INSIGHT MARCH 2022 by Prime Creative Media

INSIGHT MAR

2022

The ophthalmic sector outlines its key proposals before Australians hit the voting booth.

SHOULD YOU INVEST IN OCT-A? CPD content discussing the emerging role of the technology in modern optometry practices.

FEDERAL ELECTION WISH LISTS REVEALED

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

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INSIGHT MAR

2022

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

OPHTHALMIC SECTOR LAYS OUT PRIORITIES AHEAD OF 2022 FEDERAL ELECTION

Key ophthalmic organisations have revealed their federal election wish lists, drawing attention to issues such as workforce maldistribution and access for rural and remote communities, which optometrists say could be partially alleviated with an expedited decision around oral medication prescribing and involvement in intravitreal injection (IVI) services. The sector’s other headline proposals include strengthening the Visiting Optometrists Scheme (VOS), greater Medicare reimbursement for optometric domiciliary services, full specialist MBS billing rights for some final year ophthalmology trainees and a '90-day rule' for public cataract surgery. Optometry Australia (OA), RANZCO and Vision 2020 Australia – the

national peak body representing over 50 ophthalmic organisations – separately provided their recommendations ahead of the election to be held before 21 May. To highlight the importance of the sector, modelling was provided showing those considered blind or vision impaired had increased from 453,000 in 2016 to 840,000 now, which could exceed 1.04 million by 2030. The social and economic burden is estimated to be $27 billion annually or $46,950 per person with vision loss aged over 40. In its submission, OA stated an ageing population and “a failure to fix entrenched shortcomings” means urgent action is now required “to avert a looming eye health crisis”. The first of its initiatives included

“The Optometry Board of Australia has begun considering whether optometrists should be able to prescribe oral medications with a final decision to be taken by federal and state and territory ministers,” OA said.

Prime Minister Scott Morrison described his shock 2019 election win as a "miracle".

the need for qualified optometrists to prescribe oral medications for common eye conditions. Although this is allowed in countries like New Zealand, the UK and US, ophthalmology bodies are opposed to this in Australia. The need for optometry patients to visit a second health practitioner for such prescriptions could potentially result in additional out-of-pocket costs.

“With indications that consideration could take a further two years or longer, there is a need to expedite through a clear indication that this issue warrants an early decision in the interests of enhancing patient access and convenience.” The organisation also proposed improvements to Medicare items 10931-10933, which cover domiciliary services in the form of a loading, in recompense for “travel costs and packing and unpacking of equipment”. continued page 8

SECTOR PAYS TRIBUTE TO DR CON MOSHEGOV Just as Insight went to print, the ophthalmic community was mourning the death of Sydney ophthalmologist Dr Con Moshegov who passed away after battling COVID-19. Moshegov was the director and principal surgeon at both George St Eye Centre and Eye Laser Surgery Hornsby and was among Australia’s most highly respected and trusted experts in cataract, refractive and corneal surgery, with over 25 years' experience. The Australian Society of Cataract and Refractive Surgeons (AUSCRS) wrote: “We are very sad to hear of the loss of Con Moshegov after a battle with COVID. Con was one of our regular AUSCRS family members and is remembered as one of the most genial and vibrant individuals one could hope to meet.

“He contributed much to cataract and refractive surgery and we all vividly recall our conversations over the years. He will be sadly missed and we extend our thoughts and sympathies to his family.” The Australian Society of Ophthalmologists (ASO) also paid tribute, stating: “When his friends describe Con, the words generous, charismatic, humorous, and caring are constants. Those who knew Con socially recall a bon vivante, a raconteur, an earnest listener and always the joy of any gathering. Con’s humour and enthusiastic opinions made his lectures always a highlight of any program. “Professionally Con was an incisive thinker, clinical innovator and had ‘a great set of hands’. He made many contributions to the science and

practice of corneal, cataract and refractive surgery. Con was the first call for many Sydney surgeons who needed advice, support, or moral reinforcement.” The late Dr Con Moshegov.

Orthoptics Australia said he also contributed to teaching and nurturing of orthoptists in the workplace. The Dr Con Moshegov Memorial Award in Orthoptics Fund at University of Technology Sydney (UTS), set up to continue his legacy, raised more than $55,000 at the time of writing. Moshegov was also a beloved figure in Sydney’s Russian Orthodox Church. His funeral was held at Saints Peter & Paul Russian Orthodox Church in Strathfield on 5 February. He was survived by wife Natalie, daughter Sophia and son Julian. n

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IN THIS ISSUE MARCH 2022

EDITORIAL

FEATURES

RE-PRIORITISING EYE HEALTH With the federal election upon us, the next government is certain to devise a strategy centred on COVID-19 and the economy. In times of crisis, other priorities are often relegated to be dealt with later. It could be argued the vision and eye health of Australians has become a relative ‘backseat’ issue since 2020, but that must change post-election.

DETECTING GLAUCOMA Blood tests and new imaging capabilities could completely change glaucoma care.

Worrying Specsavers figures show in 2021 specialist referrals from its Victorian and NSW optometrists dropped 25% during lockdowns compared to pre-pandemic 2019. This is because optometrists could only see urgent and essential cases, despite constant assurances it was wellequipped to perform routine care much earlier.

HARNESSING OCT-A Dr Angelica Ly and the clinical utility of OCT-A in the modern optometric practice (0.5 CPD hours).

Routine tests so often pick up asymptomatic but damaging pathology; if the health system is paused due to a new variant in future, eye clinics must remain fully operational. At the other end of the scale, major – and sometimes unnecessary – pauses on non-urgent elective surgery has resulted in thousands of deferred eye surgeries, in a system that was already struggling to hit its KPIs. The average cataract patient now waits 172 days, which is three months more than pre-pandemic 2019.

LASTING LEGACY The CEO of Sunshades Eyewear discusses leading the company his mother started 52 years ago.

The value of good eye health and eyesight to the Australian economy is unquestionable. Vision 2020 Australia modelling shows the number of blind or vision impaired Australians sits at 840,000 and could exceed 1.04 million by 2030. This equates to a $27 billion social and economic burden annually or $46,950 per person with vision loss aged over 40.

PRACTICE PROFILE An optometrist recounts opening a greenfield practice mid-lockdown in an upmarket Sydney demographic.

EVERY ISSUE 07 UPFRONT

55 MANAGEMENT

09 NEWS THIS MONTH

56 OPTICAL DISPENSING

53 PEOPLE ON THE MOVE

57 CLASSIFIEDS/CALENDAR

54 ORTHOPTICS AUSTRALIA

58 SOAPBOX

The data speaks volumes about the importance of eyecare providers remaining open, accessible and adequately reimbursed or funded for their time. Much of the federal election proposals in our lead article (page 3) focus on these exact matters. Although it’s impossible to satisfy each recommendation, investments in Indigenous eye health, regional public eye clinics and smarter models that put the profession to work at its full scope are imperative this election. MYLES HUME Editor

INSIGHT March 2022 5

SEE YOURSELF DOING WHAT YOU LOVE WORKING AT OPSM MEANS YOU’RE PART OF SOMETHING BIGGER.

Kat Optometrist

At OPSM, we are obsessed with eye care and offering our customers the confidence in how they see the world. Our advanced technology enables us to look deeper to ensure we give the best care to every customer. When you join OPSM, you work with world class technology including the Optos Daytona ultra wide field scanner. You have many opportunities for continuing professional development through financially supported industry training, mentoring, graduate induction, peer learning communities and product training. You are rewarded with a competitive salary and bonus scheme to recognise your contribution. You have career flexibility through our extensive store network. Most importantly, you can make a real difference in the way people see the world not only from your consulting room but also by participating in our OneSight outreach program. #DoWhatYouLove

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CONTACT OUR PROFESSIONAL SERVICES MANAGERS TO EXPLORE YOUR NEXT OPPORTUNITY: NSW/ACT – Amy Pillay Amy.Pillay@opsm.com.au QLD/NT – Brendan Philp brendan.philp@luxottica.com.au VIC/TAS – Melissa Downing melissa.downing@luxottica.com.au SA – Sophie Pym Sophie.Pym@luxottica.com.au WA – Mario Basso mario.basso@luxottica.com.au NZ – Jonathan Payne jonathan.payne@opsm.co.nz

UPFRONT Just as Insight went to print, ALLERGAN confirmed Prednefrin Forte eye drops are available once again. Due to manufacturing issues, there had been a shortage, but Allergan stated it had worked closely with its global counterparts in the last 12 months to ensure its return last month. The therapy is approved for severe inflammation (non-infectious) of the eye, such as acute iritis, iridocyclitis, scleritis, episcleritis, uveitis, resistant ocular allergy and inflammation following eye surgery. In its absence, Allergan arranged a Section

19A approval for Pred Forte Prednisolone acetate eye drops 10mL (UK). “Allergan will cease supply of Pred Forte Prednisolone acetate … but it will remain available in pharmacies for several weeks." IN OTHER NEWS, Dr James Muecke was appointed South Australia’s next Lieutenant Governor. Premier Mr Steven Marshall announced the ophthalmologist would succeed Professor Brenda Wilson AM who has served since August 2014. “[Dr Muecke] is one of South Australia’s favourite sons, a true pioneer in blindness prevention and an incredibly accomplished eye surgeon – dedicating 32 years to his humanitarian work,” Marshall said. “The 2020 Australian of the Year comes to this

role with a wealth of national and international experience, and I very much look forward to working with him.” FINALLY, new research has revealed Canberra is the world’s best city for eyesight. Online UK retailer Feel Good Contacts analysed 100 capital cities, looking at several factors including noise, light and air pollution, the prevalence of vision loss in each city, and national healthcare index scores to indicate which were the healthiest and most at-risk for maintaining good eye health. The Australian capital had an overall eye health score of 9.47, enjoying some of the lowest levels of air, noise and light pollution, meaning eyes were less irritated and benefitted from more restorative sleep.

insightnews.com.au Published by:

11-15 Buckhurst Street South Melbourne VIC 3205 T: 03 9690 8766 www.primecreative.com.au Publisher Christine Clancy

n WEIRD Pranksters have stuck googly eyes on numerous Adelaide landmarks. The most notable of these was The Big Scotsman statute above Scotty’s Motel, which the bandits used a cherry picker to reach in an early morning mission. Other locations included KFC, Dan Murphy’s, Adelaide Crows headquarters and a Jim’s Handyman van, ABC reported. n WONDERFUL Queenslanders Mr Scott Preston and Mr Nathan Price have benefitted from a new traineeship for people who are blind or have low vision. Run by Vision Australia and supported by the Boosting Apprenticeship Commencements (BAC) wage subsidy scheme, the traineeship has allowed the pair to complete tertiary qualifications while undertaking paid work with the not-for-profit organisation. n WACKY Melbourne optometrist Designer Eyes in Glenroy has been left with a $20,000 damage bill after the luxury business was ram-raided. A four-wheeldrive drove into the shopfront in an overnight theft, with the burglars taking $5000 worth of designer sunglasses – including pairs of Tom Ford and Tiffany & Co, 9News reported.

STAT

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In 2020/21, 38 notifications lodged were against 44 optometrists, according to new Optometry Board of Australia data. Full report page 26.

WHAT’S ON

Complete calendar page 57.

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INSIGHT March 2022 7

NEWS

MILLIONS NEEDED FOR INDIGENOUS EYE HEALTH continued from page 3

With the current fee at $24.20, OA’s modelling suggests this grossly underrecognises the true cost, discouraging optometrists. It believes a more realistic figure would be $85 per visit. It would come at a minimal budget cost of $500,000 annually due to their infrequency, but could increase service delivery by 10%. Elsewhere, the organisation proposed $18.1 million over five years for VOS, whose services have tripled during the past decade. By putting the scheme on a firm financial footing, it would reach more First Nations people, with indications more than 21,000 additional VOS-supported eye examinations per annum are needed. Geographic access to eyecare also forms part of the basis for OA’s next proposal on intravitreal injection (IVI) services. At a cost of $500,000 over two years, OA believes there’s the opportunity to pilot collaborative care models to enhance access to IVIs in regional and rural areas. Although ophthalmology bodies are against optometrists physically administering IVIs, OA stated the pilot would see local optometrists work with visiting ophthalmologists for treatment planning, patient management and support, as well as conducting and electronically transmitting OCT scans. “It is envisaged that the pilot would be undertaken in two separate locations, including one that would enhance access to IVIs in remote Indigenous communities, working in partnership with local Aboriginal Health Services,” OA stated. “The pilot would be developed ... with relevant local health providers, health professional groups and patient representatives, and would be independently evaluated with a view to informing a broader rollout of innovative IVI care models.” Elsewhere, OA recommended the government invest $500,000 over two years, which it would match dollar-for-dollar, to continue its ‘Good vision for life’ public awareness campaign. It also proposed $500,000 over two years to build eye health awareness among primary health professionals such as GPs, practice nurses, specialists and allied health professionals. 90-DAY CATARACT SURGERY RULE In its submission, Vision 2020 Australia outlined 11 recommendations. At the top of its list was $65 million in additional funding to support the

INSIGHT March 2022

publicly funded ophthalmology outpatient services, which it recently highlighted as a major issue in NSW.

government’s commitment to end avoidable blindness in Indigenous communities by 2025, through full implementation of the 'Strong Eyes, Strong Communities' recommendations. Another important proposal called for funding of ophthalmology staff specialist positions in the public system and new eye health workforce strategies that improve access to cataract surgery and intravitreal injections in regional, rural and remote areas. “Vision 2020 Australia recommends implementing a 90-day rule for cataract surgery, whereby patients are to be seen within 90 days of requesting an outpatient visit for assessment and operated on within 90 days of booking – and reporting of performance against this. “[We also propose] an increase in publicly funded and/or affordable access to intravitreal injection and benchmarks implemented that measure reach and timeliness. For this to be successful, mandated improvements are needed to the collection and reporting of outpatient/ specialist clinic data. This would provide greater clarity on the expediency of initial appointments and treatment and ongoing access to sight saving treatment.” The organisation’s other recommendations included: • $ 26.4 million over four years to tackle "the blindness crisis" in Papua New Guinea. • A dditional $14 million per annum for disability inclusion in Australia’s aid program. • $ 5.04 million over four years to trial an on-call eye health and vision coaching and support service for disability and aged care workers and assessors.

“GRANT FULL SPECIALIST MBS BILLING RIGHTS TO FIFTH (FINAL) YEAR OPHTHALMOLOGY TRAINEES WORKING UNDER SUPERVISION IN REGIONAL AND REMOTE AREAS” GERHARD SCHLENTHER, RANZCO

In its six ‘Close the gap’ initiatives, it said funding was required for an adequate number of Aboriginal and Torres Strait Islander health workers/liaison officers, to coordinate and facilitate services. Institutionalisation of Indigenous community control into funding schemes and service delivery models is also needed to ensure Aboriginal Community Controlled Health Services are part of the decision-making process. It also reiterated the need for funding of scholarships and enrolment in specialist training programs to grow the Indigenous workforce and leadership development. The college’s five ‘workforce and training’ proposals included investment in more urban training posts in the public system, and the Regionally Enhanced Training Network (RETN), which is essential to sustainably address workforce maldistribution. “[RANZCO also calls for the granting of] full specialist MBS billing rights to fifth (final) year ophthalmology trainees working under supervision in regional and remote areas to address the maldistribution of doctors. “Also, set reportable KPIs for all specialty training – not just ophthalmology – as well as for outpatient and inpatient service delivery, making state governments and local health districts more accountable for training and outpatient service delivery.” Its six-point 'sustainability and climate change’ proposal featured the establishment of a national Sustainable Healthcare unit and a Climate Solutions Fund to support sustainable practices in healthcare and reduce the sector’s significant emissions. n

• A dedicated vision mission within the Medical Research Future Fund of $150 million over 10 years. • A national evidence-based framework for the early identification and management of vision and eye health problems in 3.5 to 5 year-old children. OPHTHALMOLOGY PROPOSALS RANZCO head of advocacy Mr Gerhard Schlenther provided a list of recommendations from the college split into five areas. Among its four proposals under ‘service delivery and preventative healthcare’, RANZCO called for measures to improve timely access to geographically available,

Optometry Australia believes the current Medicare fee for optometric domiciliary services grossly under-recognises the actual cost.

NEWS

REGIONAL OPHTHALMOLOGISTS UNDER PRESSURE IN NSW

IN BRIEF n

RANZCO has highlighted the intensifying pressure on regionally-based private ophthalmologists in NSW – potentially sending some into early retirement – due to a lack of state government funding for outpatient services in most communities. The college recently lodged a submission to the 'NSW Government parliamentary inquiry into health outcomes and access to health and hospital services in rural, regional and remote New South Wales'. RANZCO is advocating for better service provision for people living in rural, regional and remote NSW. In its submission, the college stated NSW Health provided minimal public eye clinic services in regional NSW, despite these services being eligible for public hospital funding. This means patients are more likely to have delayed treatment, travel for treatment, and prolonged poor vision before accessing care. In some instances, some may have permanent vision impairment or loss as a result. “The capacity of publicly funded ophthalmology services across NSW has stagnated, resulting in increasing inequity of access to these vital services. The long-term consequences for workforce stability, and therefore patient access to services, is of great concern,” RANZCO stated. The submission points out that the current model of care for ophthalmology in regional NSW does not allow for access to public ophthalmology outpatient services because NSW Health does not routinely fund outpatient services in regional NSW. There are some exceptions to this such as in Dubbo and Broken Hill which both have public clinics and no resident ophthalmologists. Services in these areas are supplied by regular outreach. As a result, the burden of supplying outpatient services in regional NSW largely falls upon regionally based private ophthalmology practices. Many regional private practices generally provide for the entire community – often bulk-billing patients that can’t afford to pay a gap. The onus is on the patient to disclose a financial need for bulk-billing, and in some cases this comes at significant cost to the practice. Many services, such as intravitreal injections and the ongoing treatment of established glaucoma, are provided regularly to patients with chronic ophthalmic conditions and

without these services, irreversible loss of vision could occur. Regionally based ophthalmologists in NSW are typically working under severe workforce pressure with many significantly fewer ophthalmologists per 100,000 people than their city counterparts, RANZCO stated.

The capacity of

With increasing workforce pressure publicly funded regionally, an ageing regional workforce, an services has stagnated in NSW. ageing population and ongoing population growth regionally, the college is concerned regionally based private ophthalmologists are under increasing pressure and this may result in some being forced into early retirement if their workload became unsustainable. To address this, RANZCO has called on the NSW Government to: • M andate eye outpatient delivery in all districts with public reporting of waitlist data • D evelop a centrally administered e-referral portal • D evelop KPIs and increase funding for public ophthalmology workforce • I nvestandsupporttheRANZCORegionally Enhanced Training Network, which has federal funding • E stablish an agency of telehealth, in-reach and outreach services to support the regional workforce • F und equitable delivery of cataract surgery across NSW that meets community demand • F und established NSW ophthalmology outreach services • U rgently implement Indigeneity as a comorbidity for wait list categorisation purposes. Associate Professor Ashish Agar, director of ophthalmology in Broken Hill and part of the Outback Eye Service, said this was an opportunity to fix the system that the sector cannot afford to miss. “We’ve been advocating about these issues for ages, but hopefully this time the government will engage with us to make real progress,” he said. The parliamentary inquiry was established in September 2020 to inquire and report on health outcomes and access to health and hospital services in rural, regional and remote NSW. n

B+L IPO

Bausch + Lomb (B+L) has filed for an initial public offering (IPO) on the New York and Toronto stock exchanges. It comes after an August 2020 announcement from parent company Bausch Health that B+L would spun off into an independent publicly traded entity that would consist of the vision care, surgical, consumer and ophthalmic Rx businesses. This would be separated from the remainder of the Bausch business comprising a diversified pharmaceutical company focusing on gastroenterology, aesthetics/dermatology, neurology and international pharmaceuticals. According to the company’s prospectus filed with the Securities and Exchange Commission, B+L’s revenues totalled about US$2.7 billion (AU$3.9 b) for the first nine months of 2021 and US$3.4 billion (AU$4.8 b) for the full year of 2020. It has a portfolio of more than 400 eye-related products.

RANZCO CONGRESS

RANZCO has unveiled new details for its 53rd congress later this year. After COVID-19 case numbers forced organisers to switch February’s 52nd congress in Brisbane to a virtual-only format, the college confirmed it had secured the Brisbane Convention and Exhibition Centre for the 53rd Congress to be hosted there from Friday 28 October to Tuesday 1 November 2022. Perth will now host the 54th congress in 2023, which will take place Friday 20 to Tuesday 24 October.

MYOPIA ENDORSEMENT

The Canadian Association of Optometrists (CAO) has endorsed the World Council of Optometry (WCO) myopia management as standard of care resolution. The CAO stated that it recognised myopia is a global public health issue and cannot be considered merely an inconvenience of uncorrected vision. “Since the World Health Organization’s release of the World Report on Vision in 2019, CAO’s council has been concerned about the increasing prevalence of myopia globally. The World Council of Optometry’s standard of care for myopia management provided CAO with a foundation upon which to build our position to ensure that all those who are at risk of myopia receive the best preventive and curative eye health and vision care from Canadian optometrists,” CAO president Dr Harry Bohnsack said.

INSIGHT March 2022 9

NEWS

HEALTHIA MARKS LARGEST OPTICAL ACQUISITION SINCE THE OPTICAL COMPANY TAKEOVER ASX-listed Healthia has entered into a binding agreement to acquire the eight-practice business LensPro Optometrists, securing its largest optometry acquisition since its 2020 takeover of The Optical Company. The allied health group announced the deal on 24 December. Once finalised on or before 28 February, Healthia’s optical practice tally will increase to 53, with LensPro helping expand its reach in southeast Queensland and northern NSW. The value of the transition was not disclosed. LensPro’s Queensland locations are in Booval, Capalaba, Westfield Carindale, Westfield Garden City, Mount Gravatt, Westfield Helensvale, Loganholme and Mount Ommaney, with its sole NSW practice in Tweed. Mr Aaron Kangisser, general manager of The Optical Company within the Eyes & Ears division of Healthia, told Insight the LensPro acquisition was the largest optical partnership since The Optical Company joined the Healthia group with its 41 locations more than a year ago. “[LensPro] introduces additional highly experienced optical professionals, offering fresh insights into how we can develop operations and ultimately benefit the wider portfolio,” he said. “Adding eight stores to our existing

"WITH AN ASXLISTED COMPANY BEHIND US, WE ARE ABLE TO MOVE QUICKLY THROUGH DISCUSSIONS AND HAVE THE BACKING IN PLACE"

LensPro Mount Ommaney in Queensland.

network gives us even greater scale and particularly strengthens our exposure in southeast Queensland and northern NSW. LensPro’s first store opened in 2008. The stores are located within busy and convenient shopping centres and offer a signature one-hour service utilising in-store labs.

AARON KANGISSER, THE OPTICAL COMPANY

team and importantly a well-known and trusted reputation in the community. The mix of products and their optometry-led approach align well to our existing business,” he said. “Post LensPro, Healthia’s optical division will have grown to 53 stores. With a solid pipeline of further businesses to join the group in 2022, we look forward to welcoming both the LensPro team and others on board.” Earlier in 2021, Healthia also acquired John Holme Optometrist, a two-store business with practices in Mareeba and Malanda in northern Queensland. It also previously acquired Bernie Lanigan Optometrist, located in Townsville, Queensland, and The Eyecare Place, in Abbotsford, Victoria. The total consideration for these two acquisitions (plus stock, less employee entitlements) was $620,000, with the practices expected to generate $1.4 million in revenue.

“Furthermore, this new partnership demonstrates our ambition to continue to grow the portfolio. We are currently in advanced discussions with many business owners and the LensPro deal shows that with an ASX-listed company behind us, we are able to move quickly through discussions and have the backing in place to support these types of transactions.”

Healthia listed in September 2018, to bring together well-established allied health brands across a diversified healthcare business comprising of Bodies and Minds, Feet and Ankles, and Eyes and Ears divisions. Its notable brands include My FootDr Podiatry, Allsports Physiotherapy brands and The Optical Company, as it aims to be one of Australia’s leading allied health companies. n

Kangisser said his team had known the LensPro business for some time and had always held it and the way it operated in high regard. “LensPro has a stable and experienced

MASON COX TO WEAR PRESCRIPTION SUNGLASSES FOR 2022 SEASON? A regional Victorian optical practice has supplied AFL player Mason Cox with prescription sunglasses, which the Magpies forward will seek approval to wear during matches in the 2022 season. EyeSports, owned by Mr John Carbury in Colac, reportedly dispensed the sports eyewear to Cox who has faced multiple serious eye injuries during the past three seasons that threatened to derail his career. The EyeSports business started by supplying prescription inserts for motocross, ski and motorcycle goggles in the late 1990s, but has since expanded into sports-specific eyewear for ball sports, cycling, running, watersports and tactical eyewear. AFL.com.au reported that Cox had been trialling his new specs over the pre-season, but will likely require approval to wear

INSIGHT March 2022

them in official matches. The 30-year-old is planning to wear them during day games and could wear them at night due to the floodlights at AFL grounds. “Cox first required eye surgery in 2019 after an accidental poke from then Gold Coast ruckman Peter Wright resulted in a torn Mason Cox trialling retina,” reports stated. his new prescription “It was during that operation that surgeons discovered his other retina was also detached, following an incident in a contest against West Coast defender Tom Barrass in the 2018 Toyota AFL Grand Final loss against West Coast. The two surgeries left Cox practically legally blind for a short period in 2019, where he had to spend two weeks in a dark room positioned on his back for 45 minutes of every hour, unable to move or watch TV or use his phone.”

sunglasses.

All up, Cox has reportedly had three surgeries on his left eye, and two on his right, plus cataract surgery. He has been left long-sighted in his left eye and has found the sunglasses more effective in the past couple of months, after using contacts in 2020 and 2021. On its website, EyeSports states the majority of its sports-specific eyewear won’t be found in traditional optical outlets. It has its own prescription state-of-the-art eyewear lab in Colac, and the majority of its prescription eyewear – except certified safety and authentic Oakley and Ray-Ban products – is made on-site. The company says this enables it to source the latest and best technology from around the world. Additionally, it can control quality, guaranteeing best-quality eyewear for its customers. n

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NEWS

GAP BETWEEN ‘RETINAL AGE’ AND REAL AGE LINKED TO LIKELIHOOD OF DEATH, NEW RESEARCH FINDS The difference between the biological age of the retina and a person’s actual age is linked to their risk of death, according to new research involving Melbourne academics published in the British Journal of Ophthalmology. Professor Mingguang He, from the Centre for Eye Research Australia, along with researchers from Monash University’s e-Research Centre and Medical AI Group, co-authored the paper contributing to a body of evidence suggesting the retinal microvasculature might be a reliable indicator of the overall health of the body’s circulatory system and brain. Prof He and his research team turned to deep learning to determine if it could accurately predict a person’s retinal age from fundus images to see whether any difference between this and a person’s real age, referred to as the “retinal age gap”, might be linked to a heightened risk of death. The researchers drew on 80,169 fundus images from 46,969 adults aged 40 to 69, all of whom were part of the UK Biobank, a large, population-based study of more than half a million middle aged and older UK residents. Some 19,200 right eye fundus images of 11,052 participants in relatively good health at the initial Biobank health check were used to validate the accuracy of the deep learning

"OUR NOVEL FINDINGS HAVE DETERMINED THAT THE RETINAL AGE GAP IS AN INDEPENDENT PREDICTOR OF INCREASED MORTALITY RISK" Prof Mingguang He, Centre for Eye Research Australia.

STUDY AUTHORS

model for retinal age prediction.

disease or cancer. And every one-year increase in the retinal age gap was associated with a 2% increase in the risk of death from any cause and a 3% increase in the risk of death from a specific cause, other than cardiovascular disease and cancer, after accounting for potentially influential factors, such as high blood pressure, weight (BMI), lifestyle, and ethnicity. The same process applied to the left eyes produced similar results. “Our novel findings have determined that the retinal age gap is an independent predictor of increased mortality risk, especially of non-[cardiovascular disease]/ non-cancer mortality. These findings suggest that retinal age may be a clinically significant biomarker of ageing,” the paper stated.

This showed a strong association between predicted retinal age and real age, with an overall accuracy to within 3.5 years. The retinal age gap was then assessed in the remaining 35,917 participants during an average monitoring period of 11 years. During this time, 1,871 (5%) participants died: 321 (17%) of cardiovascular disease; 1,018 (54.5%) of cancer; and 532 (28.5%) of other causes including dementia.

“The retina offers a unique, accessible ‘window’ to evaluate underlying pathological processes of systemic vascular and neurological diseases that are associated with increased risks of mortality.

The proportions of ‘fast agers’– those whose retinas looked older than their real age – with retinal age gaps of more than three, five, and 10 years were, respectively, 51%, 28%, and 4.5%.

The new findings, combined with previous research, add weight to “the hypothesis that the retina plays an important role in the ageing process and is sensitive to the cumulative damages of ageing which increase the mortality risk,” they explained. n

Large retinal age gaps in years were significantly associated with 49%-67% higher risks of death, other than from cardiovascular

GLAUCOMA SURGEON PERFORMS VICTORIA'S FIRST PRESERFLO MICROSHUNT PROCEDURE BY GLAUKOS Glaucoma surgeon Dr Nathan Kerr has performed Victoria’s first procedure with the PRESERFLOMicroShunt,firstapprovedlocally in mid-2021. Kerr, who completed a fellowship at the prestigious Moorfields Eye Hospital in London, recently treated the first patient on at Vermont Private Hospital in Melbourne.

“Rapid advances in technology mean we can now offer patients a range of options to safely lower their eye pressure, reducing or in many cases even eliminating the need for glaucoma drops. Our focus is not only on saving sight, but improving quality of life.” Kerr added.

He said more than 300,000 Australians have glaucoma, the majority requiring lifelong use of eye drops. However, eye drops may be inadequate for some, putting them at risk of vision loss and blindness.

The PRESERFLO MicroShunt, supplied by Glaukos, is a controlled, ab externo filtration device designed to deliver a unique combination of efficacy and safety for patients with primary open-angle glaucoma (POAG).

He said the PRESERFLO MicroShunt was a new procedure that may now help people with refractory glaucoma. It is a small tube surgically implanted to relieve high intraocular pressure (IOP).

Last June Glaukos announced it had secured Therapeutic Goods Administration approval for the device and is now expecting it to be listed on the Prosthesis List from 1 March 2022.

INSIGHT March 2022

It is intended for the reduction of IOP in patients with POAG where IOP remains uncontrollable while on maximum tolerated medical therapy and/or where disease progression warrants surgery. The PRESERFLO MicroShunt is 8.5mm in length.

Engineered to control IOP while decreasing post-operative risk, the company said the device is 8.5mm in length and made from proprietary, biocompatible material called SIBS [poly(styrene- block-isobutylene-blockstyrene)]. It is flexible and features a 70 μm lumen to optimise aqueous flow and decrease hypotony risk; a 3 mm distal tail enables formation of posterior bleb; the 1 mm fin prevents migration and periannular leakage, and a bevelled tip visually aids in correct device orientation1-3 (references available upon request). n

AP PLY T H E

B R A K E S TO SLOW DOWN

MYOPIA

CHILDREN

W I T H T H E F I R S T R E G I S T E R E D L OW- D O S E AT R O P I N E E Y E D R O P S * 1 , 2

*EIKANCE 0.01% eye drops (atropine sulfate monohydrate 0.01%) is indicated as a treatment to slow the progression of myopia in children aged from 4 to 14 years. Atropine treatment may be initiated in children when myopia progresses ≥ –1.0 diopter (D) per year.1

PBS information: this product is not listed on the PBS

Before prescribing please review full Product Information available via www.aspenpharma.com.au/products or call 1300 659 646 This medicinal product is subject to additional monitoring in Australia. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse events at https://www.tga.gov.au/reporting-problems. EIKANCE 0.01% EYE DROPS (atropine sulfate monohydrate 0.01%). Indication: To slow the progression of myopia in children aged 4 to 14 years. May be initiated in children when myopia progresses ≥-1.0 D per year. Contraindications: Presence of angle closure glaucoma or where angle closure glaucoma is suspected. In glaucoma susceptible patients, an estimation of the depth of the angle of the anterior chamber should be performed prior to the initiation of therapy. Known hypersensitivity to any ingredient of the product. Precautions: Risk-benefit should be considered when the following medical problems exist: Keratoconus - atropine may produce fixed dilated pupils, Synechiae - atropine may increase the risk of adherence of the iris to lens. Use in Children: atropine sulfate monohydrate should not be used in children who have previously had severe systemic reaction to atropine. Use with great caution in children with Down’s syndrome, spastic paralysis, or brain damage. Limited clinical evidence is available for the long-term safety in children and adolescents. Regular eye health clinical reviews recommended during long-term treatment, including the monitoring of anterior segment development, intraocular pressure, retinal health and myopia progression. Consider careful monitoring of anterior segment development with prolonged use in very young children. EIKANCE 0.01% eye drops should not be used in children less than 4 years of age. If children experience photophobia or glare, they may be offered polychromatic glasses or sunglasses. If children experience poor visual acuity, consider progressive glasses. Discontinuation may lead to a rebound in myopia. EIKANCE 0.01% eye drops are not indicated for use in the elderly. Possible effect on the ability to drive or use machinery due to poor visual acuity should be evaluated, particularly at the commencement of treatment. Pregnancy: Category A. Lactation: distributed into breast milk in very small amounts. Interactions: systemic absorption of ophthalmic atropine may potentiate anticholinergic effects of concomitant anticholinergics. If significant systemic absorption of ophthalmic atropine occurs, interactions may occur with antimyasthenics, potassium citrate, potassium supplements, CNS depressants, such as antiemetic agents, phenothiazines, or barbiturates. Concurrent use may interfere with anti-glaucoma agents, echothiophate, carbachol, physostigmine, pilocarpine. Adverse Effects: photophobia, blurred vision, poor visual acuity, allergy, local irritation, headache, fatigue. See full PI for other ophthalmic and systemic AEs. Dosage and administration: Treatment should be supervised by a paediatric ophthalmologist. Instil one drop into the eye as required for treatment. Minimise the risk of systemic absorption, by applying gentle pressure to the tear duct for one minute after application. Should be administered as one drop to each eye at night. The maximum benefit of treatment may not be achieved with less than a 2 year continued administration period. The duration of administration should be based on regular clinical assessment. Each container is for single use, discard after administration of dose. (Based on PI dated 25 November 2021) References: 1. Approved EIKANCE Product Information, 125 November 2021. 2. Australian Register of Therapeutic Goods. Accessed 10-Dec-2021. Aspen Australia includes Aspen Pharmacare Australia Pty Ltd (ABN 51 096 236 985) and Aspen Pharma Pty Ltd (ABN 88 004 118 594). All sales and marketing requests to: Aspen Pharmacare Pty Ltd, 34-36 Chandos Street, St Leonards NSW 2065. Tel: +61 2 8436 8300 Email: aspen@aspenpharmacare.com.au Web: www.aspenpharma.com.au Trademarks are owned by or licensed to the Aspen group of companies. © 2021 Aspen group of companies or its licensor. All rights reserved. Prepared: Dec 2021 AF06092 ASP2639.

NEWS

AGED CARE RESIDENTS’ USE OF EYE HEALTH SERVICES DISPROPORTIONATELY LOW

NHMRC GRANTS RECOGNISE COMMERCIAL POTENTIAL OF OPHTHALMIC INNOVATIONS Two vision-related innovations currently in development have received a significant financial boost as part of the Federal Government’s $15 million investment in research projects Prof Robert Casson, that will drive better University of Adelaide. healthcare.

"ANTI-INFECTIVE EYE DROPS WERE THE MOST COMMONLY DISPENSED MEDICATIONS" STUDY AUTHORS

Associate Professor Hamish Meffin from the University of Melbourne received $1,141,581 for a retinal implant with closed-loop, multichannel stimulation to improve visual acuity. Meanwhile Professor Robert Casson from the University of Adelaide has been awarded $525,106 for his work rescuing cone photoreceptors in retinitis pigmentosa with laser-delivered photobiomodulation. Both ventures are part of 19 innovative research projects to be funded through the National Health and Medical Research Council (NHMRC) Development Grant scheme.

Less than half (46%) of Australians with an eye condition accessed an eye health service within the first year of entering residential care, according to a study of senior Australians. Yet 70% used at least one ophthalmic medication. The study, published in the Translational Vision Science and Technology journal, evaluated prevalence of eye conditions, use of eye health care services, and ophthalmic medications after entering residential aged care in Australia. It involved a cross-sectional study using data from the Registry of Senior Australians (ROSA) on 409,186 individual aged care residents aged 65 years or older who entered residential aged care between 2008 and 2015.

the study’s lead researcher Dr Jyoti Khadka told Australian Ageing Agenda the findings were concerning because age predisposes Australians to having more eye conditions, but they are not accessing proper eye health services.

The study revealed optometric services were the most used eye healthcare services (42%) and anti-infective eye drops were the most commonly dispensed medications (37%).

Prevalence of any eye condition, acute eye conditions, and blindness decreased over the study period while the prevalence of glaucoma and cataract remained stable or slightly increased.

In total, 44% had an eye condition, 33% had chronic eye conditions (glaucoma and cataract were most common at 14% and 8%, respectively) and 20% had an acute eye condition. ROSA senior research fellow and

“Australia continues to be at the forefront of medical research and these projects have the potential to increase not only our understanding of diseases, but to also revolutionise their treatment,” Health Minister Mr Greg Hunt said.

A new research article published in JAMA Ophthalmology has found more than a third of young adults may experience a “myopic shift” in at least one eye after the age of 20.

Dr Samantha SzeYee Lee, Lions Eye Institute.

The article, co-authored by Dr Samantha Sze-Yee Lee, Postdoctoral Research Fellow at the Lions Eye Institute, suggests regular eye checks are essential in young adulthood – those in their 20s – to detect the onset and progression of myopia, which could increase a person’s risk of vision-related complications later in life. It was previously thought that myopia stabilises in children by their mid-teens. Lee said her team’s research signifies the importance of getting a regular eye test.

INSIGHT March 2022

The study’s authors concluded the burden of eye diseases remained high between 2008 and 2015, whereas the use of eye healthcare services was disproportionately low. n

AUSSIE STUDY DEBUNKS COMMON BELIEFS ABOUT MYOPIA

“Our government continues to provide unprecedented support to health and medical research, as we back our best and brightest researchers to transform today’s ideas into breakthrough treatments for the patients of tomorrow.” n

The government invested $15 million to advance research projects.

The study provides evidence of a significant need for eye healthcare services in residential aged care.

“We used to think that myopia, or shortsightedness, starts to develop and worsen only during childhood,” she said. “However, our study reports that about

14% of people who do not have myopia at age 20 go on to develop it by age 28. Additionally, myopia continues to worsen in about one-third of young adults in their third decade of life.” The team also discovered that women are much more likely to have myopia onset or progress than men. “Women are at 80% higher risk of myopia onset in their third decade of life and have about twice the rate of myopia progression compared to men,” Lee said. It is unclear why this is the case, although Lee and the team speculate that environmental factors, such as women’s tendency to work more in indoor-based occupations, may explain this difference. Lee said more research is needed to understand the reasons behind myopia progression in young adults. n

NEWS

AUSSIE-LED DRY EYE REGISTRY PAINTS FULLER PICTURE OF DISEASE LANDSCAPE Eyecare professionals are being reminded to participate in a new dry eye registry, led by Sydney’s Save Sight Institute (SSI), that will help the industry better determine the long-term effectiveness and safety of treatments. The Save Sight Dry Eye Registry was launched in November 2020 and is now utilised by 31 clinicians from 26 sites. It is said to be the world’s first international, interdisciplinary dry eye registry. Its international steering committee is led by Professor Stephanie Watson, of The University of Sydney’s, SSI. With the prevalence of dry eye ranging from 5% to 50% worldwide – occurring more frequently in women and the elderly – it is considered a growing public health concern due to its impact on quality of life, despite the availability of multiple treatments. Mask wear during COVID-19 has exacerbated symptoms. Despite the therapies, devices and surgical procedures developed for dry eye, few have been evaluated using post-market surveillance, the SSI reported. “Clinical registries are beginning to play significant roles in healthcare decision making as they are able to collect real-world data over longer periods of time,” Watson said.

Dry eye disease prevalence ranges from 5% to 50% globally.

“Critically, they are able to determine the long-term effectiveness and safety of treatments for dry eye.”

“CRITICALLY, [REGISTRIES] ARE ABLE TO DETERMINE THE LONG-TERM EFFECTIVENESS AND SAFETY OF TREATMENTS FOR DRY EYE” STEPHANIE WATSON, SAVE SIGHT INSTITUTE

The Save Sight Dry Eye Registry will allow clinicians to anonymously enter information into the registry that relates to multiple aspects of dry eye management, including the treatments used, individual patientreported outcomes and adverse reactions.

tool in the form of a patient graph. This assists clinicians to monitor and individualise patient treatments over time and allows the patient to become more involved in their treatment journey. Once established, the registry will be able to evaluate the clinical and patientreported outcomes from emerging therapies. It also allows patients to complete online patient reported outcome questionnaires such as the Ocular Surface Disease Index, and clinicians to grade surface staining efficiently. “In my practice this has really helped me to determine which patients would be suitable for the newer therapies on the market, as these data may be needed for authority approval,” Watson said. Dr Maria Cabrera-Aguas recently featured the registry in the Sydney Eye Podcast. She commented on how the registry was developed, its advantages and how ophthalmologists and optometrists can request access to use it. To join the registry, request access at savesightregistries.org and click‘requestaccess’.Participantswillbeasked to complete a brief training session before being granted access to the registries. For further information, contact: ssi.ssr@sydney. edu.au or maria.cabreraaguas@sydney.edu. au. n

This information is expected to have positive outcomes for patients, clinicians, government health institutions and industry. Professor Fiona Stapleton, from the School of Optometry and Vision Science, UNSW Sydney, added: “The registry will help to understand the natural history of dry eye, to predict those patients who are at a higher risk of more severe disease and to tailor treatment for individual patients.” The registry generates a patient education

EYE SURGEONS RECOGNISED IN AUSTRALIA DAY HONOURS Ophthalmologists Dr James La Nauze from Melbourne and Dr Stephen Godfrey from Surfers Paradise have been recognised in the 2022 Australia Day Honours. La Nauze was awarded Member (AM) in the General Division of the Order of Australia for significant service to ophthalmology, and to not-for-profit organisations. Godfrey was awarded Medal (OAM) of the Order of Australia in the General Division for service to medicine as an ophthalmologist. La Nauze trained at the Royal Victorian Eye and Ear Hospital in Melbourne, and at Addenbrookes Hospital in Cambridge, UK. Upon his return to Australia, he worked in Albury, NSW for 20 years. He then moved back to Melbourne and began consulting at Vision Eye Institute Footscray, where he has remained for the past 20 years.

INSIGHT March 2022

Among many professional roles, La Nauze was a board member of the Fred Hollows Foundation from 2010 to 2019, and chair of its Medical Advisory Committee from 2010 to 2016. He has also undertaken many clinical and surgical trips to remote areas of Queensland and the South Pacific and has led many surgical training teams to Vietnam, Cambodia and China. Godfrey is one of the founding partners of Outlook Eye Specialists in Surfers Paradise, established in 1999. He graduated from the University of Queensland Medical School, and after seven years as a GP and country medical superintendent in the central west of Queensland, completed ophthalmology training in Brisbane.

He obtained further experience at Taunton Hospital in Somerset, England, before settling on the Gold Coast in 1999. Godfrey is current chair of RANZCO’s Queensland branch, a position he has held Dr Stephen Godfrey.

since 2017, and has been a volunteer with the Aboriginal Outreach Eyecare Service North Queensland for 20 years. He is also a Visiting Medical Officer in the Ophthalmology Department at Gold Coast University Hospital, since 1999. Miss Patricia d’Apice, a senior consultant at the Royal Institute for Deaf and Blind Children in Sydney, was also awarded a Medal (OAM) of the Order of Australia in for service to education for people with vision impairment.

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NEWS

PRESCHOOL MOBILITY AND MOTOR SKILLS CLOSELY ALIGNED WITH GOOD VISION, STUDY SHOWS

UNDERSTANDING GENETIC TESTING SUPPORT FOR IRD PATIENTS People with an inherited eye disease (IRD) who have received genetic testing are invited to participate in a national survey led Dr Alexis Ceecee by the Centre for Eye Britten-Jones, CERA. Research Australia and the University of Melbourne.

“EXISTING CLINICAL TESTS FOR TWO-YEAROLD CHILDREN’S VISION ARE NOT PREDICTIVE OF VISUAL OUTCOMES AT 4.5 YEARS" NICOLA ANSTICE, FLINDERS UNIVERSITY

“Existing clinical tests for two-year-old children’s vision are not predictive of visual outcomes at 4.5 years, so we recommend the development of more sensitive tests for this.”

INSIGHT March 2022

Children with poorer motor skills at an early age may benefit from comprehensive eye examinations.

Using a longitudinal study of vision and neurodevelopmental milestones of a cohort of 516 children at risk of perinatal adversity, the researchers observed a direct correlation between poor motor scores at two years of age with reduced depth perception (stereopsis) at four-and-a-half-years old. The study identified the relationship between visual, cognitive, motor and demographic factors at two years of age and visual acuity and stereoacuity at fourand-a-half years of age – paving the way for development of a new approach in ophthalmic practice in the future, the paper concluded. n

RESEARCH UNCOVERS HOW RETINAL IMMUNE CELLS CHANGE IN DIABETES

“This survey helps us capture the views of people with IRDs who have had genetic testing, so that we can better incorporate their lived experience into our research,” Britten-Jones said.

Researchers from Ireland, Australia, New Zealand, Hong Kong and Canada claim in a new article in Ophthalmic and Physiological Optics that abnormal motor abilities such as inaccurate tracing, grasping and catching are warning signs.

“Children who show poorer motor skills at an early age may benefit from comprehensive eye examinations to make sure these children get the best start to life, particularly with regard to reading and learning once they start school,” she said.

The research team is also seeking input from carers and parents of a child or dependent with an IRD, where that dependent has received genetic testing for their eye condition.

The project is a collaboration with the University of Melbourne and has been approved by the University Human Research Ethics Committee. Co-researchers are Ms Sujani Thrimawithana, Ms Fleur O’Hare, Dr Thomas Edwards, Associate Professor Heather Mack, Mr Joshua Schultz, Ms Lisa Kearns, Dr Jonathan Ruddle, Dr Aamira Huq, Professor Alex Hewitt and Professor David Mackey. n

International experts in vision and neonatal development found the presence of astigmatism and abnormal motor function at two years of age may be associated with poorer vision at four-and-a-half years of age.

Senior author Flinders University Professor Nicola Anstice said vision issues go undetected in around one in four children.

The study, led by Dr Alexis Ceecee Britten-Jones and Associate Professor Lauren Ayton, will help researchers learn about the lived experience of those with IRD who have had genetic testing, and better understand how to support those who have genetic testing in future.

“We’re also hoping that this data will help to enhance genetic support for IRDs, for people to have easy, subsidised access to genetic testing and genetic support services.”

Abnormal motor skills in toddlers such as grasping may be associated with poorer vision when they reach preschool age, a new study has revealed.

Researchers at the University of Melbourne and Centre for Eye Research Australia have uncovered how retinal immune cells change during diabetes, which may lead to new treatments that can be used from an early stage of disease, before vision loss. The findings offer hope for retinal and neurological conditions.

The group of 17 researchers found a specific type of immune cell, called microglia, contact both blood vessels and neurons in the retina and can change blood flow to meet the needs of neurons. “Until recently, immune cells of the nervous system were thought to sit quietly, only responding when injury or disease occurred," co-author Professor Erica Fletcher said. "Our finding expands our knowledge of what these cells do and shows a highly unusual mechanism by which blood vessels are regulated. This is the first time immune cells have been implicated in controlling blood vessel and blood flow."

With Dr Andrew Jobling, Fletcher identified the chemical signal by which the immune cells communicate with blood vessels, and demonstrated that immune cell regulation of blood vessels is abnormal in diabetes. The studies used preclinical animal models and a range of imaging methods that allowed researchers to see retinal immune cells in a living eye. Fletcher said the findings highlight a new way of controlling and potentially preventing retinal changes in diabetes. “This finding also has implications for our understanding of other diseases of the retina and the brain. Although only at an early stage, it suggests a novel way for understanding vascular diseases of the brain with implications for our knowledge of stroke and Alzheimer’s disease." n

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COMPANY

NOVARTIS TARGETS DRY AMD GENE THERAPY IN POTENTIAL AU$2 BILLION DEAL

LVMH BUYS OUT MARCOLIN IN THÉLIOS OPTICAL MANUFACTURING DEAL French luxury goods company LVMH has reached an agreement with Marcolin to acquire 49% of the companies’ jointventure, Thélios, increasing its stake in the high-end Italian optical frames manufacturer.

Novartis has announced it is acquiring Gyroscope Therapeutics, the UK-based company behind an investigational dry ADM gene therapy that is the focus of key clinical trials in Australia.

According to a statement, Marcolin will also buy back the 10% stake LVMH acquired in the firm when Thélios was founded in 2017.

The deal, which centres on the GT005 gene therapy, will see Novartis make an upfront payment of US$800 million (AU$1.1 billion) and potential additional milestone payments of up to US$700 million (AU$970 m).

As a result of the deal, Thélios will become fully integrated within LVMH, otherwise known as LVMH Moët Hennessy Louis Vuitton.

With there being no approved treatments for geographic atrophy (GA), it remains one of the most significant unmet needs in all retinal disease categories.

“This represents an opportunity for LVMH to further strengthen its presence in the eyewear industry leveraging its Italian savoir-faire, and for Marcolin to pursue future strategic investments,” the companies said in a joint statement.

GT005 is designed as an AAV2-based, one-time investigational gene therapy for GA secondary to AMD that is delivered with a subretinal injection. Its safety and efficacy is being evaluated in a Phase 1/2 clinical trial and two Phase 2 clinical trials.

LVMH originally teamed up with eyewear specialist Marcolin four years ago to establish Thélios and create a pathway into the eyewear market.

These include the HORIZON and EXPLORE trials. Around 20 Australians with dry AMD are expected to take part in both Phase 2 studies, with Dr Tom Edwards the first to deliver the therapy locally at The Royal Victorian Eye and Ear Hospital last year.

Thélios is focussed on the luxury eyewear segment, with labels such as Dior, Fendi and Celine. In 2018, the joint-venture opened the Manifattura Thélios, its flagship production site in Longarone, within the glasses-making district of Belluno, northeast Italy, with the firm employing 800 people globally.

According to Novartis, GT005 aims to restore balance to an overactive complement system,

Glaukos has commenced Phase 2 trials of two investigational cream-based drug candidates that are applied to the eyelids to treat dry eye and presbyopia.

The therapy is delivered through the dermis of the eyelid.

The ophthalmic medical technology and pharmaceutical company announced it has enrolled the first patient into a Phase 2 study of GLK-301 for the treatment of signs and symptoms of dry eye disease (DED). On the same day, it revealed the first patient had enrolled in a Phase 2 clinical trial of GLK-302 for presbyopia. Both therapies feature Glaukos’ iLution platform, patented cream-based drug formulations applied to the outer surface of the eyelid. The cream formulation acts as a depot allowing the active pharmaceutical ingredient pilocarpine to be delivered through the dermis of the eyelid.

INSIGHT March 2022

a part of the immune system, by increasing production of the CFI protein. Complement overactivation can lead to inflammation that damages healthy tissues, and it has been strongly correlated with AMD. GT005 has received Fast Track designation from the US Food and Drug Administration for GA. “With our own pioneering research in ocular gene therapies and our experience gained from bringing Luxturna to inherited retinal dystrophy patients outside of the US, Novartis has a well-established expertise in ocular gene therapies that will position us well to continue developing this promising one-time treatment,” Novartis president Ms Marie-France Tschudin said. n

GLAUKOS TRIALS EYELID CREAM FOR PRESBYOPIA AND DRY EYE

The manufacturing facility produces around 1.5 million optical frames annually, but has the capacity to increase this as its portfolio expands. n

Thélios is focused on the luxury eyewear segment, with labels such as Dior, Fendi and Celine.

Novartis will make an upfront payment of AU$1.1 billion for the gene therapy, with more to follow.

In patients with DED, the Phase 2 trial will evaluate the safety and efficacy of three

different dose levels of GLK-301 administered twice daily versus placebo over 28 days, followed by a 14-day safety follow-up period. Endpoints will include standard signs and symptoms characteristic of DED. “Our iLution platform has the potential to address the major unmet need for patients suffering from dry eye disease and other chronic eye diseases by providing an effective, easy-to-administer, safe, dropless transdermal therapeutic,” Mr Thomas Burns, Glaukos president and CEO, said. The presbyopia Phase 2 trial will evaluate the safety and efficacy of three dose levels administered twice daily versus placebo over 28 days, for improving mesopic, high-contrast, binocular distance corrected near visual acuity while not deteriorating binocular best corrected distance visual acuity in presbyopic patients. n

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INTERNATIONAL

SPECSAVERS UNVEILS AU$110M INVESTMENT FOR CANADA EXPANSION PLANS

1-800CONTACTSLAUNCHES B2B VISION TECHNOLOGIES AND SERVICES COMPANY American contact lens retailer 1-800 Contacts has announced the formation of a standalone business, Luna Solutions, that will provide technology and services to third parties in the vision sector.

Specsavers has announced it will invest AU$110 million to cover the full clinic and optical store start-up costs for new partners as the company pursues its first foray into the North American market. The company’s ‘joint venture partnership’ franchise model has been adapted to account for Canadian optometry and opticianry ownership rules.

The new company will offer 20 integrated technologies and services – ranging from telehealth platforms for new and renewal of glasses and contacts prescriptions, eyewear virtual try-on, a digital pupillary distance tool, glasses and contacts fulfillment and more.

The world’s largest privately-owned optometry group plans to open 200 stores by 2024, after opening its first store in November. Specsavers announced it would now invest CA$100 million (AU$110 m) to cover 100% of the costs – which average around $500,000 – for independent Canadian optometrists and opticians to establish their clinics and stores while creating 2,000 jobs.

The suite of solutions is designed to enable eyewear retailers, brands and practitioners to modernise their customer experience both online and in stores.

The company stated its investment decision would help boost clinic and optical store ownership by independent optometrists and opticians, while “remaining autonomous, competitive, and able to provide consumers with better patient care and greater variety of affordable, highquality eyewear”.

“We have always been focused on the constant pursuit of a better way for vision,” Mr John Graham, CEO of 1-800 Contacts, said. “We take a customer-centric approach to make buying glasses and contacts simple and affordable. To expand our reach, we knew we’d have to expand upon our partnerships with other retailers and doctors.” According the an announcement from 1-800 Contacts, Luna is formed through the combination of Premium Vision (contact lens fulfillment services and eCommerce platform for optical retailers), Ditto (virtual try-on technology), 6over6 (the world’s first medical grade mobile subjective refraction app), and ExpressExam (a telehealth prescription renewal platform). n

1-800 Contacts has formed Luna Solutions through recent acquisitions.

INSIGHT March 2022

“At a time when we’re seeing more and more consolidation in the Canadian market with independent optometrists and

New Specsavers owner Dr Ian Scholfield (right) with retail partner Seija Gilks in Nanaimo B.C.

opticians being encouraged to sell their practices to a handful of larger players, we intend to reverse that trend and offer an alternative that enables them to own a thriving business, have access to cuttingedge technology and put their patients first,” Mr Bill Moir, general manager of Specsavers Canada, said. With the offer, Canadian optometrist and opticians will have an opportunity to become Specsavers clinic or optical store owners with the set-up costs covered in full by the company. Optometry and retail partners will begin receiving earnings generated by both the optometry clinic and the optical store immediately. n

STALEMATE OVER ONTARIO OPTOMETRY PAY DISPUTE ISN'T OVER YET Optometrists in the Canadian province of Ontario have resumed publicly-funded services for seniors and children in an act of “good faith” after refusing to provide care due to a lack of funding that saw them making up the shortfall. Ontario optometrists refused to provide publicly-funded care.

The Ontario Association of Optometrists (OAO) announced it has entered into formal negotiations with the provincial government. It followed a months-long pay dispute that meant hundreds of thousands of people couldn’t access eyecare. Media outlets have reported that government payments to optometrists for patients who are covered by the Ontario Health Insurance Plan (OHIP) have fallen significantly behind the cost of providing actual services, claiming Ontario’s health ministry only pays about $5 more for an eye exam in 2021 than it did in 1989. For several weeks, most of Ontario’s

optometrists refused to see children, seniors and others eligible for an OHIP-covered exam. At one point, 250,000 appointments had been cancelled, rising about 15,000 eye exams a day, local media report. Optometrists’ refusal to see OHIP patients delayed about 2,000 referrals for cataract surgery a week. The OAO recently said it had entered formal negotiations with the government. “As a sign of good faith, the OAO is pausing its job action, ensuring that millions of Ontarians insured by OHIP can again benefit from the expertise of their optometrist during these negotiations. “The OAO expects robust talks to begin immediately, noting the swift resolution of this issue is a top priority for both optometrists and their patients.” n

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†1-9

The first-of-its-kind presbyopia-correcting IOL with wavefront-shaping technology and a clinically proven monofocal visual Based on intermediate and functional near visual acuity, and spectacle independence with a monofocal visual disturbance profile. Please refer to product direction for use for complete list of indications, contraindications and warnings. †

References: 1. AcrySof ® IQ Vivity ® Extended Vision IOL Directions for Use. 2. Alcon Data on File, US Patent 9968440 B2, May 15, 2018. 3. Alcon Data on File, TDOC-0055575. 09 Apr 2019. 4. Alcon Data on File. TDOC-0055576. 23-Jul-2019. 5. Alcon Data on File, TDOC-0056718. 18-Jun-2019. 6. Ligabue E, et al. ACRYSOF IQ VIVITY: Natural vision at a range of distances provided by a novel optical technology. Cataract & Refractive Surgery Today. April 2020 // 7. Alcon Data on file. A02062-REP-043696, Optical Evaluations of Alcon Vivity ®, Symfony *, Zeiss* AT LARA* AT LISA IOLs. Feb 2020. 8. Lawless M. Insight news. “An IOL to change the cataract surgery paradigm?” available at “https://www.insightnews.com.au/an-iol-to-change-the-cataract-surgeryparadigm/”. Accessed Date 17.07.2020. 9. Ike K. Ahmed, et al. The Vivity Extended Depth of Focus IOL: Our Clinical Experience. Cataract & Refractive Surgery Today. February 2021. *

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disturbance profile

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RESEARCH

STUDY FINDS A THIRD OF nAMD PATIENTS COULD SAFELY STOP EYE INJECTIONS “SUCH A TEST COULD LET US TELL PATIENTS EARLY ON HOW WELLTHEYWOULD DO AND WHEN THEY MIGHT BE ABLE TO STOP"

A new study has shown up to a third of neovascular age-related macular degeneration (nAMD) patients may safely be able to stop intravitreal injections after a year. In a preliminary study of 106 people with nAMD, Johns Hopkins Medicine researchers say while their findings fall short of setting a timeline for ending treatment or predicting which patients can stop injections, they have added to evidence that many patients may not need the lifelong monthly medication. The findings also point to specific proteins produced at different levels in the eyes of those who stopped therapy, which may lead to the development of a test to identify who may be weaned off medication. “Such a test could let us tell patients early on how well they would do and when they might be able to stop,” Dr Akrit Sodhi, Associate Professor of Ophthalmology and the Branna and Irving Sisenwein Professor of Ophthalmology at the Johns Hopkins University School of Medicine and Wilmer Eye Institute, said. For the study – published recently in Journal of Clinical Investigation – Sodhi and his team analysed treatment outcomes of 106 people with nAMD whom he treated. Each patient had undergone a customised anti-VEGF injection schedule in which Sodhi monitored the response to therapy and determined whether they needed another

Schematic summarising the research. Fluid collected from nAMD patients receiving antiVEGF. Analyses on the proteins to identify biomarkers for those to be safely weaned off therapy. Credit: Isabella Sodhi and Adriana Sodhi.

AKRIT SODHI, JOHNS HOPKINS UNIVERSITY

six to 12 weeks; a handful of these patients were also ultimately weaned from treatment at the end of year two. Patients who stopped anti-VEGF treatments in at least one eye showed the best outcome, with less fluid and improved vision compared with those who required continued injections to maintain their vision. “Across the board, the patients who could enter a treatment pause did the best even though they were receiving no anti-VEGF drugs. They had better visual acuity, better gain of vision and less fluid in their retina,” Sodhi said. The researchers next sought biomarkers that could show what distinguished these patients from those who required monthly injections to maintain their vision.

injection at each visit or if they could pause, in which the injection was held unless there was evidence of new disease activity at the next visit. Eyes without treatment that showed no signs of fluid accumulation or advancing vision loss after at least 30 weeks of monitoring were considered safely weaned off anti-VEGF therapy. At the end of a year, up to a third of the patients had stopped antiVEGF treatments in at least one eye.

They found apolipoprotein B100 protein was present at much higher levels in the eyes of patients who had been weaned off anti-VEGF treatment. They further observed levels of this protein were higher in patients who did not develop nAMD compared with patients who did. They hypothesised this protein may help protect patients from developing the disease.

That amounted to 38 of 122 (31%) of treated eyes. A smaller percentage of eyes still required monthly injections, amounting to treatments for 21 of 122 (17%) patients’ eyes. The other half required treatment every

In mouse models, those genetically engineered with elevated B100 levels had less abnormal blood vessel growth in the retina than mice with lower levels, suggesting the protein has a protective effect. n

CANBERRAVISIONRESEARCHERSTOUT‘EXERCISEINAPILL’FOR NEUROLOGICAL DISEASES Eye researchers from The Australian National University (ANU) have identified unique molecular signals that could hold the key to developing a supplement that administers “the health benefits of exercise” to people incapable of physical activity.

but also the central nervous system and eye diseases such as AMD. Associate Professor Riccardo Natoli, head of Clear Vision Research at ANU, said the molecules could potentially be hijacked, recoded and “bottled up” in a pill and taken like a vitamin.

The molecular messages – which were the focus of a systematic review into the benefits of exercise on the central nervous system and eyes published in Clinical and Experimental Ophthalmology – are sent to the brain and potentially the retina immediately after exercise.

“The beneficial messages being sent to the central nervous system during exercise are packaged up in what are known as lipid particles. We are essentially prescribing the molecular message of exercise to those who physically aren’t able to,” he said.

The ANU team is conducting research to better understand what impact these molecular messages have on retinal health,

The new ANU review of existing literature set out to discover what impact exercise has on the retina and whether exercise can

INSIGHT March 2022

help maintain good eyesight as people age.

Dr Joshua Chu-Tan and A/Prof Riccardo Natoli. Image: Tracey Nearmy/ANU.

Dr Joshua Chu-Tan, also from the ANU Clear Vision Research Lab, said: "We know exercise is good for our eyesight, but to what extent is still unknown. Our aim is to understand the benefits of exercise at the molecular level and how it is beneficial for the central nervous system and the retina. We found the benefits of exercise extend far beyond what has traditionally been known, however this has been largely understudied in the retina.” The researchers believe the futuristic supplement therapy could one day help patients suffering from neurological diseases such as Alzheimer’s and Parkinson’s. n

TECHNOLOGY

MOJO VISION EYES FITNESS WEARABLES MARKET WITH SMART CONTACT LENS TECHNOLOGY Smart contact lens startup Mojo Vision has signed strategic partnerships with leading sports and fitness brands. The company says it has identified an opportunity in the wearables market to deliver real-time performance data to athletes through its hands-free, eye-controlled user interface. According to Mojo, the collaborations will aim to provide next-generation user experiences that combine augmented reality, wearable technology and personal performance data. The companies will work together using Mojo’s smart contact lens technology, Mojo Lens, seeking ways to improve access to data and enhance athletes’ performance during sporting activities. The initial partnerships include Adidas Running (running/training), Trailforks (cycling, hiking/outdoors), Wearable X (yoga), Slopes (snow sports) and 18Birdies (golf). “Today’s wearable devices can be helpful

Through its strategic partnerships, Mojo Vision wants to explore additional smart contact lens interfaces and experiences to understand and improve the delivery of data for athletes of varying skill levels and abilities.

Mojo Lens overlays images, symbols and text on users’ natural field of vision. Image: Mojo Vision.

to athletes, but they can also distract them from the focus of the activity; we think there’s a better way to deliver athletic performance data,” Mr David Hobbs, senior director of product management of Mojo Vision, said. “Wearable innovation in existing form factors is starting to reach its limits. At Mojo, we’re interested in better understanding what’s still missing and how we can make that information accessible without disrupting someone’s focus and flow during training.”

According to the company, its Mojo Lens product is backed by years of scientific research and technology patents, overlays images, symbols and text on users’ natural field of vision without obstructing their view, restricting mobility or hindering social interactions. Mojo calls this experience ‘invisible computing’. In addition to the sports and wearables market, the firm is planning an early application to help people struggling with vision impairment by using enhanced image overlays. Mojo is working with the US FDA through its Breakthrough Devices Program, which provides safe and timely access to medical devices for irreversibly debilitating diseases. n

OPTOMETRY

OPTOMETRY BOARD OF AUSTRALIA MEMBERS JUDITH HANNAN (BOptom, MBA) Appointed as chair (first term) and reappointed as practitioner member from New South Wales for three years (second term) from 2 December 2021.

Initially a primary care optometrist who owned and ran her private practice for many years until transferring the business to her partner optometrist, Mrs Hannan has since been a locum in the southwest area of Sydney in private practice, industrial consulting and corporate practices.

Introducing THE NEW-LOOK OPTOMETRY BOARD OF AUSTRALIA

he Optometry Board of Australia (OBA) has appointed its ninestrong board for the next three years, including its next chair and new practitioner members for Tasmania and South Australia.

NSW optometrist Mrs Judith Hannan, who assumed the role of chair on 2 December, takes over from Adelaide optometrist Mr Ian Bluntish who was appointed as an inaugural member for South Australia in 2015 before assuming the chairmanship from 2015. Hannan has previously been the NSW OBA member for the past three years. With Bluntish’s departure, Miss Renee Slunjski – a therapeuticallyendorsed optometrist practising for the eight-practice independent optometry group National Vision Optometrists – becomes the South Australia member for the first time. Tasmanian independent optometrist Mr Martin Robinson, who operates Martin’s Eyecare near Hobart, has also recently commenced his first term. The third new member of the board is Mr Benjamin Graham who will serve his first three-year term as one of three community members. The OBA opened the applications period on 16 January 2021 before closing them on 21 February 2021. This took place over 14 National Boards regulating health professions under the National Scheme. Across all health and medical disciplines, 443 applications were received – 253 applications for practitioner member vacancies and 190 applications for community member vacancies. All appointments are made by the Ministerial Council for up to three years, under the Health Practitioner Regulation National Law.

INSIGHT March 2022

She is also on the Wollondilly Council and is a member of many committees. She is a member of the Optometry Council of NSW and the Australian Hand Therapy Association Accreditation Committee, and has qualifications in business and mediation. Previously, she has been the president of a group of councils in the Macarthur region. She has been awarded for her medical advocacy work for the introduction of a cancer therapy drug to PBS.

A/PROF ANN WEBBER (PhD MS FAAO, BAppSc(Optom)(Hons), GradCertOptTher) Reappointed as practitioner member from Queensland for six months (third term) from 15 December 2021.

A/Prof Webber is a primary eyecare practitioner with clinical and research interest in paediatric optometry. She commenced independent private practice in 1991, currently practising in Bulimba, an inner eastern suburb of Brisbane. She also holds a part-time Associate Professor appointment in the School of Optometry and Vision Science at Queensland University of Technology, and provides a clinical service within the Ophthalmology Department of the Queensland Children’s Hospital. Webber served for more than a decade on the Optometry Australia Queensland Division Council, including two terms as state president and chair of the Education Sub-committee. She was first appointed to the Queensland Optometry Registration Board in 2000 and served as deputy chair of the Queensland Board from 2009. From the inception of Ahpra, she has served as a member of the OBA Registration and Notification Committee, and was appointed to the OBA in 2015.

DR CARLA ABBOTT (BOptom, PhD, PostGradDipOcTher, FACO) Reappointed as practitioner member from Victoria for three years (second term) from 2 December 2021.

Dr Abbott is a therapeutically-endorsed optometrist who has primarily worked in academia and public health for the past 15 years. She is a research fellow with the Centre for Eye Research Australia conducting translational research studies and is a consultant optometrist and teaching clinician for more than 10 years at the Australian College of Optometry (ACO). As part of her research training, Abbott has completed post-doctoral

fellowships at the Save Sight Institute and Devers Eye Institute (Oregon, USA). She has also worked in private optometry practice including in country Victoria. Abbott has served as a director on the Council of the ACO (2010-11), and was an auditor of CPD for the Optometry Council of Australia and New Zealand (OCANZ; 2015-17). She is also a member of the Optometry Australia Age-related Macular Degeneration Clinical Practice Guide Working Group (2018).

STUART AAMODT (BOptom(Hons), PGCOT, BEcons) Reappointed as practitioner member from Western Australia for three years (second term) from 9 December 2021.

RENEE SLUNJSKI (BMedSc(VisSc), MOptom, CertOcTher) Appointed as practitioner member from South Australia for three years (first term) from 8 December 2021.

Miss Slunjski is a therapeutically-endorsed optometrist practising for the eight-practice independent optometry group National Vision Optometrist. She has worked with remote Indigenous communities in the APY Lands and Port Augusta. She has practised in the Riverland, Perth, Nepal and at the State University of New York as part of her university placements. Slunjski has a Graduate Certificate in Management, and is working towards completing her Masters in Business Administration.

Mr Aamodt joined Perth Eye Clinic as a clinical optometrist and dry eye specialist in December 2018 after previously being an optometry director at Specsavers Willetton. He has worked in independent, corporate, public and remote optometry settings across Australia and overseas. Prior to studying optometry, he completed a degree in economics and worked for a financial institution as a credit analyst. Aamodt has mentored optometry students on externship for the last four years. He has a keen interest in the delivery of optometric services to remote and Indigenous communities in Western Australia. His board experience includes a previous role on the Optometry Association Board (Victoria Division).

ANTHONY EVANS (BBus, DipEd) Reappointed as a community member for three years (third term) from 3 December 2021.

Mr Evans has extensive financial and general management experience as a senior executive and board director in the health, aged care, education, resources and not-for-profit sectors. His roles in the health sector have included being a board member of Perth Primary Care Network and Therapeutic Guidelines.

A/PROF ROSEMARY KNIGHT Reappointed as a community member for three years (third term) from 2 December 2021.

A/Prof Rosemary Knight recently retired from the position of principal adviser in the Commonwealth Department of Health. Previously, she was head of the School of Public Health and Community Medicine in the Medicine Faculty at UNSW. She has worked for 30 years in the health sector providing expert advice, teaching and mentoring, supporting research, doing policy and program development and guiding implementation and evaluation. She has an interest in health policy, cancer, Indigenous health and health services research, as well as translating evidence into practice.

MARTIN ROBINSON (BAppSc(Optom) ) Appointed as practitioner member from Tasmania for three years (first term) from 2 December 2021.

As a graduate from the class of 1994 at QUT, Mr Robinson originally worked in country Queensland. This included fly in, fly out work in concert with Dr Gary Brian of the Fred Hollows Foundation in remote Aboriginal and Torres Strait communities. He also worked with corneal surgeons, fitting RGP contact lenses to post graft corneas. In 2006 he moved to Hobart and since 2009 he has been owner and principal optometrist in his own independent optometry practice, Martin’s Eyecare. He has an interest in contact lenses and dry eye, speaking at conferences and writing education pieces for optometrists. He has mentored optometry students on externship for several universities for several years. Since 2017 he has been Tasmanian state president of the Cornea and Contact Lens Society of Australia (CCLSA), and national vice president of the CCLSA since 2018.

BENJAMIN GRAHAM Appointed as a community member for three years (first term) from 13 December 2021.

Mr Graham has worked for several peak bodies and professional associations in healthcare, agriculture and migration since 2007. Much of his experience working has focused on communication, marketing, membership, media and business development work. He has also served as an interim CEO, general manager and executive director during his time working in the associations sector. Graham has been a director on several not-for-profit boards including serving as chair, company secretary and chair of corporate governance sub-committees. Currently he is extending his skillset working for the Australian Government in communication and administrative roles. n Source: Optometry Board of Australia/Ahpra.

INSIGHT March 2022 27

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GLAUCOMA

a m o c u gla

THE FUTURE OF

DETECTION AND MONITORING

False colour images of cell autofluorescence superimposed on an image of a human eye. Blue: normal cells, pink: cells under oxidative stress. Image: Professor Ewa Goldys, UNSW.

Glaucoma affects an estimated 300,000 Australians but half of them don't know it. Early detection is considered vital to prevent irreversible vision loss and blindness. With the global eyecare sector’s focus on World Glaucoma Week between 6–12 March, Insight takes a closer look at advances in glaucoma research in Australia, particularly innovations in testing and diagnostic technologies.

ecognising the limitations of current glaucoma screening techniques, including timeliness and cost effectiveness, researchers have seized on the opportunity to target these shortcomings to design low-cost tests that deliver rapid results. Not only can their new screening and diagnostic tools detect glaucoma sooner, they could potentially one day form part of national screening programs and alleviate the direct and indirect costs of glaucoma to the Australian healthcare system, projected to hit $784 million by 2025. This month Insight speaks with three researchers, all non-eyecare professionals but experts in their chosen fields, about their work to develop all new imaging devices – and even a blood test – to pick up high-risk individuals before irreversible vision loss sets in.

INSIGHT March 2022 29

GLAUCOMA

FLUORESCENT HYPERSPECTRAL IMAGING

Physicist and biomedical engineer PROFESSOR EWA GOLDYS has collaborated with a team of clinicians, including ophthalmologists, to develop a novel imaging technology for early detection and monitoring.

Goldys is deputy director of the ARC Centre of Excellence for Nanoscale Biophotonics at UNSW that develops novel tools for biomedical diagnostics. The centre’s research has now extended into the ophthalmic industry where she is working with a team of clinicians – including Clinical Associate Professor Andrew White at Westmead Hospital, Professor Robert Casson, Head of Ophthalmology and Visual Sciences at the University of Adelaide, and UNSW Scientia Fellow Dr Nicole Carnt – to develop a bespoke camera that will help ophthalmologists measure the oxidative stress of cells and tissues in the retina. “Ophthalmology is an area of clinical medicine producing extensive images of the eye – even mobile phone cameras today are equipped with amazing image capability. At the same time, science is developing better technical analysis of images. We’re building on that particular junction in time to provide deeper image analysis,” Goldys says. In 2021, she was awarded Glaucoma Australia (GA)’s ‘Quinlivan’ Research Grant to support her research in fluorescent imaging technology to detect glaucoma. Goldys’ imaging innovation obtains information about the health status of the retina and the optic nerve, providing the opportunity for early disease detection and the ability to commence treatment before irreversible blindness sets in. “Neurons die, which is irreversible. We need to know when do neurons start to be in trouble?,” she says. “When there is progressive loss of vision, it is clearly too late. We need to address vision loss earlier. This represents an unmet need.” Refurbishing current technology that is user-friendly and noninvasive, Goldys and her team are photographing the eye, then splitting the image into different colour segments. “Our lab is full of bespoke imaging systems. We are currently refurbishing and re-engineering a fundus camera for trials with a small Australian company called Quantitative Pty Ltd,” she says. “It’s like shining sunlight through a prism. Once separated into

individual colours, light provides nuanced information. We’re interpreting colours and shapes of cells, by a method that links colour to specific molecules, which are central to metabolism. “Cells need energy to survive. At a cellular level, neurodegeneration is a symptom of cells losing energy supply.” As part of their pre-clinical research, Goldys and her team are currently testing metabolism in cells that are affected, and are interfering with cells by exposing them to oxidative stress. “We have proven oxidative stress is inducing colour change in cells. Our study on this was published in peer-reviewed journal Redox Biology, which is not an ophthalmology journal,” Goldys says, adding she is aware of the debate in ophthalmology about countering oxidative stress by supplementing with antioxidants. Their proof-of-concept study demonstrated that an imbalance of unstable molecular species called ‘free radicals’ will change the colour of cells – and a new imaging technique could allow clinicians to detect and decode this colour without needing to take samples from the body. “In our study of cell cultures and tissues in the lab, we found that colour is like a thermometer for oxidative stress,” Goldys says. With the support of the ‘Quinlivan’ Research Grant for the next two years, Goldys hopes to have finished pre-clinical trials within one year. GENETIC TESTING FOR DEGENERATIVE EYE DISEASE

DR GEORGIE HOLLITT from Flinders University College of Medicine and Public Health, and Flinders Medical Centre, is leading a prospective assessment of polygenic risk scores to predict diagnosis of glaucoma and age-related macular degeneration.

Known as the Genetic Risk Assessment of Degenerative Eye Disease (GRADE) study, Hollitt is building on the work from previous work including a long-running international collaboration between Flinders University and the QIMR Berghofer Medical Research Institute, and other research partners around the world, to identify genetic risk factors for glaucoma. Working alongside Professor Jamie Craig and Associate Professor Owen Siggs, both from Flinders University, Hollitt is part of a team of Australian researchers who have identified 107 genes that increase the risk of glaucoma, and developed a genetic test using thousands of common genetic variants to detect people at risk of going blind from the condition. Their ultimate aim is to be able to offer blood or saliva tests to people when they turn 50 (regardless of family history) so they can find out if they are at risk, and then act to prevent vision loss. “Glaucoma and age-related macular degeneration (AMD) are the two most common causes of irreversible vision loss among elderly people worldwide. This is because both diseases are asymptomatic in the early stages, there are no clear screening recommendations for either condition, and broad community screening is not currently costeffective,” Hollitt says. “This is problematic as current glaucoma treatment options are highly effective at slowing or preventing disease progression, while AMD treatments for early-stage disease are currently undergoing clinical trials. For these reasons, identifying cost-effective screening methods to facilitate early diagnosis and timely intervention is important. This can be achieved with polygenic risk score (PRS) testing.”

Professor Ewa Goldys with a refurbished Topcon device at the ARC Centre of Excellence for Nanoscale Biophotonics at UNSW. Copyright: Ewa Goldys.

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Flinders University is conducting a prospective clinical trial which aims to clinically validate the PRS tests for both glaucoma and AMD.

The study is inviting 1,000 individuals aged over 50 years from the general population in South Australia to have their PRS calculated for both conditions. “The scores will be used to categorise participants as being in either the highest 10%, lowest 10% or within the middle 80% of risk within the study population, based on our previous work in Nature Genetics,” Hollitt says. The previous study she is referring to characterised optic nerve photographs of 67,040 UK Biobank participants and used a multitrait genetic model to identify risk loci for glaucoma. “A portion of individuals from each group will then undergo a thorough eye examination to compare the rate of glaucoma or AMD diagnostic classification across the risk spectrum of the PRS, with an expectation to see a higher rate of glaucoma and AMD diagnosis in the high-risk groups of the PRS compared to the average or low risk groups,” Hollitt says. “The tests, performed on a blood or saliva sample, have the potential to identify high-risk individuals before irreversible vision loss occurs, and also have the potential to allow glaucoma and AMD screening to reach a broad population. With more data supporting the clinical validity of this testing, PRS may soon become part of routine clinical care.” Hollitt says the application of PRS testing would not be possible without assessing the attitudes of healthcare professionals towards it. To that end, Flinders University is also conducting a questionnairebased study assessing this in the context of glaucoma. “Healthcare professionals, including ophthalmologists, optometrists and orthoptists, will be at the forefront of the delivery of personalised medicine so it will be important to demonstrate acceptability of PRS testing from these groups before it is implemented into clinical practice,” Hollitt explains.

More traditional methods of detecting glaucoma, such as OCT, could prove less cost effective than newer methods, particularly as part of a national screening program.

“This confidential online survey will inform training and resources for healthcare workers who may be involved in offering the test, referring or counselling patients as well as interpreting results from the test.” (For more information regarding GRADE and the questionnaire,

GLAUCOMA

contact Dr Georgie Hollitt at georgie.hollitt@flinders.edu.au).

“It could also promote a community-wide screening program, reaching people who might not otherwise seek treatment until it’s too late.”

In addition to the GRADE study, the same team has expanded on the Targeting at Risk Relatives of Glaucoma patients for Early Diagnosis and Treatment (TARRGET) study after preliminary results were reported last year.

Speaking about the novelty of the new diagnostic test, Kumar highlights how it differs from current methods.

This family-based study, a partnership between Glaucoma Australia, Flinders University, the University of Western Australia/Lions Eye Institute, the University of Tasmania, Sydney Eye Hospital and WA Department of Health, provides personalised risk information to family members of a person with glaucoma and encourages them to have a glaucoma screening appointment.

“Our method estimates the effect of the partial alteration of the optical nerve conduction by measuring the changes to the reflexive adaptation to ambient light conditions and is measuring a primary symptom of the disease.”

The first phase of TARRGET approached immediate family members of people with advanced glaucoma and has recently expanded to include family members of people with non-advanced disease. To date, more than 3,500 people with glaucoma have been sent forms requesting mailing information for their family. From this, more than 2,000 family members have been sent personalised risk information and 785 family members have completed an eye check and provided information back to the study regarding their glaucoma status. Based on current return rates, the study expects to receive contact details for approximately another 2,000 family members who will, over the coming 12 months, also receive personalised information regarding their risk of developing glaucoma based on the type and severity of glaucoma in their affected family member. Feedback from family members to date indicates that more than 50% of those contacted have glaucoma or show suspicious early signs of glaucoma requiring monitoring (glaucoma suspects). These are family members of people with advanced disease, and in the future the study will continue to include data from family members of those with non-advanced glaucoma. The study encourages family members to talk to each other about glaucoma and reminds participants that eye health checks must be a regular and ongoing commitment to prevent vision loss. COMPUTERISED GLAUCOMA SCREENING TEST

DR DINESH KUMAR and other inventors of a new rapid screening test for glaucoma that could help advance early detection of the disease are planning clinical trials starting sometime this year.

Developed by a research team of engineers and ophthalmologists led by RMIT University in Melbourne, the test uses infrared sensors to monitor eye movement and can produce accurate results within seconds. While current glaucoma screening techniques are based on measuring the patient’s visual field, this new technique developed at RMIT estimates the damage to the nerves and is therefore more direct, its developer says. As opposed to the current method of diagnosing glaucoma, which requires a 20-minute visual field test, the new test takes 10 seconds to show if there is a risk of glaucoma, which could lend itself to being a central component in a national screening program. Lead researcher Dr Dinesh Kumar, Professor and leader of Biosignals, School of Engineering at RMIT University, says early detection, diagnosis and treatment could help prevent blindness, so making screening faster and more accessible is critical. “This research will allow a non-contact, easy-to-use and low-cost test that can be performed routinely at general clinics,” he says.

INSIGHT March 2022

“The current method of detecting glaucoma is based on a retinal functionality test and is a measure of secondary symptoms,” he explains.

The pioneering technology differentiates between glaucoma and healthy eyes by analysing changes in pupil diameter and pupillary hippus. Kumar says his team’s technical brief involved engineering a solution to overcome the disadvantages inherent in current measuring techniques. “In glaucoma patients, the optic nerve is partially compromised due to excessive intraocular pressure. We have measured the complexity of the pupil reflexivity during steady state ambient light conditions. Reduction in the complexity is an indication that the optic nerve pathway is partially blocked or damaged,” Kumar says. “While this can be achieved using different techniques such as delay in the response to a stimuli, the difficulty in such is that it requires accurate control of the ambient light conditions. The other disadvantage of using stimuli-based approach is that it would measure the delay, which may not be evident when the nerve is partially compromised.” He continues: “We have overcome the above limitations by measuring the natural reflex of the pupil in normal light conditions. We have measured the continually changing pupil diameter and measured the signal properties. Not only is this quick, and does not require a special-purpose room, it also does not require the patient to voluntarily participate and can be observed using an infrared camera located at about 0.5 meters from the patient’s face. Being a more direct measure of the change, this has the potential for detecting the disease even before there are any vision symptoms, though this has not yet been tested." In the study conducted by Kumar and RMIT colleagues Dr Quoc Cuong Ngo, Susmit Bhowmik and Marc Sarossy, pupils were measured 60 times per second using a low-cost commercial eye tracker. The study’s corresponding paper, ‘Pupillary complexity for the screening of glaucoma’, was published in IEEE Access and credits Essendon Eye Clinic and Laser Centre for assisting with the study. Under ambient light conditions, patients looked at a computer screen while custom software measured and analysed specific changes in their pupil size. The software then compared the results against existing samples of glaucoma and healthy eyes to determine the risk of glaucoma. Co-author Dr Quoc Cuong Ngo says the new technology was faster and better than any similar AI-based approach. “Our software can measure how the pupil adjusts to ambient light and capture minuscule changes in the shape and size of the pupil,” he says. “Existing AI glaucoma tests require the patient to be perfectly still for up to 10 minutes. Our tech does the job in 10 seconds, without compromising on accuracy.” The team is now looking to adapt the technology to work with smartphone cameras instead of the eye tracker used in the study and investigate its suitability to detect the disease even without visual field symptoms. With further research, the software could also be extended to detect other neurological conditions. Kumar is hopeful the test could be available to the Australian market by the end of 2023. For more information about a commercial partnership or the clinical trial, email biosignalslab@rmit.edu.au. n

CPD

LEARNING OBJECTIVES: At the completion of this CPD activity, optometrists will have developed their knowledge of optical coherence tomography angiography (OCT-A).

Including: • Recognise the limitations of OCT-A, including common artefacts, compared to fluorescein angiography • Appreciate the core technical principles of OCT-A • Understand the evolving clinical applications of OCT-A

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY: HYPE OR HOPE? It has been almost 10 years since OCT-A was introduced commercially. For optometrists considering a 'new' technology to sink their teeth into, DR ANGELICA LY outlines the clinical utility of OCT-A and highlights its emerging role in the modern optometric practice.

ye disease impacting on retinal vasculature is increasing due to the aging population and the rise of systemic diseases such as diabetes. Consequently, the ability to noninvasively evaluate retinal vasculature helps primary eyecare providers to make informed decisions regarding the management of their patients. Optical coherence tomography

angiography (OCT-A) represents the latest innovation capable of providing remarkable, high-resolution, in vivo images of the ocular microvasculature without the need for intravenous dye. In essence, the technology works via repeat scanning of the same transverse location. Subsequent scans are analysed for differences

ABOUT THE AUTHOR: Dr Angelica Ly BOptom (Hons) GradCertOcTher PhD Lead Clinician (Macula), Centre for Eye Health Lecturer, UNSW School of Optometry and Vision Science

in signal amplitude, intensity, or phase variance – known as ‘decorrelation’ – which are subsequently presented as blood flow. Applied hundreds of times in adjacent locations, an en face view can be generated and adjusted to project the decorrelation signals confined to specific layers (Figure 1).1-4 The aim of this article is to introduce readers to the usefulness of OCT-A via a specifically curated case series. It is not intended to ‘teach’ readers how to interpret OCT-A, but rather, to acquaint them with the possible applications, which may be helpful to those considering investing in the technology. PROSPECTIVE BUYERS’ GUIDE TO THE TECHNICAL PRINCIPLES OF OCT-A

Figure 1: Standard OCT-A imaging results of a healthy eye. (All images in this case were taken using a single 3x3mm scan at different layers of the same eye using the Zeiss Cirrus 6000 OCT Angioplex). Each en face angiogram is accompanied by a structural OCT B-scan (below) presented through the fovea centre with the flow overlay and segmentation lines toggled on to show the specific level at which the angiogram was generated.

As a non-invasive imaging modality, the key advantage of OCT-A is that images can be acquired multiple times in single or different visits with minimal fuss. The device is often well-tolerated by patients, based on the same core technology as structural OCT, and provides direct visualisation of vessel morphology. On the other hand, and in contrast to fluorescein or

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boundaries are one consideration. However, the operator should also be able to manually adjust these boundaries by location, thickness, and shape e.g.: to align with the curvature of the RPE or to lay flat horizontally. As with standard structural OCT technology, OCT-A segmentation errors are often unavoidable especially in cases of retinal pathology. Manual segmentation correction options and the functionality of these tools are becoming increasingly sophisticated. Some devices provide the option of ‘auto-propagating’ changes made on one B-scan to adjacent slices.

Figure 2: (Case 1) Imaging results of the presented case with polypoidal choroidal vasculopathy: A) En face OCT-A view, B) colour fundus photograph, C) En face structural OCT and D) OCT B-scan.

indocyanine green angiography, OCT-A does not provide any information on vessel leakage or filling speed. For practitioners thinking of purchasing a device, it’s important to point out that different manufacturers typically use different OCT-A proprietary algorithms. AngioVue of the RTVue XR Avanti by Optovue uses split-spectrum amplitude decorrelation angiography. AngioPlex OCT-A associated with the Cirrus HD-OCT 6000 by Zeiss uses optical microangiography. These varying algorithms can cause subtle variations in the output images, so it may be worth comparing or ‘trying before buying.’ Other technical points of difference include scan speed, scan area and resolution. These hardware parameters significantly affect acquisition time and so, they may limit the day-to-day usefulness of the purchased device, especially in uncooperative patients, older patients with media opacities or individuals with poor fixation/nystagmus. Software differences, including the pre-set slab views, output quantitative metrics (‘analytics’),

and the user interface, are also important considerations. At a minimum, the operator should be able to review the cross-sectional, structural B-scans in tandem with en face images. COMMON SOURCES OF MISINTERPRETATION OR UNUSABLE OCT-A DATA INCLUDE: • Motion artefacts • Projection artefacts • Segmentation errors. Motion artefacts – Most OCT-A devices will have some form of in-built eye tracking or motion correction, but sensitivity varies, and, at times, these corrective features can themselves create new artefacts or contribute significantly to the scan acquisition time. Projection artefacts – The impression of superficial vessels on to deeper layers, also represents a major limitation of OCT-A technology so some form of a ‘projection artefact removal’ feature is often included. It can be helpful to be able to toggle on or off this feature as required. Segmentation errors – As described above, the pre-set slab views or automated segmentation

Finally, other features including change analysis (and instrument differences in their ability to align and register follow-up scans against baseline, the presentation of these findings and associated analyses/reporting functions), an anterior segment or glaucoma module may also interest certain practitioners. In short, OCT-A is a complex, rapidly evolving technology. In addition to reviewing the technical specifications of a brochure, prospective users are encouraged to ask device representatives to demonstrate the usefulness and ease of use of the associated OCT-A software before buying. CASE 1: POLYPOIDAL CHOROIDAL VASCULOPATHY A 70-year-old Asian male with a known history of central serous chorioretinopathy in his left eye returned for a scheduled follow-up assessment. He reported a clear view on the Amsler grid and denied any new visual or ocular symptoms. Entering unaided visual acuities were significantly reduced, especially in the left eye, at 6/9.5 right eye and 6/30 (improved to 6/15 with pinhole) left eye. The right retina appeared healthy. The left eye showed hypopigmentary abnormalities at the superior macula with associated subfoveal subretinal fluid. OCT-A showed choroidal neovascularisation (including a polypoidal lesion coincident with a notched pigment epithelial detachment and connecting

Figure 3: Multimodal imaging findings for Case 2: A) Optomap composite, red and green separation images, B) Optomap fundus autofluorescence and Spectralis OCT-A results of the C) retina and D) vitreoretinal interface. The yellow rectangle in the Optomap image delineates the acquired OCT-A field of view.

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CASE 3: SUB-CLINICAL DISEASE A 55-year-old asymptomatic female in good health, taking prescription medication for rosacea only, was referred for a macular assessment. Entering unaided visual acuities were 6/7.5 right eye and 6/6 left eye. Amsler grid testing was unremarkable in both eyes and Mars contrast sensitivity was similarly within normal limits at 1.76 log units in each eye. Fundus examination showed focal RPE pigmentary abnormalities at the left inferotemporal macula with no associated drusen, and a corresponding flat irregular pigment epithelium detachment using structural OCT and underlying thick choroid. OCT-A at baseline did not show any convincing evidence of neovascularisation. Outcome The patient was followed regularly for the next two years. Follow up assessments showed the development and eventual resolution of associated subretinal fluid and possible macular neovascularisation using OCT-A. The patient will continue ongoing monitoring and have her images regularly reviewed virtually by an ophthalmologist. Key lesson

Figure 4: Colour fundus photographs (top), OCT-A (middle) and OCT B-scans (bottom) related to Case 3. Each column presents the findings of a single examination, conducted at baseline (left), approximately 21 months later (middle) and 24 months later (right).

branching vascular network) just above and temporal to the left macula (Figure 2). Outcome The patient was referred and seen promptly by a retinal specialist, who performed both fluorescein and indocyanine green angiography to confirm the presence of occult choroidal neovascularisation and associated polypoidal lesions. He was diagnosed with polypoidal choroidal vasculopathy and treated immediately via intravitreal therapy using Eylea and will be followed closely. Key lesson OCT-A in conjunction with structural OCT imaging is a useful screening tool for distinguishing proliferative from non-proliferative disease, including polypoidal features CASE 2: ABNORMAL RETINAL NEOVASCULARISATION A 48-year-old female was referred for further investigation of a lesion in her right eye, first noted and managed some 20 years ago by an ophthalmologist overseas. She reported systemic hypertension and was otherwise in good general health. She denied any new changes in her vision. Unaided visual acuities were 6/9.5-2 (improved to 6/9.5 with pinhole) right eye and 6/7.5+2 left eye. Examination showed a right visually significant epiretinal membrane, likely longstanding in nature and secondary to former

chorioretinitis or uveitis. There was associated fibrosis, foveoschisis and disruption of the subfoveal ellipsoid zone, explaining the reduced visual acuity. Abnormal retinal neovascularisation was also observed among the superotemporal midperiphery with no obvious signs of retinal vascular occlusion or vasculitis (Figure 3). The left posterior eye was unremarkable. Outcome The patient was referred non-urgently to an ophthalmologist. The ophthalmologist reported that the cause of the abnormal retinal neovascularisation was deemed unclear; however, wide field Optos retinal angiography was performed to assess the full extent of retinal ischemia and treatment options including sectoral panretinal laser treatment with or without intraocular anti-VEGF injections were presented. The option of epiretinal membrane peel surgery was also discussed with the patient on the presumption that surgery would be to protect her existing level of vision and prevent future, sight threatening vitreous haemorrhage, tractional retinal detachment or further worsening of the ERM. Key lesson OCT-A forms a useful screening tool for abnormal retinal vasculature but is currently limited by field of view.

OCT-A can be a helpful monitoring tool especially of ‘sub-clinical’ disease, such as non-exudative macular neovascularisation. In this fast-paced technological world, eyecare professionals face ever-increasing pressure to apply the newest, ‘latest and greatest’ gadget to patient care. Clinical testing, including ocular imaging and OCT-A, can be used for disease diagnosis, screening, and monitoring.5 This brief case series highlights the value and emerging role of OCT-A in optometric practice. Disclosures: The author has no conflicts to declare. REFERENCES 1. T an ACS, Tan GS, Denniston AK et al. An overview of the clinical applications of optical coherence tomography angiography. Eye (Lond) 2018; 32: 262-286. 2. Spaide RF, Fujimoto JG, Waheed NK et al. Optical coherence tomography angiography. Prog Retin Eye Res 2018; 64: 1-55. 3. Spaide RF, Fujimoto JG, Waheed NK. Image Artifacts in Optical Coherence Tomography Angiography. Retina 2015; 35: 2163-2180. 4. Campbell JP, Zhang M, Hwang TS et al. Detailed Vascular Anatomy of the Human Retina by Projection-Resolved Optical Coherence Tomography Angiography. Sci Rep 2017; 7: 42201. 5. Power M, Fell G, Wright M. Principles for high-quality, high-value testing. Evid Based Med 2013; 18: 5-10.

NOTE: Optometry Australia members can scan the QR code or visit the online version of this article at insightnews.com.au/cpd/ to enter their details to have their CPD hours automatically updated to their Learning Plan. Event ID: 90004000, Session ID: 10265

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LEARNING OBJECTIVES: At the completion of this CPD activity, optometrists will have developed their knowledge of femtosecond laser assisted cataract surgery (FLACS).

Including: • I dentify patients who would benefit from FLACS and write informed referrals • Learn the benefits and risks of FLACS • Understand the steps in the patient experience as they undergo FLACS • Understand post-operative complications and comanagement

FEMTOSECOND LASER CATARACT SURGERY AND ITS PLACE IN 2022 As the demand for cataract surgery increases, so does the need for authentic co-management of the condition. DR LEWIS LEVITZ delves into the clinical aspects of FLACS to help optometrists counsel patients and assist them in making informed choices about their surgery.

ataract surgery is the most commonly performed operation in Australia.1 It is a wonderful operation in that it restores both sight and functionality, and is often a lifechanging event.

by the fact that cataract surgery is already a very safe operation. Although there are inherent risks with any operation, the chances of having a safe operation, whether one uses conventional or laser assisted surgery, is above 97%.4

However, when I tell patients about the small chance of a complication, they sometimes nod their heads and think about some other poor chap that this might happen to. It is confronting for people to realise that if something does go wrong, it can go very wrong and have profound consequences.

Some of the complications, such as cystoid macular oedema are usually self-limiting. Other complications, such as posterior capsular rupture, are more serious. This can lead to the surgeon being unable to use the selected toric or multifocal lens or having to use an anterior chamber lens.

A cataract operation is made up of a set of steps, each of which can lead to increasing safety with regards to the next step. If one step is incorrectly performed, it can lead to an escalating cascade resulting in a poor outcome.

Occasionally, the patient needs a second operation to remove pieces of the nucleus or cortex from the vitreous. A ruptured posterior capsule can also lead to decreased vision from chronic cystoid macular oedema and the risk of endophthalmitis increases. All of the above can lead to a disappointed patient with less-thanexpected vision.

It was to standardise and make some of these steps uniform that femtosecond laser assisted cataract surgery (FLACS) was introduced.2,3 This expensive technology both has, and has not, lived up to initial expectations. The problem of assessing whether FLACS makes cataract surgery safer is made difficult First author

Year

Study type

CAPSULOTOMY The capsulotomy can be the most challenging part of the operation. There has been no dispute

Evidence level

FLACS (Posterior capsular rupture %

Conventional cataract surgery Posterior capsular rupture %

Chen Li et all 14

2021

Meta-analysis

0.0%

1.47%

Day et al 9

2020

PRCT

0.0%

0.5%

Roberts et al 7

2019

PRCT

0.0%

3.0%

Scott et al 10

2016

Multiple surgeons

0.65%

1.17%

Wang et al 13

2018

Multiple surgeons (post vitrectomy eyes)

0.0%

12.0%

Brunin et al 11

2017

Registrars

0.0%

3.0%

Hou et al 12

2015

Registrars

0.0%

3.0%

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Dr Lewis Levitz MBBCh, MMed, FCS(SA)Opht, FRCSEd, FRANZCO Vision Eye Institute

that laser capsulotomy position and shape is very precise.5 The capsulotomy should overlap the optic of the lens in each and every case. This decreases posterior capsular opacification and may be an important factor if the patient is offered a multifocal or extended depth of focus (EDOF) lens where exact placement and stability are paramount. Having a laser with the ability to cut an exact capsulotomy regardless of the size of the eye certainly puts the patient at an advantage before the ophthalmologist proceeds to the next step. Most surgeons are able to perform a very good capsulorhexis in most cases, but only a laser will guarantee the same amount of circularity in every case. Laser capsulotomy has proved useful in complicated trauma cases, in cases of zonular weakness, and in white cataracts.5 NUCLEUS DIVISION

Table 1: Posterior capsular complications reported in FLACS versus conventional cataract surgery. PRCT=prospective randomised controlled trial.

ABOUT THE AUTHOR:

It was initially thought that using a laser to divide the nucleus into quadrants or sections would reduce the ultrasound power needed to remove the cataract.62 This has been a contentious issue in the literature with studies both supporting this idea7 and studies showing that it made no difference.89 This is not at all surprising as each surgeon has a unique way of operating and

having a nucleus divided into quadrants would be irrelevant for many surgeons. VISION The latest randomised prospective studies show no long-term visual benefit in using FLACS with regard to long term vision.7,8,10 POSTERIOR CAPSULAR COMPLICATIONS So, if the patients have no visual benefit from FLACS, why are people still offering this as an expensive technology? In 2016, it was shown that all surgeons who changed from performing conventional cataract surgery (CCS) to performing FLACS had a reduction in their complication rate, regardless of their level of experience.11 A reduction in complication rate was also seen during registrar training12,13 and when operating on post -vitrectomized eyes.14 Two prospective randomised controlled trials were published in 2019 and 2020.108 It was noted that, using current software, there was a "significant reduction in posterior capsular rupture in the femtosecond laser assisted group."8 A large meta-analysis of all current randomised controlled studies stated in 2020 that "in our subgroup of randomised controlled trials, posterior rupture seemed less with FLACS , which was of clinical significance…".7 The most recent meta-analysis of randomised controlled trials once again showed the benefit of FLACS with regard to posterior capsular complications.15 Again, this validates the fact that the capsular rupture rate is less than 1% in almost all series of FLACS where more than 1000 patients were enrolled.16 This does not mean that all surgeons who use conventional surgery are less safe or should change to FLACS. One has to take into account that complications are very rare with regards to cataract surgery and that for some surgeons, the decrease in complications would be hard to measure.17 Table 1 shows posterior capsular complications reported in FLACS versus conventional cataract surgery. WHAT WILL YOUR PATIENT EXPERIENCE? As the patient’s primary eyecare provider, the optometrist is in a unique position to prepare their cataract patients for the next phase of their treatment. Your patient will have questions and will want to know what to expect. They will want to be reassured. If they chose to have FLACS, you might want to explain the following steps: The patient would expect to be wheeled into a laser suite on a trolley. They would expect to be in the laser suite for five to seven minutes. The patient would have a drop of local anaesthetic applied to the eye. A speculum, which is a small medical device that looks like a large paper clip, would be placed in the fornix. This keeps the eye open and allays the patient’s

Figure 1: The patient interphase connects the laser machine to the patient’s eye.

Figure 2: Patient interphase, from the patient’s perspective.

often expressed fear of ‘what happens if I close my eye during the procedure.’ There is minimal if any discomfort.

exfoliation, which is associated with capsular weakness. These patients would be ideal for FLACS as no forces would be applied to the capsular bag during capsulotomy.5

The laser machine would be connected to the patient’s eye by either a plastic device that looks like a plastic cup, or a columnar device that looks like a small tube. This is called the patient interphase (PI). The PI in certain machines holds a small contact lens that is almost identical to a slightly thickened contact lens used in your practices. It allows the PI to attach to the cornea with suction. The patient would be asked to look at a target surrounded by light. Many years ago, a more solid contact lens was used. However, a softer material with a better fit is now used (Figures 1 and 2). The machine would then apply suction to stabilise the eye and the surgeon initiates the laser with a foot pedal. The actual laser procedure may take less than 40 seconds. It is silent and the patient is often still waiting for ‘their laser’ when the suction is released and they are reassured that all went well. The patient would then either be taken to theatre where they would have their cataract removed under topical anaesthetic or to the anaesthetic bay to have a local subtenons anaesthetic given by the anaesthetist.

In a similar vein, the referring optometrist would know if they had an elderly patient with corneal endothelial disease who might also benefit from FLACS.7 I also suggest to all my patients who have chosen EDOF or multifocal lenses that they should consider having FLACS. That way, there is a greater chance that their intraocular lens will be well placed with a 360-degree capsular optic overlap holding the lens stable in the capsular bag.18 (Having part of a multifocal lens slip through an eccentric or irregularly capsulorhexis and lie in a tilted position could change the optics of the visual system). If you are co-managing a patient who has had The Alcon LenSx Femtosecond Laser System. Image reproduced with permission of Alcon.

Once in theatre, the corneal incision, if made by the laser, would be opened manually or the surgeon would make a new incision. This is the first time the eye is ‘open’ as the laser has cut the capsulotomy and divided the nucleus into quadrants or segments without exposing the intra-ocular contents to the outside environment. HOW DO YOU KNOW WHO MIGHT BENEFIT? Optometrists are ideally placed to see which patients would benefit from being offered FLACS. The optometrist is usually the first person to notice if a patient has pseudo-capsular

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FLACS, then you might mention beforehand that they may have a small sub-conjunctival haemorrhage around the limbus after the operation. This sometimes occurs if the suction causes a tiny subconjunctival vessel to bleed. This is totally innocuous and of no importance. THE PLACE FOR FLACS Femtosecond assisted laser cataract surgery does not give better final vision than conventional cataract surgery. However, recent high-level evidence has demonstrated that FLACS decreases the risk of having a complication which could lead to a poor visual outcome. The process itself is quick and pain-free and is sometimes over before the patient realises it has begun. It definitely has a place for certain ocular conditions and when high precision with regards to capsular size and position is needed. n

REFERENCES 1. W hat Are The Most Common Surgeries In Australia? Surgery.com.au. Accessed October 31, 2021. https://www.surgery.com.au/common-surgeries-in-australia/ 2. A bell RG, Kerr NM, Vote BJ. Toward zero effective phacoemulsification time using femtosecond laser pretreatment. Ophthalmology. 2013;120(5):942-948. doi:10.1016/j.ophtha.2012.11.045 3. R oberts T V., Lawless M, Bali SJ, Hodge C, Sutton G. Surgical outcomes and safety of femtosecond laser cataract surgery: A prospective study of 1500 consecutive cases. Ophthalmology. Published online 2013. doi:10.1016/j. ophtha.2012.10.026 4. A bell RG, Darian-Smith E, Kan JB, Allen PL, Ewe SYP, Vote BJ. Femtosecond laser-assisted cataract surgery versus standard phacoemulsification cataract surgery: Outcomes and safety in more than 4000 cases at a single center. J Cataract Refract Surg. Published online 2015. doi:10.1016/j. jcrs.2014.06.025 5. B ala C. Femtosecond laser capsulotomy. J Cataract Refract Surg. Published online 2021. doi:10.1097/j. jcrs.0000000000000728 6. H atch KM, Schultz T, Talamo JH, Dick HB. Femtosecond laser-assisted compared with standard cataract surgery for removal of advanced cataracts. J Cataract Refract Surg. Published online 2015. doi:10.1016/j.jcrs.2015.10.040 7. K olb CM, Shajari M, Mathys L, et al. Comparison of femtosecond laser–assisted cataract surgery and conventional cataract surgery: a meta-analysis and systematic review. J Cataract Refract Surg. Published online 2020. doi:10.1097/j.jcrs.0000000000000228 8. R oberts HW, Wagh VK, Sullivan DL, et al. A randomized controlled trial comparing femtosecond laser–assisted cataract surgery versus conventional phacoemulsification surgery. J Cataract Refract Surg. Published online 2019. doi:10.1016/j.jcrs.2018.08.033 9. Schweitzer C, Brezin A, Cochener B, et al. Femtosecond laser-assisted versus phacoemulsification cataract surgery (FEMCAT): a multicentre participant-masked randomised superiority and cost-effectiveness trial. Lancet. Published online 2020. doi:10.1016/S0140-6736(19)32481-X 10. Day AC, Burr JM, Bennett K, et al. Femtosecond Laser-

Assisted Cataract Surgery Versus Phacoemulsification Cataract Surgery (FACT): A Randomized Noninferiority Trial. Ophthalmology. Published online 2020. doi:10.1016/j. ophtha.2020.02.028 11. Scott WJ, Tauber S, Gessler JA, Ohly JG, Owsiak RR, Eck CD. Comparison of vitreous loss rates between manual phacoemulsification and femtosecond laser–assisted cataract surgery. J Cataract Refract Surg. 2016;42(7):10031008. doi:10.1016/j.jcrs.2016.04.027 12. Brunin G, Khan K, Biggerstaff KS, Wang L, Koch DD, Khandelwal SS. Outcomes of femtosecond laser-assisted cataract surgery performed by surgeons-in-training. Graefe’s Arch Clin Exp Ophthalmol. 2017;255(4):805-809. doi:10.1007/s00417-016-3581-x 13. Hou JH, Prickett AL, Cortina MS, Jain S, De La Cruz J. Safety of femtosecond laser-assisted cataract surgery performed by surgeons in training. J Refract Surg. Published online 2015. doi:10.3928/1081597X-20141218-07 14. Wang EF, Worsley A, Polkinghorne PJ. Comparative study of femtosecond laser-assisted cataract surgery and conventional phacoemulsification in vitrectomized eyes. Clin Exp Ophthalmol. Published online 2018. doi:10.1111/ ceo.13133 15. Chen L, Hu C, Lin X, et al. Clinical outcomes and complications between FLACS and conventional phacoemulsification cataract surgery: a PRISMA-compliant Meta-analysis of 25 randomized controlled trials. Int J Ophthalmol. Published online 2021. doi:10.18240/ ijo.2021.07.18 16. Levitz LM, Dick HB, Scott W, Hodge C, Reich JA. The latest evidence with regards to femtosecond laser-assisted cataract surgery and its use post 2020. Clin Ophthalmol. Published online 2021. doi:10.2147/OPTH.S306550 17. Levitz L, Reich J, Hodge C. Posterior capsular complication rates with femtosecond laser-assisted cataract surgery: a consecutive comparative cohort and literature review. Clin Ophthalmol. Published online 2018. doi:10.2147/OPTH. S173089 18. Levitz, L M, Scott, W; Lawless, M; Dick, B; Nagy Z. Comment on : Comparison of femtosecondlaser-assisted cataract surgergery and conventional cataract surgery:a meta-analysis and sydtemic review. J Cart Refract Surg. 2021;47(2):278.

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EYEWEAR

Creative director Hamish Tame (from left) with designers Kadee Ryan, Ashlie Callinan and Maggie Allingham.

Socially conscious

EYEWEAR COMPANY TAKES IT TO THE HEAVYWEIGHTS Sunshades Eyewear was established 52 years ago by pregnant Bondi woman Betty Lasse who was small in stature but with a formidable personality. Today, her son runs the $50 million Australian business that is going toe-to-toe with the global eyewear giants.

wenty-six years ago, when Sunshades Eyewear CEO Mr Rodney Grunseit joined the business his pharmacist mother started many years earlier, he developed the philosophy: “Anyone who retails eyewear in Australia, we are here to do business with you.” It’s a mantra that’s reflected in the company’s expansive product portfolio today, spanning from entry level sunglasses through to $20,000 Cartier diamond-encrusted eyewear. As a result, it caters to a vast and versatile range of eyewear retailers, encompassing major department stores, sunglass outlets, and optometry corporates and independents. The private Australian-owned company now generates around $50 million annually by providing the full suite of services comprising in-house design, marketing, manufacturing and distribution. These include headline licenses such as Oroton, Le Specs, Karen Walker and Cancer Council. It also has the Australian and New Zealand distribution rights for the luxury Kering Eyewear portfolio, including Gucci, Cartier, Saint Laurent, Chloe and Bottega Veneta. “Very early on in my tenure I said that Sunshades will supply anyone who retails eyewear at all in Australia. Our strength lies in our experience with all facets of the industry, from global boutique fashion brands to mass market and private label brands,” Grunseit says. “Although we do supply corporates like Luxottica with OPSM and Sunglass Hut, we offer such a large selection of product that businesses like

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independent optometry practices can easily select eyewear that differentiates them and matches their demographic. For example, if they want to be boutique, they might order Balenciaga, Bottega Veneta or Cartier, or if they are seeking eyewear with high turnover that sells like crazy, they might order Oroton and Le Specs.” Based in Sydney with more than 100 staff, Grunseit has no hesitation saying Sunshades is the nation’s largest locally-owned eyewear company. It’s a remarkable feat for a firm that his mother, the late Ms Betty Lasse, established 52 years ago. She began importing unbranded sunglasses as a side business, while operating her Ramsgate Avenue pharmacy in Bondi. Lasse was considered a woman before her time. She started the business in her 40s while pregnant with Grunseit. It boomed – and at one point she became the largest importer of sunglasses into Australia in terms of units. By the mid-1970s she relinquished her pharmaceutical career to focus on the eyewear business, buoyed by the establishment of a direct supply chain with three sunglass manufacturers in Taiwan, one of which the business still works with today. Growing up, Grunseit gleaned a strong work ethic from his mother, who would rather be on the road for business than perform domestic duties like many of her contemporaries. “My mother was 5ft 2; she was delicate with a bit of scoliosis, but she had

the personality and vivaciousness of a giant,” Grunseit says. “Everyone loved her because she was such a loving, beautiful human being, and she created a culture of complete respect and honesty, alongside her ‘D.B.S.’ – don’t be scared – motto for the business. That means we embrace anything whether it’s at an entry price point, unbranded or branded. Because of my mother, the company has always had a very strong female essence; she was very maternal and that has flowed down to myself. I like to emulate her raison d’etre. Over 20% of our staff have been in the company over 10 years, it’s a really lovely place to work and that shows in everything we do and create.” ENTERING THE OPTICAL MARKET After completing university, Grunseit joined Sunshades in 1995. Within the first few years he helped secure supply agreements with major fast fashion chains helping to propel the business.

The Oroton, Le Specs and Karen Walker brands all have a significant focus on sustainability.

Soon the company was approached by Disney to make children’s sunglasses. Back then, Lasse wasn’t familiar with the world of eyewear licensing, but told her son she would support him if he wanted to pursue it. “We worked with our factories, choosing the right styles, printing on the frames, packaging them beautifully, making beautiful display stands, and all of a sudden from selling cheap sunglasses in the marketplace, we were dealing with David Jones, Myer, OPSM, Sunglass Hut, all the big eyewear guys – and that really changed the nature of who we were from then until now,” Grunseit recalls. “Other brands gravitated to us because they saw what we were doing. We were offered Fiorelli, which then led to our relationship with Oroton 20 years ago.” The Oroton licence marked Sunshades’ first foray into optical. Grunseit says it remains one of Australia’s only true luxury homegrown brands and continues to be the hero of the Sunshades optical business. “In-store, our products often find themselves in one of the top three positions against massive brands – we only have to look at Oroton, which I don’t hesitate to say it is in the top three brands in optical in Australia,” he says. “At one point I would have said Oroton would have found itself in 90% of all optical stores. That has probably changed since Specsavers, Bailey Nelson and Oscar Wylee have come along. I wouldn’t use numbers like that now, but I would say Oroton sits in all good optometrists, around 70%, and there are

some independents who like to have a completely different boutique mix but might carry Oroton in their drawer because they know there is demand for it.” When Sunshades entered the optical sphere, Grunseit recalls the often sterile and male-dominated nature of optometry businesses. He says Sunshades arrived with a different view – and predominantly female workforce – asking practices to continue providing the technical knowledge, while referring to the experts for eyewear design and craftsmanship. The company was soon incorporating fashion into function with its designs. The Oroton licence, in particular, was among the first Australian eyewear brands that spoke loudly about its DNA as a fashion business. “When you look at what works successfully today, our Gucci numbers have gone through the roof – that’s because people are looking for design, fashion, energy and lifestyle, instead of something that blends into their face, even though that still makes up a good chunk of the business,” Grunseit explains. “We were lucky to be involved with Karen Walker helping her design, manufacture and distribute her eyewear, which was number one in the world for a period in terms of its positioning. What we created with Karen was considered avant-garde, and it was catching the attention of consumers worldwide. But then we started seeing major brands emulate that, which we were incredibly proud of, taking on the big designer brands of the world.” DESIGN, PRODUCTION AND SUSTAINABILITY Being a full-scope eyewear company, Sunshades Eyewear has many departments that include warehouse and logistics and merchandise planning, through to six teams of account managers and merchandisers (sales) servicing multi door retailers, optometry, sunglass specialty, surf/youth, fashion and pharmacy, covering more than 4,000 Australasian stores. It also employs IT and planning experts that help to interpret volumes of eyewear sales data, which can be filtered to incredibly granular levels. (Sunshades claims to be the Australian eyewear leaders in electronic data interchange). “We can tell you the size, shape, colour and lens colours that sell in every postcode around Australia,” Grunseit says. “Because we design, manufacture and distribute most of our products, we can use the data to ensure we are getting the best-selling shapes and designs to the right businesses.” Mr Hamish Tame is creative director of Sunshades, as well as designer of the Le Specs collection. He has been with the company for more than 18 years and says having access to such detailed data ensures his designers can factor top-selling trends into new eyewear models to ensure they sell through the retailer.

The late Betty Lasse with her son Rodney Grunseit who now runs the company.

Tame’s four-strong design team comprises varying personalities who like to design their eyewear with different methods, whether that be sketches or sculpting existing frames with files, drills and plaster. Prior to COVID-19, they travelled up to three months of the year, visiting major optical fairs

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EYEWEAR

moments that have propelled us into a new phase of growth,” Tame explains. Global expeditions often include trips to some of Sunshades’s eight factory partners in Taiwan and China. Here, they’re able to examine new sustainabilityfocus materials and the latest manufacturing processes. Grunseit says the emergence of innovative materials are vital to Sunshades Eyewear as consumers and retailers demand products with a smaller ecological footprint. This extends to factory operations and supply chains too. “We work with the biggest retailers in the world and many of them insist the factories are audited for not only quality, but social, ethical and environmental standards,” Grunseit, who has taken Chinese lessons to help communicate with factory owners, explains. “Plus the size of business places us in the handful top 10% of eyewear companies in the world, so we are able to meet factories’ minimums and therefore have the freedom to choose who we work with.” Locally, Sunshades has implemented a comprehensive sustainability strategy as well.

Oroton is one of Australia’s only true luxury homegrown brands and remains the hero of the Sunshades Eyewear optical business.

Le Specs has been the incubator – with the Le Sustain collection – where they have created zero waste and use 100% recycled packaging, in line with its commitments under the Australian Packaging Covenant. It also hopes to launch two new materials each year, with Le Specs already launching frames made from meadow grass, rice husk, coffee grounds and post-consumer recycled plastic. Oroton has started transitioning to a bioacetate and Cancer Council eyewear comprises recycled acrylics and demonstration lenses.

such as MIDO in Milan and Silmo Paris or vintage stores in Stockholm to draw inspiration.

“The more exciting part is around how we start to influence and create meaningful change by using our platform as a sustainable business model across multiple brands,” Tame says.

“Because design sits at the heart of the business there is a fearlessness of having to present our work before the sales and planning teams. People get behind new concepts and like to give new things a go; it’s often those

“That is the rewarding piece of it. There is a lot of time and investment in getting this up and running, but we believe it’ll have a snowball effect very soon.” n

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

✔ Include brand name on script

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If clinically necessary for the treatment of your patients, consider prescribing by brand. PBS Information: Xalatan (latanoprost 0.005% eye drops, 2.5 mL) and Xalacom (latanoprost 0.005% + timolol 0.5% eye drops, 2.5 mL) are listed on the PBS as antiglaucoma preparations and miotics.

Before prescribing please review Product Information available via www.aspenpharma.com.au/products or call 1300 659 646. Minimum Product Information: XALATAN® (Latanoprost 50 µg/mL) Eye Drops. Indication: Reduction of intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension. Contraindications: Hypersensitivity to ingredients. Precautions: Change in eye colour due to increased iris pigmentation, heterochromia; eyelid skin darkening; eyelash and vellus hair changes; aphakia; pseudophakia; macular oedema; other types of glaucoma; contact lenses; severe or brittle asthma; herpetic keratitis; driving or using machines; elderly; children; lactation. Pregnancy: Category (B3) Interactions: other prostaglandins, thiomersal. See PI for details. Adverse Effects: Iris hyperpigmentation; eye irritation (burning, grittiness, itching, stinging and foreign body sensation); eyelash and vellus hair changes (increased length, thickness, pigmentation and number of eyelashes); mild to moderate ocular hyperaemia; punctate keratitis; punctate epithelial erosions; blepharitis; eye pain; excessive tearing; conjunctivitis; blurred vision; eyelid oedema, localised skin reaction on eyelids; myalgia, arthralgia; dizziness; headache; skin rash; eczema; bronchitis; upper respiratory tract infection; abnormal liver function. Uncommon: Iritis, uveitis; keratitis; macular oedema; photophobia; chest pain; asthma; dyspnoea. Rare: periorbital and lid changes resulting in deepening of the eyelid sulcus; corneal calcification. See PI for details and other AEs. Dosage and Administration: One eye drop in the affected eye(s) once daily. Other eye drops should be administered at least 5 minutes apart. (Based on PI dated 09 December 2019) Minimum Product Information: XALACOM® (latanoprost 50 µg/mL and timolol 5 mg/mL) Eye Drops. Indication: Reduction of intraocular pressure (IOP) in patients with open-angle glaucoma and ocular hypertension who are insufficiently responsive to other IOP lowering medications. Should not be used to initiate therapy. Contraindications: Reactive airway disease including bronchial asthma (or history), or severe chronic obstructive pulmonary disease (COPD). Sinus bradycardia, sick sinus syndrome, sino-atrial block, second or third degree atrioventricular block, overt cardiac failure, or cardiogenic shock. Hypersensitivity to ingredients. Precautions: Beta-blocker systemic effects: cardiovascular/respiratory reactions; first degree heart block; cardiac failure; severe cardiac disease; severe peripheral circulatory disturbance/disorders; mild/moderate COPD; consider gradual withdrawal prior to major surgery; Beta-blocking ophthalmological preparations may block systemic beta-agonist effects (inform anaesthetist); history of atopy or anaphylactic reaction; caution in hypoglycaemia or diabetic patients, hyperthyroidism, myasthenia gravis; concomitant beta-blocker or prostaglandin not recommended. Ocular Effects: change in eye colour due to increased iris pigmentation; heterochromia; eyelid skin darkening; eyelash and vellus hair changes; aphakia; pseudophakia; macular oedema; other types of glaucoma; herpetic keratitis; filtration procedures; corneal diseases; contact lenses; elderly; children; driving or using machines. See full PI for details Pregnancy: Do not use in pregnancy (Pregnancy Category C) Lactation: Do not use in breast feeding mothers. Interactions: oral calcium channel blockers; catecholamine-depleting drugs or beta-adrenergic blocking agents; antiarrhythmics; digitalis glycosides; parasympathomimetics; narcotics; monoamine oxidase (MAO) inhibitors; CYP2D6 inhibitors; adrenaline; antidiabetic agents; thiomersal. See PI for details. Adverse Effects: For complete list see full PI. Ocular: eye irritation; hyperaemia; abnormal vision; visual field defect; iris hyperpigmentation; eyelash and vellus hair changes; conjunctivitis; blepharitis; corneal disorder; eye pain; keratitis; photophobia; cataract; conjunctival disorder; errors of refraction; macular oedema; corneal calcification; corneal oedema and erosions; blurred vision; dry eyes; periorbital and lid changes resulting in deepening of eyelid sulcus; darkening of skin of eyelids, skin reaction on eyelids; diplopia; ptosis; choroidal detachment (following filtration surgery). Systemic: Serious respiratory and cardiovascular events (e.g. worsening of angina pectoris, atrioventricular block, cardiac failure, cardiac arrest, respiratory failure, pulmonary oedema, asthma); herpetic keratitis; chest pain; anaphylaxis; skin rash; headache; depression; myalgia; arthralgia; dysgeusia; vomiting; abdominal pain; sexual dysfunction. Dosage and Administration: One eye drop in the affected eye(s) once daily. Other eye drops should be administered at least 5 minutes apart. (Based on PI dated 21 February 2020) References: 1. IQVIA Dec 2020 Aspen Australia includes Aspen Pharmacare Australia Pty Ltd (ABN 51 096 236 985) and Aspen Pharma Pty Ltd (ABN 88 004 118 594). All sales and marketing requests to: Aspen Pharmacare Pty Ltd, 34-36 Chandos Street, St Leonards NSW 2065. Tel: +61 2 8436 8300 Email: aspen@aspenpharmacare.com.au Web: www.aspenpharma.com.au Trademarks are owned by or licensed to the Aspen group of companies. © 2021 Aspen group of companies or its licensor. All rights reserved. Prepared: February 2021 AF05537 ASP2433

PROFILE Tracton Optometrists, an independent practice in Bondi Junction.

Against the odds:

OPENING A GREENFIELD PRACTICE IN SYDNEY’S EAST

Optometrist DANIEL TRACTON took a calculated risk in opening a greenfield practice in the middle of a lockdown last year in a highly competitive, upmarket Sydney demographic. It’s an experience he describes as not for the faint-hearted.

onstruction on Tracton Optometrists, an independent practice based in the heart of Bondi Junction, took place during a snap lockdown mid-2021 – when the suburb was hit with NSW's thenbiggest COVID cluster, driven by the highly contagious Delta variant. “We planned to open in early July, but we went into lockdown at the end of June, which resulted in a three-month delay in opening,” says Tracton, who established the business with his wife and operations manager, Ms Michelle Tracton. “We opened three weeks before lockdown ended and could only provide critical care. It was a difficult balancing act,” he says. But by late October – and out of lockdown with the state then 84% fully-vaccinated – he says the business was doing well. But it has been a process fraught with uncertainty and anxiety. Tracton encountered significant challenges to open his own practice. While some factors were in his control, others were not. There was already an abundance of optometry practices, particularly corporate chains, in his chosen location – Bondi Junction. Piled on top of that were construction restrictions due to COVID, no government income support, and the considerable task of building a patient base from scratch.

ALL ROADS LEAD TO BONDI After graduating with a Bachelor degree in optometry from UNSW, Tracton began his career working as a managing optometrist in two of Sydney's most successful optical businesses in the mid to late 1990s – Prevue Eyewear (now part of The Optical Co) and AV Simon Optometry. He completed an MBA at the Australian Graduate School of Management at UNSW before joining OPSM where he was responsible for buying lenses, contact lenses and contact lens solution for the chain’s Australian and New Zealand stores. Within a few years, Tracton was promoted to group director for lens and contact lens products at Luxottica Retail. There, he was responsible for product strategy and profitability of these categories for OPSM, Laubman and Pank, and Budget Eyewear across Australia and New Zealand, totalling, at the time, 540 optical outlets. After an eight-year stint with Luxottica Asia Pacific and OPSM, Tracton went “back into the trenches”, working as a principal optometrist at a Sydney practice, and added a postgraduate Certificate in Ocular Therapeutics to his resumé. In 2014, he was appointed principal optometrist at LensPro Optometrists in Bondi Junction.

Yet, he has managed to overcome these hurdles by establishing a point of difference with state-of-the-art technology, an on-site lens laboratory and focusing on meaningful relationships with patients.

Then, at the beginning of 2021, Tracton decided to strike out on his own, in Bondi Junction, in what can only be described as a highly saturated and competitive market.

“It’s been tough, but we have come out the other side. Setting up Tracton Optometrists has been a labour of love and although a challenge during COVID restrictions, it has definitely been worthwhile,” he says.

The eastern Sydney suburb has two OPSM stores, two Specsavers stores, Bailey Nelson, Oscar Wylee, Bupa Optical, George & Matilda Eyecare, 1001 Optical, Carolina Lemke Berlin, HCF Eyecare,

INSIGHT March 2022

Optical Masters, and one other independent practice. Tracton estimates Tracton Optometrists is the first independent optometrist-owned greenfield practice to open in Sydney’s eastern suburbs in 20 years. He describes his decision to open a new practice in a location where he is competing with at least 13 others as an “interesting conundrum”, but it’s an area and community he knows well.

Daniel Tracton, practice owner and principal optometrist.

“I’m a Bondi local; I grew up here. My kids go to school in the area, and I’m involved in community organisations,” he says.

“Over the years the population in Bondi Junction has increased significantly and continues to grow with increasing residential high-rise accommodation options for all age groups. This provides a village-like environment within a regional shopping and health precinct. There is also a broad diversity of patients, from backpackers to executives.” Tracton also speaks Russian and French, giving him an advantage in communicating with Bondi’s immigrant communities, as well as the French-speaking population in Bondi’s neighbouring suburbs, Woollahra, Paddington and Maroubra. “I’ve always had a passion for languages, and it has been a real advantage in my optometry practice,” he says.

their days and nights cataloguing stock. “We were able to log into our practice management software remotely, set up our retail pricing and formulate our marketing plans,” he says. As the practice fit out was completed and Tracton Optometrists was in a position to open – albeit still during lockdown – Tracton promoted his new practice on social media and advertised in the local press. Patients started making appointments, stemming from Tracton’s longestablished community network. “We were pleasantly surprised how it tracked. We’ve done a few things differently. As an independent practice we are prioritising long-term relationships with patients and providing continuity of care. We offer a range of products including high-end frames and specialty contact lenses as well as care for patients before and after cataract surgery,” he says. “We invested in cutting-edge Nidek equipment, all networked, the latest Huvitz lens edger, a large lens inventory, low vision aids and other specialty hard-to-find optical appliances. We are really trying to go back to the basics of good quality community optometry. Not fast retail, but high touch, personalised eyecare.” Although it is still early days in terms of business, Tracton says they are currently exceeding their forecasts and are pleased with their strong start. “I believe that there is always a place for independent optometrist practitioners who invest in long term relationships and create a unique experience for patients. It is certainly not as easy as when I graduated as an optometrist in 1995 but the patients will always appreciate that you have the extra time to spend with them as an independent eyecare professional.” n

SETTING UP Finding the right real estate wasn’t a difficult process. Tracton knew he wanted a street-facing location, rather than a shopping centre. A former retail space with a “good street frontage location” became available when the previous tenant vacated unexpectedly. Although the retail space was only 50-square metres, he engaged a designer who was able to visualise a bespoke, high-end but functional space. The practice has partnered with leading lens suppliers Essilor/OSA and Tokai Optical, and has an onsite lens laboratory, which Tracton embedded as a competitive point-of-difference and to enable the practice to provide good service time and quality control. While knowing he would be competing with established practices, Tracton didn’t expect to be staring down a pandemic while trying to get his business off the ground. “It was challenging because sub-contractors couldn’t come on site, due to the lockdown,” Tracton says. “There were mandated limits on tradespeople on site and requirements for each trade to attend separately, as well as a period of complete lockdown. This caused delays and challenges. Our shopfitter, Soho Projects, had to be very strict in the management and coordination of the on-site attendance.” In addition to the time-pressure, Tracton also felt the pinch financially. “As a business owner in NSW, we needed to prove a reduction in turnover in order to qualify for state government financial support in grants and rent relief. Although our delayed opening was a result of the COVID lockdown we did not qualify as we did not have a track record of trade. We fell through the cracks and couldn’t get any financial assistance.” Prior to the snap lockdown, Tracton organised to have frames from several suppliers delivered to the practice in time for the anticipated opening. Instead, confined to their home during lockdown, the frames were delivered to their home and Tracton and Michelle spent

The practice is located near at least 13 others, which are predominantly corporates.

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' n a p a J n 'Made i LENSES

LENSES A UNIQUE PREMIUM OFFERING

The vacuum deposition coating process for Tokai Optical lenses.

Tokai Optical is a proud Japanese ophthalmic lens company with a long history, however it’s a relative newcomer to the Australian optical market. That isn’t stopping the company from making a mark on the local independent scene with its premium lens portfolio.

everal years ago, a customer came into the Melbourne boutique Henderson Optical and began discussing a high index 1.76 ophthalmic lens. Although for several years it had been touted as the world’s thinnest plastic optical material available, locally there was little known about the product and indeed its manufacturer. The CBD practice, located in The Strand Melbourne, began making inquiries to see how it could add the lens to its premium offering for a predominantly affluent demographic. “After some searching online, I found the 1.76 lens was a product of a Japanese company called Tokai Optical,” store manager Annie recalls. “After some further research we found a distributor in Queensland and started doing business with them. As an independent business that goes back to the 1950s, we have ongoing relationships with many lens labs and only use the top-end products from each. The Tokai 1.76 is such a unique product and became our go-to for super thin lenses, and the relationship has since expanded into other areas including high quality lens coatings and tinting.” The Henderson Optical anecdote is befitting of many other business accounts Tokai Optical has opened in Australia in recent years, as it seeks to impose itself on the national lens market. It is particularly geared towards the premium category, with lens technology designed from the ground up by an in-house R&D team – the company’s most expensive department. For most of the past decade, the Tokai brand has been represented in Australia through a distributor. But the company changed tack in 2019 and established a formal subsidiary (Tokai Optical Australia) now operated by Queensland-based Mr Justin Chiang, a trained optical dispenser with more than 20 years’ industry experience working for corporate and independent groups. Established in 1939, privately-owned Tokai Optical is one of the oldest in the lens market. However, until the early 2000s, it was solely focused on the

INSIGHT March 2022

domestic Japanese market where today it holds 16% market share, making it the largest manufacturer in size and third biggest in Japan. Globally, this makes it a relative market latecomer, but it has rapidly increased its footprint to now operate in more than 50 countries. Chiang acknowledges Australia’s small and mature optical market – with expanding vertically-integrated corporates – makes it more difficult for a company like Tokai to break through. But it has defied expectations to date, even with COVID, and has secured significant supplier agreements with practices in NSW and Victoria. “We are certainly growing, and it is because we are retaining our customers,” he says. “Some customers are starting with a unique product they can’t get elsewhere. Over time they have found the feedback is very good and they will tend to use more of our lenses.” Explaining Tokai’s positioning in the premium category, Chiang says examples include the scrapping of conventional surfacing in 2009, meaning every tier of its portfolio is produced with the freeform method as standard. More than 20 years ago, it also made UV protection standard in all its lenses, even down to 1.5 index, which it says was many years ahead of its rivals. As a result, Chiang says Tokai arrived in Australia looking to target independent boutiques. While this has transpired, the firm has also opened accounts with several independents in low-to-middle income demographics, some who are using the company’s standard lenses as a premium offering. “We believe everyone should have an opportunity if they want to use Tokai lenses, so if a chain or group approach us, we will be open to doing business with them,” he explains. “But at the same time, we do want to protect our independent optometrists. While the price between what certain stores pay can vary up to 60-70% for other products – which is quite ridiculous – we don’t

Japan-headquartered Tokai Optical was established in 1939 and aims to produce almost all of its products in its own region.

compromise on the price to gain sales just as we don’t compromise on the quality to save the cost.” KEEPING IT ‘IN-HOUSE’

Justin Chiang, Tokai Optical Australia.

Th-Eyecare, an independent that set up in a shopping centre in the Sydney suburb of Strathfield in 2016, is another boutique offering Tokai lenses. The practice’s clientele consists mostly of high-income patients from various backgrounds.

Principal optometrist Ms Thao Hoang says she was drawn to Tokai after a conversation with an optometry friend. On a trip to Japan, shortly after opening her practice, she visited the Tokai factory and was impressed by its lab technology and personnel. “I came back to Australia and have supported them ever since; I’ve been using their lens products for five years and they have never disappointed, even with the difficult jobs I have high confidence in their lab,” she says, explaining that Tokai accounts for 90% of her lens sales. “I know how the lenses are designed, because I have seen the factory and machinery, but most importantly when customers begin using them they are very happy, which is important for customer retention.” Chiang says the Tokai’s factory and R&D team set the platform for the business.

Despite a market trend towards producing lenses off-shore for costeffectiveness, he says the company remains one of the very few who still manufacture the bulk of its products in its own region. The only exceptions are a Shanghai factory – established to avoid China’s stringent importing regulations – and a Belgium factory producing basic products to support a partnership with a national optical chain. “Made in Japan has always meant high quality, even though it costs more for us, we want to protect and maintain the control we have over our production processes, which includes environmental and working conditions for our employees,” he says. Because of this, Chiang says Tokai has been able to implement an effective sustainability strategy. It has been an early adopter in this space, first obtaining ISO 9001 (quality management systems) and 14001 (environmental management systems) certification in 2000. In 2005 it also became a zero-emission facility; the allowable amount of domestic discharge per person a day is 50g, but the company has achieved 9.7g a day per employee including both industrial and personal waste. This is possible through initiatives that, among others, see lens production by-products converted into charcoal as an industrial energy resource, and cafeteria cooking oil converted into biodiesel to run its generator. Most importantly, however, Chiang said Tokai’s ‘in-house’ philosophy extends into lens development and production. It avoids outsourcing any of its processes or products, except for the raw lens material, which are provided by

a handful of chemical companies globally. The company states this is possible through its major focus on R&D, its most resource-intensive department. It employs chemical engineers who develop patented formulations they then take to the raw lens producers. This has helped it compete at the highest levels with its lens coatings and produce the famous 1.76 index lens, which are said to be up to 47% thinner than conventional lenses made from the CR-39 monomer. “Some companies may not develop their own coating formulas, instead they go to the chemical companies and request certain elements like blue light blocking, or level of scratch resistance, that are then produced for them,” Chiang explains. “Tokai writes every single coating formula in-house, and that’s because of our optical film division who produce coatings for industries like fibre cables, surveillance camera lenses, and a light concentrator to receive Cherenkov radiation; these require much higher grade coatings and to satisfy certain industries you need to understand light and how the chemicals interact with that. “That’s why we were able to produce unique products like the world’s thinnest lens because we work alongside the chemical company with our own technology. Even now some may not be able to tint their high index lenses to certain colours or percentages because they have to work with what the chemical company has, but we can effectively tint to the darkest sunglass colour in all materials we have.” According to Tokai, other examples of its chemical engineering capability include medical filters, the market’s most durable anti-reflective coatings, a new anti-bacterial coating and anti-fog properties that are built into the lens chemical structure. It was the first in the world to launch hydrophobic multicoat, and has produced a lens called Lutina, which Chiang describes as the next generation of UV protection. “Most of the market focuses on blocking UV, but later studies have also shown that high energy violet, in the 400-420nm visible light range but close to the harmful UV level, can deteriorate the lutein in your eye, which is essential to maintaining eye health and requires vegetables with yellow pigmentation. Lutina absorbs high energy violet through it’s material and is available across all lens material,” he says. AUSTRALIAN OPERATIONS Tokai Australia is based in Brisbane, but it is pursuing a national footprint, with some of its largest accounts located in NSW and Victoria. Relative to more well-known brands, Chiang says it is price competitive, and also offers basic lens options that still possess relatively high levels of technology such as freeform production and premium anti-reflective coatings. Prior to COVID, the turnaround time was five to eight days While its lab continues to produce and ship lenses in three days, on average, shipping through DHL amid the pandemic has pushed this turnaround times to seven to 10 days. “Some optometrists perform their own edging, but some don’t have that capability and prefer we do it, so we also offer a fitting service in Australia,” he adds. n

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MYOPIA Angus Hatfield-Smith, of Device Technologies (left), and Ulli Hentschel, of Hoya Australia.

t n e m e g a n a m myopia

COVERING ALL BASES OF

Myopia’s prevalence has spawned all-new innovation and unexpected collaborations. One of those is a threeway company alliance promising Australian optometrists a new one-two approach to myopia management.

ith myopia set to reach epidemic proportions, there’s arguably never been a stronger incentive for industry and the eyecare profession to unite against one of the largest looming modern-day public health problems. It’s remarkable to consider that by 2050, every second person is projected to have myopia. While this is a daunting proposition, it’s spurring the rapid innovation of purpose-built diagnostics and treatments to slow progression rates in children. At present, few manufacturers, if any, are offering an end-to-end diagnostic and treatment solution for myopia. Often eyecare professionals are required to either offer interventions without key diagnostic and monitoring tools like an optical biometer, or need to find room in their budgets to invest in such equipment with little assistance or incentive. The manufacturers behind two of the latest myopia innovations in Australia want to address this issue through a new alliance offering optometrists “a onetwo approach” to myopia management. In October, Haag-Streit – producer of the Lenstar Myopia optical biometer with myopia-specific software – and Hoya Vision Care – manufacturer of the MiYOSMART defocus spectacle lens – signed a global preferred partnership agreement. At the local level, Haag-Streit’s Australasian distributor Device Technologies and Hoya Vision Care Australia & New Zealand are managing the program to pave a smoother path for optometrists towards optical biometer ownership. Mr Ulli Hentschel, national training and development manager for Hoya Australia, says through a dedicated partnership program, Hoya and HaagStreit are supporting eyecare professionals in acquiring the device – now called Lenstar Myopia by Hoya – to strengthen their myopia management capabilities and expand this part of their clinical practice. The collaboration will also see the companies work together on practice business building and education initiatives. Since the local introduction of MiYOSMART in October 2020 – described as one of the most effective spectacle lens interventions – more optometrists have been motivated to offer myopia management, Hentschel says.

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Optometrists are reportedly seeing the value in prescribing the lens for young children that have either not had any myopia treatment yet or less effective spectacle lenses. Others have found the lens a good option for kids not ready for contact lenses, or those that don’t want to continue with a contact lens approach. “We’ve seen many practices that might have been reluctant to set themselves up for contact lens interventions like orthokeratology (orthoK) start to offer myopia management for the first time through MiYOSMART,” Hentschel explains. “While still offering similar efficacy as the other best available interventions like orthoK, soft contact lenses and specific concentrations of atropine, MiYOSMART comes into its own through being safe, and easy-to-prescribe; it’s a pair of glasses a child needs to wear, and something parents are more familiar with.” Trials have concluded children wearing Hoya’s MiYOSMART lens had 60% less myopia progression compared with single-vision wearers as measured by the axial elongation, and a 59% reduction in spherical equivalent refraction.1 Newer data shows the lens continued to slow myopia progression after three years, while patients who switched from single-vision had a significant slowdown in their condition. The optimal age for commencing treatment and whether rebounding occurs with discontinued wear is yet to be determined. With Australian optometrists prescribing MiYOSMART for a little over a year now, Hentschel says they have been inquiring about how to expand their myopia offering. This unmet need has formed the basis of Hoya’s new HaagStreit/Device Technologies partnership. “The aim both at a global and local level is to get more optometrists involved in myopia management in a way that would be considered gold standard,” he says. “Having an optical biometer like the Lenstar Myopia and its accompanying software not only helps to educate a parent on myopia management, but allows the optometrist to track it far more consistently than they might have otherwise. For Hoya globally, we recognised we had this amazing product that can help many children, but there remained the need for a platform to educate

parents about the importance of taking action, while also monitoring the child’s myopia over time.” BIOMETRY – THE NEW REFERENCE To develop the Lenstar Myopia, Haag-Streit has taken its well established Lenstar 900 optical biometer – popular among cataract surgeons – and optimised it for myopia management by incorporating specialised software, EyeSuite Myopia. Device Technologies introduced the instrument in the first half 2021, with optometrists trialling the system across the country. “At its core from a hardware perspective, the Lenstar Myopia accurately and quickly measures axial length and keratometry, as well as additional metrics useful in myopia management,” Device Technologies ophthalmic diagnostics product manager Mr Angus Hatfield-Smith says. “Biometry is a key tool in myopia management, being able to measure and track changes in eye length allows practitioners to fully understand the effectiveness of different treatment pathways in slowing the elongation of the eye.”

The software provides easy-to-read graphs that can show aspects like axial length growth over time.

To underpin the hardware, Hatfield-Smith says the system uses the latest axial length growth curves from the myopia experts at the Erasmus University Medical Center in the Netherlands, developed with leading myopia authorities Dr Thomas Aller and Mr Pascal Blaser.

“The apprehension about contact lenses for young children meant a lot of parents were opting for no myopia control, atropine or less effective spectacle lens options. MiYOSMART removes a lot of those barriers and has been a wonderful addition.”

“So far the device has been very well received by Australian optometrists, especially the software because, uniquely, the Lenstar Myopia has the ability to show you the potential outcome across multiple different treatment options, as well as treated vs untreated over time," Hatfield-Smith says.

As part of his myopia offering, Yau also has an optical biometer, which he says has enabled a better understanding of periodic axial length growth and how effective the treatments are working to control this.

“These graphs make it very effective for the optometrist to visualise treatment plans using graphical overlays of biometric and refractive data, while clearly communicating to parents about the different interventions potentially suitable for their child.”

“On occasions it can be surprising. The refractive error may tell a different story to the axial length. Some demonstrate an extremely flat cornea and very long axial length for moderate myopia, whereas for others a steeper cornea, modest axial length and high myopia may be the result,” he says.

In addition, the EyeSuite Myopia software enables clinicians to define environmental factors and their impact based on recent research findings and to visualise their changes over the period of myopia management. These may include myopic parents, the age of onset, reading time or using electronic devices and time spent outdoors.

“Clinically, [the optical biometer] has allowed us to more closely ascertain how well the treatments have worked and often guides clinical decision making to be more aggressive in treatment such as adding a secondary treatment. It has also guided discussions with parents about environmental considerations, sleep patterns and sunlight exposure and importance in compliance with treatments.”

Hatfield-Smith says many optometrists subscribing to the Hoya/HaagStreit program will be adding an entirely new instrument to their practice, or upgrading a conventional optical biometer.

Optometrist Dr Trusit Dave, director of EYETECH Optometrists in the UK, has offered myopia management for years, but last year made dedicated investments in marketing and technology.

“Investing in new technology is a fantastic way to broaden the services available in any practice, enabling growth, but recovering the investment cost is also important. Treatment conversion is key to this, so by combining diagnosis and treatment, this program has made access to each more affordable than ever.” SETTING YOUR PRACTICE APART Optometrist Jenkin Yau, of Sanctuary Lakes Eyecare in Melbourne, has offered myopia control options for the past seven years. He initially started with orthoK, atropine and distance centre multifocal contact lenses, but expanded into other specially designed contact lens options as they came to market. “But MiYOSMART had been on our wish list for as long as I had heard about the initial lens trials in Hong Kong and China,” he says. The Lenstar Myopia by Hoya offers biometry capability supported by specialised software.

This included the Lenstar Myopia, which he believes sets his practice apart by giving confidence to diagnose myopia more accurately, while providing an objective basis to assess the probability of myopia over time in children who are not yet myopic. He can also offer a more individualised assessment, rather than a loose assessment based on refraction, family history and lifestyle. “We know that refraction, particularly in children, is variable. When a child presents with 6/6 vision and is -0.25 or -0.50, are they really myopic? We can improve our accuracy by putting the child through a cycloplegic refraction or we could perform biometry – or both. Biometry and other metrics such as the AL/CR ratio have been shown to have good sensitivity and specificity in detecting myopia.” Trusit chose the Lenstar because it was globally accepted as a leading device for axial length for cataract surgery. It also has the Tideman axial length growth charts (over 12,000 eyes from Netherlands and England) and the ability to import latest growth curves for specific populations. “What sets this device apart is the automatic positioning system, it improves repeatability and also speeds up the capture process,” he says. “Finally, the Lenstar offers excellent reports and a logical way to communicate findings with children and their parents. Anyone who is involved in myopia management will confirm this aspect is probably the most timeconsuming part of any consultation.” n NOTE: References will appear in the online version of this article.

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INTRAOCULAR LENS

a t s i V n e g n i optimis s e m o c t u o c i r to

AIMING TRUE:

With Bausch + Lomb releasing the toric version of its enhanced enVista platform, surgeons discuss how they are improving outcomes, even in complex cases. The company is also incorporating a new generation toric formula into its lens calculator.

n October 2020, ophthalmic device manufacturer Bausch + Lomb (B+L) released its upgraded enVista monofocal intraocular lens (IOL) in Australia, featuring a modified lens material for faster unfolding and a new pre-loaded delivery system. These enhanced features were welcomed by ophthalmologists who have traditionally relied on the hydrophobic acrylic lens – first launched in 2012 – for its robust, glistening-free material, visual clarity, predictable outcomes and, more recently, unexpected functional intermediate vision in some patients reported by some surgeons. Since the arrival of the improved enVista monofocal with the new SimplifEYE delivery system, B+L has introduced the toric form of the lens (called the enVista Toric pre-loaded). Now, surgeons report the lens’ other attributes – such as aberration-free optics, haptic design and rotational stability – are contributing to optimal outcomes for astigmatic patients and others with irregular corneas.

Rostov spoke of her experience with the new enVista Toric pre-loaded at last year’s Australian Society of Cataract and Refractive Surgeons (AUSCRS) conference, presenting on aberration neutral IOLs in complex cataract cases such as post-refractive surgery, keratoconus, transplant patients and other irregular corneas. She says complex cases make up about 30% of her cataract work, with the enVista Toric pre-loaded being a mainstay due to its versatility. B+L has designed the IOL with step-vaulted, modified-C haptics that vault the haptic posteriorly to form direct contact with the capsular bag. The haptics also include fenestration holes that help evenly disperse post-operative capsular contractile forces. Talley Rostov says these attributes result in a very stable IOL, with little concern about rotation. “Which we know is very important when considering IOL toric alignment, and the ability of the IOL to stay precisely where you place it,” she says.

In recent months, B+L has also been updating its enVista toric calculator to now incorporate the Emmetropia Verifying Optical (EVO) Formula 2.0. It’s a new generation formula developed by Singapore’s Dr Tun Kuan Yeo who completed his 2015 anterior segment fellowship under internationally renowned Western Australian ophthalmologist and creator of the Barrett Formula Suite, Professor Graham Barrett.

“And we know hydrophobic acrylic IOLs opposed to hydrophilic are also very stable, and when you’re talking about cases of DMEK, DSEK or a retinal procedure where there maybe air and gas in the eye, a hydrophilic lens may opacify, but with the enVista platform you don’t have to worry, so it’s versatile and amenable to those situations.”

Seattle-based corneal, refractive and cataract surgeon Dr Audrey Talley

With complex corneal cases making up a significant proportion of her work,

INSIGHT March 2022

Talley Rostov says the aberration-free lens design has been key to providing optimal outcomes for patients who may have decentration from previous refractive surgery, zonular issues, corneal transplant, high angle kappa, or differences in the alpha angle. She has also found the design ideal for multifocal or aberrated corneas such as keratoconus.

“EVEN IF THERE'S DECENTRATION OVER TIME, I DON’T HAVE TO WORRY ABOUT A LESS-THANPERFECT RESULT DUE TO THE ABERRATION-FREE DESIGN”

“While some IOLs are excellent, they have additional negative spherical aberration and this creates issues in cases that could involve some decentration,” she explains. “If you’re using a platform with no additional spherical aberration (enVista), you’re going to get the same great outcome, even if there’s some difference between the visual axis and centre of your IOL. That makes it extremely versatile, user-friendly for the surgeon, as well as giving great outcomes for your patients. “I use the enVista Toric routinely with patients after corneal transplantation. As good as you might be, there usually is some residual astigmatism – and just because they have previous corneal pathology, there’s no reason to believe they are stuck with less-than-ideal vision; we have a real opportunity to make a big difference with the enVista platform.” In other complex cases, Talley Rostov has implanted the enVista Toric preloaded in a patient in his 50s with a history of congenital lens coloboma where a portion of the natural lens is missing. He also had -3.0 D of astigmatism. Performing femtosecond-laser-assisted cataract surgery (FLACS), she combined the enVista Toric with a capsular tension ring and found the lens was well-centred. “Even if there is decentration over time, I don’t have to worry about him developing a less-than-perfect result due to the aberration-free design. He had a fantastic refractive outcome; he said he’d never had better vision in his life." Another case involved a 64-year-old woman who had cataract surgery elsewhere with a toric multifocal IOL. She was unhappy with her vision, even with a corrected residual refractive error. Tomography revealed previously undetected keratoconus with expected increased higher order aberrations. An IOL exchange was performed, with the enVista Toric ultimately implanted. There was also a radial keratotomy (RK) patient she treated with the enVista. “Both had excellent outcomes. The keratoconus patient, in particular, had a huge improvement in quality of vision, could drive again and her glare, haloes and other aberrations were resolved. “With RK, once a refractive patient, always a refractive patient – and when it comes to cataract surgery they are seeking that crisp vision just like when they had RK, LASIK or PRK surgery, so the ability to correct astigmatism for these patients means you’re doing them a great service.” Talley Rostov has also found the IOL’s fenestration holes allow for intraoperative lens manipulation. For example, she’s been able to rotate the IOL in either direction once implanted (some can only be dialled in one direction), if the lens becomes slightly off axis during steps like viscoelastic removal. ‘SURPRISING’ INTERMEDIATE VISION Queensland ophthalmologist Dr Sunil Warrier practises at Terrace Eye Centre and Redlands Eye Specialists in Brisbane and is head of the ophthalmology

DR AUDREY TALLEY ROSTOV US OPHTHALMOLOGIST department at the Mater hospital network. He has been among the first Australian specialists to offer the enhanced enVista platform. About 65% of his cataract patients receive a monofocal, with the enVista being his primary choice, and the enVista Toric pre-loaded accounting for around 30% of that. With B+L changing the ratios of two polymers in the lens material, Warrier has noticed drastic improvements with the faster unfolding time, and overall ease-of-use with the SimplifEYE preloaded delivery system. “With pre-loaded IOL systems, the two common methods involve either screwing it down, or a plunger mechanism; this screw system (SimplifEYE) is very controlled so you can stop at any point,” he says. “Ninety-eight percent of the time you can have the lens unfold in the bag, so there’s no need to take a second instrument and push it in, effectively cutting out an additional step.” Like Talley Rostov, Warrier has been impressed with the enVista’s rotational stability, which he puts down to how the haptics interact with the capsular bag. He’s also found an unexpected number of patients achieving intermediate vision. This surprising advantage is to do with pre-existing corneal spherical aberration, as discovered by Californian ophthalmologist Dr Mitchell Shultz. Through corneal analysis, he’s found patients in the +0.25 to +0.31 μm positive corneal spherical aberration range get the most enhanced depth-of-field. Warrier spoke to Shultz about this, and then asked his clinic’s optometrist to measure intermediate vision in enVista patients. “Over 50% were 6/12 or better at 80-100cm, and some were even 6/6,” he explains. “This has surprised me because it’s not really the aim of this lens. Patients still need reading glasses, but that’s not really the sales pitch for this. When they’re driving, they can see the dashboard comfortably, and the distance is great.” NEW GENERATION FORMULA For surgeons to optimise outcomes, B+L realised it needed to modernise its toric calculator. Over time, use of its legacy calculator has diminished in Australia, largely because it only accounted for anterior corneal astigmatism. Australian surgeons have increasingly turned to later generation formulas such as Barrett Toric Calculator (BTC) and EVO Toric 2.0 that account for newer parameters such as posterior corneal astigmatism – influential in toric refractive outcomes. The first generation of the EVO formulas were released by Dr Tun Kuan Yeo in 2017. The results of clinical studies showing its equivalence and/or superiority to other leading formulas prompted B+L to embed the EVO Toric Formula 2.0 in its enVista Toric calculator. Yeo, a senior consultant with the National Healthcare Group Eye Institute at Tan Tock Seng Hospital, Singapore, and senior clinical lecturer for Yong Loo Lin School of Medicine, National University Singapore, says his 2015 fellowship under Prof Barrett was influential in him developing the formula.

Some surgeons have noticed a faster unfolding time with the latest enVista IOL. Image courtesy of Dr Sunil Warrier, Terrace Eye Centre and Redlands Eye Specialists, Brisbane.

At the time, he was conducting toric calculation research, with the BTC “exploding” in popularity that year. In his free time, he was conducting research on posterior corneal astigmatism and stumbled across an algorithm that could predict for this and be applied to any standard formula.

INSIGHT March 2022 51

INTRAOCULAR LENS

thickness or central corneal thickness that either couldn’t be measured as accurately, or at all, during their time.

“OLDER FORMULAS USE LESS MEASUREMENT PARAMETERS THAT ARE NOT ABLE TO ADDRESS SOME OF THE OUTLIERS” DR TUN KUAN YEO DEVELOPER OF THE EVO TORIC FORMULA 2.0 “But because of the shortcomings of the traditional standard formulas, I decided to create my own formula so it could bring the best out of the algorithm,” he explains. In a presentation in 2019 at the American Society of Cataract and Refractive Surgeons Meeting, which won best paper of the session, Yeo presented a comparison of the performance of different toric formulas in 117 eyes. He says it showed the EVO Toric had the highest percentage of eyes within 0.50D prediction for cylinder, effectively equivalent to the BTC, and preforming better than the Abulafia-Koch regression, Johnson and Johnson Vision online toric calculator, and Holladay I toric formula. According to Yeo, for IOL power calculations, traditional formulas haven’t performed well in extreme eyes, a shortcoming his EVO formula has also sought to address. They didn’t account for newer parameters like anterior chamber depth, lens

“The older formulas use less measurement parameters that are not able to address some of the outliers,” he says. “For example, traditional formulas were built based on ultrasound axial length, but newer measurements of optical biometry are more precise, and the newer formulas such as the EVO harness these newer measurements and are able to correct for the bias seen in extreme eyes. At the same time, the theory behind the formula seems to fit a lot of different eyes, and that is why we are seeing improved accuracy today.” Yeo made his formula freely available online to the public in 2017. His efforts have also seen him invited to the exclusive IOL Power Club. Today, Google Analytics figures show an average of 900 EVO IOL calculations are performed daily worldwide, with Spain ranking first and Australia – where the Barrett formulas remain popular – ninth. The EVO formulas are based on the theory of emmetropization and generate an ‘emmetropia factor’ for each eye. Yeo has already developed a third version, which is in the process of being validated. “It is mainly to improve accuracy in extreme eyes: very short eyes, long eyes, flat keratometry, steep keratometry, and other atypical eyes because we are doing very well for the average eye,” he says. “Because technology improves, the formula is designed in a way it can be upgraded, scalable and futureproof, so that if new measurements are available, they can be incorporated easily.” Finally, with the introduction of the EVO Toric 2.0 formula, Yeo says B+L will become one of the few IOL manufacturers to use an online toric calculator that will not only predict the toric power, but also the IOL power. n

“Eyecare Plus develop and manage essential digital marketing and national promotions that help grow my practice, so we can focus on caring for our patients.” Liz Muller Optometrist, Eyecare Plus Altona

Multi Award Winning Practices Looking to buy, sell or join contact Philip Rose 0416 807 546 or philip.rose@eyecareplus.com.au

CAREER

People

ON THE MOVE A wrap on the latest appointments and industry movements within the ophthalmic sector.

OPTOMETRIST JOINS PEAK BODY'S TEAM OF NATIONAL ADVISORS Dom Willson has commenced at Optometry Australia as a Professional Services Advisor. He joins the team of national advisors providing one-on-one advice on clinical, ethical and complex issues. He has nearly 30 years’ experience as an optometrist in metro locations and remote communities in the NT and NSW. He owned Custom Eyecare for over 20 years and spent a decade working for the Brien Holden Vision Institute in his spare time as a locum optometrist for Indigenous communities.

APAC LEADERSHIP RESHUFFLE AT ALCON Mr Chintan Desai has joined Alcon as Vice President of the company’s Surgical business in the Asia Pacific region. He joins Alcon following 23 years at GE Healthcare, most recently as CEO for Southeast Asia. He was integral in leading the commercial team to deliver consistent doubledigit growth and established a strong leadership structure to enable sustainable, long-term growth.

DARRELL BAKER TAKES ON NEW ROLE AT BLEPHAROSPASM AUSTRALIA Former Optometry Australia president and Western Australian optometrist Mr Darrell Baker has been appointed on to the board of Blepharospasm Australia. Baker, who has an interest in neuroophthalmic disorders, will help oversee special projects. “Not only will we benefit from his technical expertise but his experience in governance and strategic planning will be invaluable," chairman Mr John Yeudall said.

DR ALEX HUI TO RETURN TO CORE IN CANADA The Centre for Ocular Research & Education (CORE) announced Dr Alex Hui would become its Head of Biosciences. Hui was previously a Senior Lecturer at the School of Optometry and Vision Science at UNSW Sydney, but will soon relocate to CORE’s facility in Waterloo, Canada. He is an author on more than 30 publications and has been an invited speaker at conferences worldwide. In addition to drug delivery systems, his research has focused on ocular therapeutics, myopia control, and contact lenses. He is also an Associate Editor for Clinical and Experimental Optometry.

ESSILORLUXOTTICA WELCOMES NEW BOARD DIRECTOR EssilorLuxottica has appointed Ms Virginie Mercier Pitre as a new Board Director. This follows her recent nomination as the new President of Valoptec Association, the independent Association of EssilorLuxottica’s employee shareholders. She replaces Ms Juliette Favre, who was President of Valoptec Association from 2015 to 2021 and served three terms on the Valoptec board, which is the maximum allowed by the association bylaws. Pitre is currently Vice President of Commercial Europe at Essilor.

MAJOR APPOINTMENT AT GEORGE & MATILDA EYECARE Dylan Oblein has been appointed Regional Manager for Southern NSW and ACT at George & Matilda Eyecare. He has more than a decade of experience in the optical industry, having previously been employed as Regional Manager at Luxottica, Product Specialist at Device Technologies, Retail Director at Specsavers in Penrith, and Regional Sales Manager at OPSM in Sydney and Northern Beaches.

Do you have career news to share? Email editor Myles Hume at myles.hume@primecreative.com.au to be featured. INSIGHT March 2022 53

A PANDEMIC-INFLUENCED CARE MODEL COVID-19 HAS FORCED THE EYECARE SECTOR TO ESTABLISH NEW CARE MODELS THAT GIVE EQUAL CONSIDERATION TO TIMELY ACCESS AND SAFETY, AS ROYAL CHILDREN’S HOSPITAL MELBOURNE CHIEF ORTHOPTIST CATHY LEWIS WRITES.

S CATHY LEWIS

"WITH LIMITED PUBLIC HEALTH FUNDING, THE CURRENT CARE MODELS WILL STRUGGLE TO MEET THE INCREASED DEMAND ON SURGICAL WAITLISTS AND OUTPATIENT CLINICS"

ince the start of the pandemic, Australian eyecare providers have experienced many workplace challenges. The effect on service provision has varied according to the restrictions in place and patients’ clinical need and urgency, but finding a balance between the appropriate care timeframe and safety has been challenging. Melbourne has spent more days in lockdown than any other city and orthoptists and ophthalmologists at the Royal Children’s Hospital (RCH) Melbourne have become adept at the constant rate of change, implementing several initiatives, some outlined below. This has led to a positive work environment and patient experience, and improved collaboration with Orthoptist Navdeep Kaur in a RCH eye clinic tele-consult. Image: Alvin J Aquino/RCH Communications. external eyecare providers.

•C OVID-19 triage guidelines for outpatient eye clinics were implemented early on and are constantly adjusted according to the restrictions in place. These dictate whether appointments can be booked for face-to-face or telehealth. •T elehealth consults: Although not always ideal, tele-consults have become a permanent fixture. They provide an opportunity for parents to ask questions and receive advice, with an interpreter service included when required. The examiner can visually assess and observe the child and advise the family whether they should see an external eyecare provider while waiting for their face-toface RCH appointment. Interestingly, several families preferred tele-consults as travel time and the cost of face-to-face bookings were eliminated, while providing a calmer experience for children. • A Home Visual Acuity Test Kit and educational video was created early in 2020 to support tele-consults as there were limited resources to assist families with the home assessment. This is especially difficult for paediatric vision assessments when inducing crowding is essential for amblyopia detection and children often don’t know their alphabet. This was a time-consuming workflow as families were contacted and emailed a Home VA Test, matching card, instructions, recording sheet and link to the instructional video. Those without a printer were posted packs. The Home VA results were returned to RCH electronically and entered into the

INSIGHT March 2022

child’s electronic medical record (EMR) for reference during the tele-consult.

Approximately 11,500 patients are booked into the RCH eye clinic each year. This has remained stable during the pandemic, but the • e ye.clinic@rch.org.au email was created booking types changed. Tele-consults weren’t for communication between RCH, families, booked pre-pandemic, whereas 3,950 were and external colleagues as the need to comanage patients increased. This provided a booked in 2020 and 2,950 in 2021, with the pathway for all involved to exchange scans, pattern continuing in 2022. Although useful, results, and information. The RCH EMR also tele-consults cannot compare with in-clinic has a patient portal for direct communication examinations, resulting in a huge back log waiting for face-to-face appointments. In between the patient and staff. response, RCH increased the number and •M icrosoft Teams virtual daily huddle has types of orthoptist-led clinics which has been excellent for communicating daily been invaluable for service provision – and priorities, and just as importantly, enabling as we revise care models internally this may our team to feel connected. Running be expanded. Also, based on the success department meetings and internal CPD with LOEC, RCH will continue to investigate events virtually has enabled greater access additional options for co-management with for staff, the majority of whom are sessional, external eyecare providers. leading to increased participation. It will take time to fully understand • Co-management with external eyecare COVID’s impact on patients, but as it providers: Due to COVID, the waitlist to see continues, and with limited public health an RCH orthoptist increased and orthoptic funding, the current care models will student placements couldn’t be offered struggle to meet the increased demand on throughout much of 2020. In response, surgical waitlists and outpatient clinics, so La Trobe University (LTU) implemented a we must be innovative to ensure service student-led orthoptic clinic overseen by delivery is sustainable and timely. n an orthoptist (Latrobe University Orthoptic Eye Clinic - LOEC). The RCH collaborates by referring in patients from the orthoptic ABOUT THE AUTHOR: CATHY LEWIS is the Chief Orthoptist at the Royal Children’s Hospital Melbourne waitlist for co-management based on an and a casual lecturer in orthoptics at La Trobe University. agreed set of protocols. RCH has referred over 500 patients for co-management. As ORTHOPTICS AUSTRALIA strives for excellence a result, orthoptic students gain clinical in eye health care by promoting and advancing experience, RCH patients receive eyecare the discipline of orthoptics and by improving eye health care for patients in public hospitals, in appropriate timeframes while waiting for ophthalmology practices, and the wider an RCH orthoptist, and LTU surveys reveal community. Visit: orthoptics.org.au families are satisfied.

MANAGEMENT

DISCHARGE FROM DAY PROCEDURES A PATIENT ARRIVES FOR A SCHEDULED EYE PROCEDURE, TO BE PERFORMED UNDER SEDATION. THEY PLAN TO TAKE THE TRAIN HOME WITH NO SUPPORT PERSON. RUANNE BRELL AND DR PATRICK CLANCY DISCUSS YOUR OPTIONS.

S RUANNE BRELL

ometimes, despite best efforts at explaining discharge requirements, a patient will not have a support person to accompany them home. In such scenarios, practitioners may be concerned about their responsibility if a patient is discharged alone and:

• i njures themselves or someone else when travelling home, or •e xperiences a post-procedure complication.

DR PATRICK CLANCY

In a small number of cases, patients have been harmed and healthcare providers criticised over discharge practices. It appears processes broke down or responsibilities were unclear. Patients may not have been appropriately assessed for discharge, or not clearly advised of the risks of driving themselves. GOOD PROFESSIONAL PRACTICE In assessing a patient’s fitness for discharge, practitioners are expected to exercise clinical judgement, guided by applicable professional and regulatory guidelines. The Australian and New Zealand College of Anaesthetists (ANZCA) 'Guideline for the perioperative care of patients selected for day stay procedures' (PG15) (DSP Guideline) sets out good professional practice for such procedures. It provides patients should only be discharged when a responsible adult is available to transport them in a suitable vehicle (not a train, tram, or bus). A responsible person should stay with the patient at least overnight. You need to ensure patients understand the risks material to their situation. •M ake discharge criteria and expectations clear well before the scheduled date of the procedure so patients can plan appropriately. •W arn of the potential effects and risks of the procedure and any medication. Explain how sedation or medications may affect their ability to resume driving or other tasks and for how long.

•P rovide written and verbal instructions about post-anaesthesia and post-procedural care. Include a contact number and location for emergency medical care if necessary. Once you’re satisfied a patient is well enough to be discharged, there is rarely a legal basis to detain them if they insist on leaving. A patient can only be detained in hospital against their will if they meet the requirements for involuntary admission under the relevant legislation. MANAGING DIFFICULT SCENARIOS It’s helpful to consider in advance some ways to manage potentially difficult scenarios. Patients who plan to leave unaccompanied – If the patient arrives unaccompanied, can they arrange for a support person? If not, it may be appropriate to postpone the procedure. This will be a clinical decision. If you decide to proceed, you may need to advise the patient to stay until the effects of sedation have worn off enough and they can safely leave alone. This assumes your facility has arrangements for staff to stay until the patient has recovered, and that you can transfer them to hospital if there are unexpected complications and they are not going to be able to go home. They should still travel home in a taxi or car, if possible, rather than using public transport. Consider also appropriate follow-up arrangements to ensure someone checks in on the patient the next day. What if they plan to drive? – Practitioners often ask what to do if a patient insists on driving after sedation. Practitioners are expected to advise patients not to drive until they have sufficiently recovered, physically and mentally, but do not generally have a duty to report to the licensing authority.

If the patient insists on leaving, practitioners should obtain a signed confirmation they left against medical advice.

However, if you’re concerned a patient may pose a serious risk to their own health and safety, or they may put someone else at risk, there may be grounds to breach patient confidentiality and report them to the police. This situation can be complex, so seek advice first. Documentation – Always document any information, materials and advice you gave the patient. If the patient insists on leaving, include their signed confirmation they left against medical advice, and your clinical rationale they had capacity to make that decision. Disclaimer: This article is intended to provide commentary and general information. It does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practise proper clinical decision making with regard to the individual. circumstances. n

ABOUT THE AUTHORS: RUANNE BRELL is a senior legal advisor in the Advocacy, Education and Research team at Avant with over 15 years’ experience in health and medical law. She also provides advice to Avant’s members via its Medico-legal Advisory Service. DR PATRICK CLANCY is a senior medical adviser at Avant. He has been a doctor for over 25 years and was previously a member of a state medical board. Patrick has presented and written widely on medico-legal topics, with a focus on minimising the risks faced by doctors.

INSIGHT March 2022 55

DISPENSING

HOW VITAL ARE QUALIFIED OPTICAL DISPENSERS? MANY DISPENSERS DON’T REALISE THE VALUE THEY CAN BRING TO AN OPTICAL PRACTICE, STIFLING THEIR CAREER GROWTH. IN PART ONE OF HIS SERIES, STEVEN DARAS EXPLAINS WHY THEY’RE THE BUSINESS’ POWERHOUSE.

STEVEN DARAS

"OPTICAL DISPENSERS SHOULD START TO SHOWCASE THEIR KNOWLEDGE, TALENT, AND IMPORTANCE TO THEIR EMPLOYERS"

ptical dispensing has been around in some form since the first spectacles were made. The science of optometry includes optical dispensing, so it’s always been a part of vision correction. In Australia, education for optical dispensing began circa 1954 and at a similar time, optometry moved from being taught at various technical and private colleges to university study. Previously, qualified optical dispensers were registered/licensed in only some jurisdictions. This meant people couldn’t move interstate to work unless they were registered. The Federal Government wanting ‘a level playing field’ reduced this to the lowest common denominator by removing registration allowing people to work across borders. Thus, there are many people who call themselves ‘optical dispensers,’ but aren’t actually qualified. They are usually taught in-house but due to their busy workplaces may have little time for quality teaching. In lower prescriptions, selling a pair of glasses is relatively easy. However, in higher prescriptions this is harder. They may not be able to recognise potential problems due the eye’s condition or the prescription itself. Problems that aren’t recognised and avoided often lead to people having issues with their glasses that can lead to complaints, refunds or not wearing them. Not a good result for anyone involved. Qualified optical dispensers learn about the eye, lenses, frames and how they combine to improve vision. They recognise ocular conditions and potential problems that may impact the prescription, taking steps to avoid these. They offer the best options to the wearer. Optical dispensers don’t realise their importance to the industry – and from a business perspective they’re a powerhouse. Look at any successful optical business in Australia from large to smaller optical chains, buying groups, independent practitioners etc., and the bulk of their business comes from optical dispensing. Optometry and optical dispensing must work side-by-side to realise this potential. Some optometrists don’t see it, thinking

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It’s the selling of spectacle frames, ophthalmic lenses and treatments that generate the most revenue for practices.

the consultation is more important when, in fact, dispensing is just as important from a quality practice and financial point of view. It’s like asking if the chicken or egg came first? Change that to ask, what’s more important, the eye test or dispensing the prescription? The answer to this is both; a successful practice can’t have one without the other. Major optical chains and other practices don’t build empires from dollars generated by optometry fees; they build them from the dollars generated through optical dispensing. From small private practices to big optical retailers, it’s the selling of spectacle frames, ophthalmic lenses and treatments that brings in the most money. A good dispensing team will help build and support a thriving practice. Hypothetical example: a new practice opens and in the first week 100 people have been booked for a bulk-billed test at $60 per person. During that week 40 spectacles are dispensed in-house. These vary from single vision ($100) to progressives ($800) at an average price of $400. •O ptometrist – 100 tests @ $60 generates $6,000 •O ptical dispenser – 40 spectacles @ $400 generates $16,000 The dispensing brings in more money, so makes a significant contribution to the success of that start-up company. Yet most optical dispensers don’t realise this and have allowed themselves to be relegated to a bit role, or that of salesperson. This suits employers as they can pay

lower wages. There’s also potential for employer-backed advocacy groups – representing ‘thousands of members (staff)’ – to set up and have a voice with government to keep wages static. Optical dispensers have been herded towards the retail path for years and this will help to keep them in check. Unfortunately, many dispensers have only themselves to blame as they don’t apply their knowledge to give good advice and create dispensing plans to increase business, showing the boss their importance. Instead, most take the easy option and just sell glasses following a sales pattern. Optical dispensers should start to showcase their knowledge, talent, and importance to their employers. They can do this by offering quality optical dispensing advice by educating their clients to the variety of visual requirements they have and matching them to the huge range of optical products available through Australia’s optical wholesalers (ODMA et al) who bring the world’s best optics to their door. Hopefully, this brings recognition, promotion, and rewards from a grateful employer. n

ABOUT THE AUTHOR: 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.

2022 CALENDAR MARCH 2022 COPENHAGEN SPECS Copenhagen, Denmark 5 – 6 March copenhagenspecs.dk

MIDO EYEWEAR SHOW Milan, Italy 30 April – 2 May mido.com

MAY 2022

ASO 2022 EXPO

BARCELONA SPECS

Melbourne, Australia 18 – 20 March asoeye.org/event-page-expo

Barcelona, Spain 7 – 8 May info@barcelonaspecs.com

VISION EXPO EAST New York, US 31 March – 3 April east.visionexpo.com

APRIL 2022 AUSTRALIAN VISION CONVENTION (AVC) Queensland, Australia 9 – 10 April optometryqldnt.org.au/avc

10TH SUPER SUNDAY CONFERENCE Sydney, Australia 22 May optometry.org.au

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

JUNE 2022

NSW RANZCO & OPHTHALMOLOGY UPDATES!

NOSA ANNUAL CLINICAL AND SCIENTIFIC MEETING

Sydney, Australia 27 – 28 August ranzco.edu

Canberra, Australia 9 – 12 June kathpoon@bigpond.com

SEPTEMBER 2022 VISION EXPO WEST

JULY 2022 NORTH QUEENSLAND VISION Cairns, Australia 9 – 10 July optometryqldnt.org.au/nqv

Las Vegas, US 14 – 17 September west.visionexpo.com

OCTOBER 2022

AUGUST 2022

EYECARE PLUS NATIONAL CONFERENCE 2022

OSHOW2022

AUSCRS

Sydney, Australia 27 – 28 May marketing@odma.com.au

Noosa, Australia 3 – 6 August auscrs.org.au

Broadbeach, Australia 28 – 30 October web.cvent.com

SPECSAVERS – YOUR CAREER, NO LIMITS All Specsa Graduate Opportunities – Australia and New Zealand ve s tores n rs The Specsavers Graduate Recruitment Team have several exciting graduate opportunities available across Australia o with O w and New Zealand. With continued growth in providing eyecare to patients across ANZ, now is an exciting time to join CT and be part of the company bringing Optometry to the forefront of the healthcare industry. At Specsavers, you will have access to cutting edge technology and be part of leading the way in improving lives through better sight. If you are a final year student or recent graduate seeking employment, please contact apac.graduateteam@specsavers.com today.

Interested in relocating to NZ? Specsavers has a range of opportunities for NZ optometrists looking to return home. From North to South, we have fantastic opportunities for optometrists at all levels. And as a Specsavers optometrist, you’ll have the chance to advance your skills and become part of a business that is focused on transforming eye health outcomes in New Zealand. Be equipped with the latest ophthalmic equipment (including OCT in every store for use with every patient) and develop your clinical experience across a range of interesting conditions and an ever-growing patient base. You’ll also have the support of an experienced dispensing and pre-testing team, the mentorship of store partners and access to an exemplary professional development program. There’s no place like home – so if you’re ready to return, let us help you. Western Australia Locum Optometrists: New Year, New Career At Specsavers, we like to work with the most talented optometrists and give them what they need to thrive. This includes the provision of the highest quality equipment, ongoing enhancement of skills and access to industry leaders. Have you considered Locum Optometry: variety, travel and the opportunity to expand your network? We have several vacancies across WA and seeking optometrists who have a real passion to provide the best service to the people of Western Australia. With work available across the state, reach out today for a confidential conversation on how we can assist your locum lifestyle. Optometrist Joint Venture Partnership opportunity – Specsavers Wollongong, NSW Wollongong is a coastal city in Australia, 80kms south of Sydney along the Grand Pacific Drive. Surrounded by surfing beaches and rock pools, trails encircling the forests and rocky cliffs of Mt. Keira, hang gliders launching from Bald Hill Wollongong has something to offer everyone. Specsavers opened the Wollongong store in 2010 and had a relocation and all new shop fit in 2020. The store is conveniently located in the Crown St Mall and offers 3-test rooms, 8 dispense points, over 1000 frames available and a dedicated audiology room. Optometrist opportunities in far north QLD Looking for great weather all year round? Specsavers are expanding our Optometry team in QLD’s far north. Home to rainforests, beaches, markets and a vast array of great cafes, bars and restaurants along with access to the Great Barrier Reef, there is something to suit everyone. You’ll work with market leading equipment – including OCT, be supported by experienced retail teams and have access to excellent opportunities for further career development. Part or full-time considered. Extremely attractive salary including relocation support, birthday/volunteer Leave, Specsavers Perks staff discount program, free glasses, 30% off glasses voucher for family and friends each year.

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: QLD, NT, VIC & TAS Optometrist enquiries: Marie Stewart – Recruitment Consultant

marie.stewart@specsavers.com or 0408 084 134 WA, SA, NSW & ACT Optometrist enquiries: Madeleine Curran – Recruitment Consultant

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

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

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

apac.graduateteam@specsavers.com

SOAPBOX

PSYCHOLOGICAL STRAINS OF OPTOMETRY

BY PROF SHARON BENTLEY

n my roles as an employer of optometrists and an academic, it seemed to me mental health issues and burnout in our industry have been increasing during the past 10 years. Anecdotally, early career optometrists were reconsidering their professional options, academics were burnt out from increasing teaching workloads and research funding constraints, and students were struggling to juggle their studies, need to work and general life challenges. In 2013 Beyond Blue conducted Australia’s first 'National Mental Health Survey of Doctors and Medical Students' and found doctors and medical students had high rates of burnout and were more likely to experience psychological distress than the general community. This prompted a group of us at Queensland University of Technology (QUT) to conduct the first survey of registered practising Australian optometrists to estimate rates of psychological distress and burnout, and in so doing, determine the likely magnitude of the problem. The study was conducted in November 2019, prior to the COVID-19 pandemic. Standard mental health and burnout questionnaires were used, in addition to invited comments on the topic. Nine per cent (505) of Australian optometrists responded to the survey. Rates of burnout and moderate-to-severe psychological distress were high (31%) relative to the general population and consistent with rates for other healthcare professionals, such as doctors, nurses and pharmacists. Optometrists aged under

INSIGHT March 2022

probability of leaving a profession. It’s essential the situation is addressed, particularly for our early career optometrists. While optometry would benefit from studies to inform the most appropriate next steps and evaluate the effectiveness of strategies, much has been written about how to reduce burnout in medicine, nursing and business, which could be applied to optometry. For example, mental health promotion programs, monitoring and support programs by employers and professional bodies targeted at both the individual and workplace level, workload 30 were 3.5 times more likely to report reduction, fostering a sense of belonging, moderate-to-severe psychological distress as well as mental health and resilience compared with optometrists over 30 years. programs at university for optometry Younger age and burnout were significant students prior to entry to the profession. risk factors for psychological distress. It’s important to note our study was According to the World Health conducted just prior to the COVID-19 Organization, ‘burnout’ is a syndrome pandemic, which imposed many resulting from chronic workplace stress additional challenges and stresses for and is characterised by: feelings of optometrists. It’s likely optometrists energy depletion or exhaustion; increased have been even more susceptible to mental distance from one’s job, or developing mental health conditions feelings of negativity or cynicism related to and burnout during this time. We are one’s job; and perceived low self-efficacy currently seeking funding to design and and achievement in one’s profession evaluate evidence-based interventions (feeling ineffective at work). for optometry that will enable individuals Additional specific studies are needed to thrive, engage, commit and find to explore the exact reasons for burnout meaning in their work at the personal and among optometrists. However, the most organisational level. frequent work-related issues mentioned ‘The Mental Health and Wellbeing Survey by participants in our study were of Australian Optometrists’ by optometrists retail pressures, workload and career Professor Sharon Bentley (second from dissatisfaction. Too much focus on sales right), Associate Professor Alex Black (far targets rather than patient care was right), Professor Joanne Wood (second perceived as problematic. Commercial from left) and Ms Amanda Griffiths from pressures were also noted by optometry the Centre for Vision and Eye Research, business managers and owners. School of Optometry and Vision Science, Most participants talked about QUT, psychologist Professor Nigar insufficient breaks and working late because of seeing too many patients with Khawaja (far left) from QUT’s School of appointments that are too short, making Psychology and Counselling and health the pace of work feel stressful. They also psychologist Dr Fiona Fylan from Leeds described feelings of job insecurity related Beckett University UK, was published to increasing numbers of graduating in Ophthalmic and Physiological Optics optometrists and frustration with lack in 2021. n of opportunities for career progression. Some find optometry monotonous. Name: Prof Sharon Bentley Burnout is a complex issue, affecting Qualifications: PhD MOptom MPH individuals as well as healthcare CertOcTher GAICD CF FACO FAAO (DipLV) organisations and patients. Studies AFHEA (Indigenous) have shown burnout is associated with Organisation: Queensland University of reduced productivity, absenteeism, Technology patient errors, poor attitudes to patients, Location: Brisbane Years in profession: 33 high staff turnover and increased

RATES OF BURNOUT AND MODERATETO-SEVERE PSYCHOLOGICAL DISTRESS WERE HIGH (31%) RELATIVE TO THE GENERAL POPULATION.

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OPTICAL DISPENSING

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