whether from vehicular accidents, assault with loss of vision, visual field problems from visual pathway damage and double vision from ocular motor nerve palsies etc. Other intriguing aspects are pupillary, lid and orbital problems plus, of course, stroke complications and the weird and wonderful syndromes that make our work so fascinating. Sorting out visual and/or field loss and cranial nerve palsies from patients with brain tumours, particularly pituitary and suprasellar tumours such as craniopharyngiomas and meningiomas, provide regular work. Hence, we liaise closely and share patients with: neurologists, neurosurgeons, endocrinologists, plastic and maxillofacial surgeons, cardiologists, rheumatologists and immunologists. A sad indictment of our transition to sedentary lifestyles, plus the rise of poor diets, is the huge rise in prevalence of idiopathic intracranial hypertension (IIH), with its curious predilection for obese young women. The previous term ‘benign intracranial hypertension’ has been replaced by IIH as this disease certainly is rarely benign. I’ve seen too many medicolegal cases of gross field loss and/or legal blindness wherein the patients’ headache was misdiagnosed and treated as migraine as no one had done fundoscopy and thus not detected the papilledema indicating an actual diagnosis of IIH. In terms of diagnostic advances, a wonderful ‘new’ clinical tool for N/O is

We perform OCT tests prior to neurosurgical decompression of, for example, tumours that are embarrassing the optic nerve or chiasmal function and thus enable us to predict whether visual recovery is likely or not following surgery. This information is of great help. The evolution of neuro-imaging has been the most helpful factor in confirming accuracy of our N/O diagnosis. In the US, the high rate of subspecialisation has led to a dearth of general ophthalmologists and so N/Os are filling that niche. Certainly, we tend to be referred patients with symptoms and signs our colleagues are unable to diagnose. As for a career in N/O, most have done overseas fellowships in the larger N/O centres in the UK, US or Canada, but they need consultant positions in our teaching hospitals to maintain their expertise. Most NOSA members are in the older age group (myself included), but fortunately we've welcomed new young colleagues to our ranks. But we need to recruit more. Those interested should arrange time with a N/O to discuss training pathways. Recently trained members returned from overseas can also help. Finally, may I conclude with a plea to referring optometrists? Please desist in faxing black and white copies of OCT results as these are absolutely indecipherable: much better to email colour copies instead! n Name: Professor John L. Crompton; AM, RFD, MBBS, FRANZCO, FRACS. Business: Eye Consultants SA. Position: Clinical Professor (Ophthalmology), University of Adelaide. Immediate Past President of NOSA. Location: North Adelaide plus teaching N/O & ocular-motility surgery at Royal Darwin Hospital. Years in profession: 44.

IN THE US, THE HIGH RATE OF SUBSPECIALISATION HAS LED TO A DEARTH OF GENERAL OPHTHALMOLOGISTS AND SO NEUROOPHTHALMOLOGISTS ARE FILLING THAT NICHE

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