INSIGHT April 2023

OPTOMETRY'S LATEST 'DISRUPTOR'

Why Peter Larsen is joining forces with Chemist Warehouse to launch an eyecare network.

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MYOPIA MANAGEMENT SPECIAL REPORT

A 20-page report covering high myopia and axial length, to combination treatment.

'A MONOFOCAL-LIKE DISTURBANCE PROFILE'

The resurgence of an IOL category offering patients an extended range of vision.

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OPTOMETRIST WAREHOUSE MODEL PLANS TO SYSTEMATICALLY LINK PHARMACY WITH EYECARE

On only the second day of opening Optometrist Warehouse on Glenferrie Road in the Melbourne suburb of Malvern, a new patient was diagnosed with proliferative diabetic retinopathy. They lived across the road and simply wanted their eyes checked yet didn’t live in a recognised diabetes hot spot and weren’t referred by a GP or medical specialist.

According to Optometrist Warehouse managing director Mr Peter Larsen, the case highlights the flaws in the current healthcare system, including optometry, that will become a major focus of Australian optometry’s newest venture, backed by pharmacy retailer Chemist Warehouse.

By identifying at-risk patients

in the pharmacy setting, it’s believed a conjoined optometry practice could have a major impact on community health.

“There are 600,000 estimated Australians who have diabetes who are not getting their eyes checked, but hardly anyone is doing anything about it,” Larsen said.

“An optometrist sends a recall letter, but the patient doesn’t turn up. Whose responsibility is that? The patient goes to the GP and they say you should get your eyes tested, but who checks if they do? A pharmacist hands over medication and may or may not have a conversation about eye health. The person with diabetes is told it’s their responsibility. I’m a bit unusual because I want to

take responsibility.”

So, when Chemist Warehouse approached Larsen to lead the company’s eyecare venture –vowing to “disrupt” the industry –he didn’t hesitate.

“This approach is creating a patient-centric business and looking at all the outcomes that should happen in primary eyecare

and then creating a model that is able to deliver that,” he said. It’s fair to say Optometrist Warehouse’s entrance into the national optical landscape has turned heads. In Larsen, it has a well-credentialed optometrist and business operator who is best known for bringing Specsavers to Australia and New Zealand in 2007 before departing the company 13 years later.

The initial expansion plans include a handful of pilot stores in 2023, followed by a mass network rollout, but Larsen warns it is early days and will depend to some extent on the outcomes of the Malvern and other pilot stores.

“A business has got to solve

continued page 8

RECORD INTAKE FOR MAJOR GRAD EMPLOYER

Specsavers has welcomed a record number of graduates in 2023, with 168 newly-qualified optometrists joining the business across Australia and New Zealand in the first week of February.

The unprecedented number of graduates is the largest single intake the business has accepted into its Graduate Program since its inception, and is a 29% increase on the previous year. In Australia, 138 graduates have accepted roles in both metro and regional stores, and 30 have joined Specsavers in New Zealand.

While the figures suggest high employment prospects for optometry graduates, large employers like Specsavers are at odds with Optometry Australia

(OA) about whether the sector requires more optometrists in the coming decades.

“In Australia, there are currently 10 million people not accessing the eyecare services they need. These are people who could be at risk of eye conditions or who could have a better quality-of-life if only they saw an optometrist and received glasses,” Specsavers ANZ director of optometry Dr Ben Ashby said.

“Unfortunately, the problem is getting worse, a report by Deloitte Access Economics calculated that the number of optometrists required to support the level of clinical demand is projected to grow from 4,234 in 2018 to 7,841 by 2037. At Specsavers, we’re

doing all we can to change lives through better sight because we believe no one should have to encounter vision loss that could have been prevented.”

He said this included supporting the growth and placement of more optometrists and optometric services across Australia and working with optometrists to best use their skills and support their goals.

Figures reported by Insight in 2021 found optometry’s full-time employment rate is one of the highest among all sectors at around 95%. Optometry graduate numbers will only increase as cohorts from newer optometry

continued page 8

HOSPITAL ROLE

Early-career optometrist CLAIRE ONG is pursuing her passion in paediatric care in a newly created role at the Women’s and Children’s Hospital in Adelaide.

The pilot Optometrist Warehouse store, employing two optometrists, opened in suburban Melbourne in February 2023.

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IN THIS ISSUE

The statistics around myopia are sobering when you stop and think. In 27 years, every second person you interact with may have the condition. What other diseases can you say that about?

Currently 36% of Australians and New Zealanders are estimated to have myopia, but this could rise to a staggering 55% by 2050, with Australia expected to have 4.1 million high myopes by then.

Of course, this will only happen if myopia management isn’t widely implemented. It’s heading in the right direction, but we aren’t there yet.

TECHNICAL TROUBLES

RIGHT START

Why more graduates are choosing to begin their careers at OPSM and Laubman & Pank.

During my 4.5 years with Insight, it’s been remarkable to watch the number of myopia-related products come to market. While companies have an obvious commercial imperative, it’s an opportunity for a meaningful impact on the global community.

In a world of uncorrected short-sightedness, children struggle at school, adults aren’t as productive, and many are susceptible to more serious blinding diseases later in life.

This month, we cover the industry’s mobilisation to combat myopia. One of these is in the field of optical biometry: it seems every few months a new company is releasing a myopia-configured device to capture the gold standard measurement of axial length. We spotlight the latest technology, and ask Sydney optometrist Dr Jim Kokkinakis about his preferred instrument (page 40).

But diagnostics are only useful if there’s a therapy. In Australia, the suite of interventions is expanding, especially around spectacle lens-based products. Following the launch of HOYA’s defocus lens in 2020, Essilor entered the race in 2022 and, as revealed in our Myopia Product Showcase on page 47, Rodenstock is now joining the fray.

COMBINATION THERAPY

The right time to prescribe atropine with spectacles for myopia management.

54

PATIENT PERSPECTIVES

The final piece of the puzzle is research and education. Australia is blessed with some of the world’s leading myopia authorities, and perhaps no one is more qualified than Brisbane’s Dr Kate Gifford who has co-authored a CPD article on high myopia on page 31.

With more tools at their disposal and information available, it’s surprising to still hear stories of young, progressing myopes being prescribed single vision lenses. The barrier to entry has never been lower for myopia management. It’s vital practitioners begin now to rein in the public health crisis hurtling towards us.

Technicians are the unsung heroes who keep the ophthalmic sector ticking over.

Dr Lana Del Porto on why cataract patient reported outcome measures matter.

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UPFRONT

Just as Insight went to print, O=MEGA/WCO4 organisers have revealed applied research and collaboration will be core themes of the upcoming conference, taking place in Melbourne 8-10 September. Optometrist

Mr Timothy Lo, an Optometry Victoria South Australia board member and program director for the event, said the program is unique, and will be a first for Australia due to its global focus and diversity of topics. “From what I’ve seen so far, there will be significant and

WEIRD

Brisbane Uber drivers have repeatedly refused blind man Mr Henry Macphillamy the service because of his guide dog. He told the ABC that in most cases, the rideshare driver would cancel the job once they found out an animal would be travelling too. Fines of up to $14,000 apply to those who refuse service to a person with a guide dog. Uber apologised and issued him a $35 credit.

WONDERFUL

The world’s most popular YouTuber Mr Beast funded 1,000 cataract surgeries for disadvantaged Americans. The eight-minute clip has more than 114 million views, but has caused division. Some say the stunt was exploitative, but he says he paid for the surgeries from his own money. Others applauded him for shedding light on eyecare inaccessibility.

WACKY

A 21-year-old Florida man has made global headlines after documenting his battle with Acanthamoeba keratitis on social media after falling asleep in his contact lenses. After it took doctors more than a month to officially diagnose him, Mr Michael Krumholz required a corneal transplant and has partly regained some vision in his left eye.

cutting-edge content.” IN OTHER NEWS , the Specsavers Clinical Conference (SCC) is returning October 28-29, providing two days of CPD content from a line-up of industry-leading speakers. The event, now in its 12th year, will feature an in-person conference as well as live online broadcast for optometrists across Australia and New Zealand. To ensure the conference is available to as many optometrists as possible, the in-person aspect of the event will be held at the Hotel Sofitel Sydney Darling Harbour, with strictly limited places. It

will also be available on-demand after the conference. FINALLY, George & Matilda Eyecare (G&M) has welcomed a long-standing Nelson Bay practice owned by optometrist Mr Ian Brigden. Brigden, who established his own practice in 1980, said he decided to join G&M on the recommendation of colleagues. “It will help in my succession planning for a well-earned retirement. I hopefully will be able to continue practising in the same manner as I have been without all the paperwork involved in the normal day-to-day running of a practice,” he said.

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PRESBYOPIA PUZZLE

The latest Australian Institute of Health and Welfare data estimates 687,000 Australians have presbyopia, creating greater demand for IOLs offering an extended range of vision. Page 56

WHAT'S ON

Complete calendar page 69.

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Optical Dispensers Australia's first biennial industry conference will be held over two days at the iconic Sydney Masonic Centre, and is open to all optical industry members.

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21 MAY

Optometry NSW/ACT’s event at Luna Park, Sydney, is promising an optometry-led, face-to-face conference with affordable and clinically-relevant content.

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'A BUSINESS HAS GOT TO SOLVE PROBLEMS'

continued from page 3

problems – and the problems that we have in Australia are linked to the disconnection of health workers and stakeholders,” he said.

“What’s underpinning this is the plan to systematically link pharmacy with optometry to solve problems in the community. We then want to connect to other stakeholders in terms of GPs and specialists, to service the population that comes to us, to not only resolve refractive problems but vision-related diabetes health problems and systemic health problems, which, as research shows, are increasingly linked to the eyes.”

It’s not yet clear how the expansion will take shape, whether through greenfield stores, acquiring existing practices, or acquiring retail property neighbouring existing Chemist Warehouse stores. It’s also too early to say how practice ownership will be structured, whether that’s corporately-owned or through franchise agreements.

Larsen believes any healthcare service must be accessible and embrace research to ensure it is delivering the right outcomes.

He said the scale of Chemist Warehouse’s footprint means, if successful, this new approach of serving the population who are seeking pharmaceutical care could have a significant impact on their eyecare,

like the walk-in patient at Optometrist Warehouse on the second day it opened.

“We want to ensure we see people when they need to be seen,” he said, adding that Optometrist Warehouse intends to join the KeepSight program that is shifting the dial on diabetes-related vision loss.

“KeepSight is at least pointing to a strategy to deliver what needs to happen in this country. We’re connecting the dots through ophthalmic e-referral platform Oculo and practice management software to ensure that happens with people with diabetes, but we’ll also be working on an internal process to ensure that we’re delivering quality service, not just transacting.”

But it’s not just people in the community with diabetes who may be picking up a medical script that need their vision tested. Rates of undiagnosed glaucoma and macular degeneration may also improve if patients in at-risk groups are detected in a pharmacy setting.

With two optometrists employed in the first pilot store, Larsen said the team is still bedding down their IT, systems and processes.

Open seven days a week, the company said it would provide a state-of-the-art advanced eyecare service, employing hospital-grade clinical technology designed to

assist with the early detection of eye conditions, partnered with discounted prices on all optical products.

“It’s tremendously exciting. We have ZEISS, who have the gold standard in visual fields, an iCare EIDON Ultra-Widefield, and the leading technology partner, Topcon, with their image management software, OCT and Myah device for axial length and corneal topography,” Larsen said.

“We want to evolve standardised clinical journeys to solve problems and work collaboratively with technology partners, medicine and with pharmacy. Right from the outset, we are committed to doing research and to sharing data inclusively to industry to enable health service improvements for everybody.”

Optometrist Warehouse is also stocking household brand names for various budgets, including Levi’s, Tommy Hilfiger, Kendall & Kylie, Marc Jacobs, Karl Lagerfeld, Jimmy Choo and Rag & Bone.

In addition, an exclusive in-house brand San Paolo will be available combining fashion with affordability and practicality.

“All eyecare services – including clinical technology – are bulk-billed, meaning patients have no out-of-pocket expenses whatsoever. The focus is on a professional and high-quality service offering that is accessible and affordable for all," Larsen said.

OPTOMETRIST NUMBERS CLIMB 19% IN FIVE YEARS

continued from page 3

schools at the University of Canberra (UC) and the University of Western Australia (UWA) enter the workforce.

OA has remained concerned that workforce supply will outpace demand. Although its information is anecdotal only, the organisation said that most practices looking to recruit graduates “have been able to do so quite readily”.

“Our perception is that there may be some slight easing in demand for graduates,” OA interim CEO Ms Sky Cappuccio said.

“It is wonderful that, at this moment in time, the vast majority of new graduates are able to secure

employment. This is a situation we wish to retain. We have concerns that the ongoing supply of new graduates into the market will soon outstrip demand for their services.”

Cappuccio said the industry continued to see more optometrists entering, than retiring, each year, and during the past five years there has been rapid growth in the size of the optometry workforce.

From December 2018 to December 2022, Australia Health Practitioner Regulation Agency figures show registered optometrist numbers have risen from 5,675 to 6,796, an increase of 1,121 or 19%.

“Whilst it’s important to seek to

match university graduation numbers to community need, there is also opportunity to be looking at how we make most effective use of our skilled workforce to meet community need in new and innovative ways. We are and have always been committed to supporting all recently graduated optometrists transition into their working life, and ensuring they have a viable, rewarding and long-term future in their chosen career,” Cappuccio said.

“In recent years there have been significant changes to the funding of universities, and we are watching to see how this will impact further development of entry-level optometry education.”

Optometry graduates have readily found work after university.

“WHAT’S UNDERPINNING THIS IS THE PLAN TO SYSTEMATICALLY LINK PHARMACY WITH OPTOMETRY TO SOLVE PROBLEMS IN THE COMMUNITY.”

PETER LARSEN, OPTOMETRIST WAREHOUSE

ODMA CEO FINOLA CAREY STEPS ASIDE AFTER 27 YEARS WITH ASSOCIATION

Optical Distributors & Manufacturers Association (ODMA) CEO Ms Finola Carey will leave the organisation at the end of April to take up semi-retirement, as the organisation turns its attention to finding a successor.

Carey has served in the role since 2010 and has spent a collective 27 years in the organisation, having previously served as executive director and federal secretary.

ODMA chair Mr Robert Sparkes paid tribute to her substantial contribution to the industry and to the development of the association.

“Finola has been an inspirational leader of ODMA over a long period and we wish her well for the future,” he said.

“She has helped the industry evolve positively, led our advocacy efforts across a range of issues and navigated the organisation through the pandemic when many associations faltered. Finola is a creative thinker in strategy and planning – her knowledge of effective governance has time and again ensured proven outcomes for ODMA.”

Carey was one of the architects of the joint venture agreement between ODMA and Optometry Victoria South Australia out of which O=MEGA – one of the southern hemisphere’s premier optical events – was born. She also played a major role in securing the World Congress of Optometry for Melbourne in 2023.

“One of the legacies Finola leaves is the industry’s focus on differentiation of independent optics. While there is still work to do, this has begun a real change which is having a deep impact,” Sparkes said.

“Finola leaves ODMA in a very strong

position, with record support and a positive balance sheet.”

Carey said the time was right for retirement and to pursue fresh challenges.

“It has been a true privilege to lead this organisation, but the time is right for me to wind down and pursue other opportunities,” Carey said.

“I’m incredibly proud of the work of ODMA and the powerful and positive impact we have had on the industry and the community.”

She added: “It has been immensely rewarding to build relationships which help shape the optical landscape and grow the independent market. My heartfelt thanks to our Board, and staff present and past, as well as the great many members from whom I have learnt so much over the years.”

While Carey has been on leave in recent months, Ms Amanda Trotman has stepped in as acting CEO.

Carey will finish at the end of April 2023. ODMA’s succession planning for a new CEO is well under way.

Finola Carey has served in the ODMA CEO role since 2010.

IN BRIEF

LENS LAUNCH

HOYA Vision Care Australia & New Zealand has launched Nulux iDentity V+ single vision lenses with 360° visual comfort, the latest addition to its free-form single vision lens portfolio. The lens is designed for patients who struggle with peripheral distortions in conventional single vision lenses and want to have 360° visual comfort everywhere they look. According to HOYA, the lenses are tailored to patients' individual measurements, frame choice and wearing needs. They are said to offer focused vision in all directions “and superb visual performance over the entire lens”. “For a long time, single vision wearers have been underserved. The technology available to differentiate their experience is here, and we are proud to bring it to market,” Mr Craig Chick, managing director of HOYA Vision Care Australia & New Zealand, said.

HEALTH PREMIUMS RISE

A new analysis has revealed Australian families with private health insurance could see their premiums rise by an average of $141 this year, while retirees could see an average increase of $167, after the Federal Government announced an average rise of 2.9% for policyholders. However, the peak body for the national health insurance sector says Australian health funds have delivered a premium increase well below inflation, citing the cost of medical devices as a key driver in rising premiums. The new data comes less than six months since most health fund members were hit with premium increases between October 2022 and January 2023.

ENVOY ON VISION

Australia is among more than 60 countries and 150 eye health organisations calling on the United Nations to create a Special Envoy on Vision to serve as a global champion for vision and mobilise national action on eye health. It is proposed the Special Envoy will serve as a global advocate and spokesperson, rallying governments to action. They will promote valuable strategic partnerships to achieve more, faster; they will raise global awareness of the importance of eye health, and they will accelerate the international community’s implementation of the UN resolution on vision.

THE OPTICAL COMPANY BUYS KOSMAC & CLEMENS AND VISION EYE HEALTH

The Optical Company (TOC), part of allied health group Healthia Ltd, has entered agreements to acquire iconic regional Victorian optometry network Kosmac & Clemens and the two-clinic Vision Eye Health on the Gold Coast.

The latest acquisitions bring TOC’s total footprint to 59 stores. Across the past two years the firm has expanded its network by 40% by bringing on board well-established optometry businesses. The network also comprises nib Eye Care, The Optical Co, LensPro, Kevin Paisley Optometrists, Stacey & Stacey Optometrists plus independents Lanigans, John Holme Optometrists and The Eye Place.

According to a statement, Kosmac & Clemens is an optometry-led network founded in 1992 with a strong reputation in the local area and respected across the broader optical industry.

The business’ practices are well established across central Victoria, including the foundation clinic in Kyneton, as well as Bendigo, Heathcoate, Castlemaine, Woodend and Maryborough.

The addition of Kosmac & Clemens complements Kevin Paisley Optometrists as a second iconic regional Victoria optometry brand to join the TOC network, the company said.

Vision Eye Health, founded by Mr Gary Bormann, is family-led, with Rebekah continuing the legacy started by her father who practised optometry for more than 35 years. The two clinic locations in Southport Park and Runaway Bay increases TOC’s presence on the Gold Coast to four locations.

“It’s a privilege to be in a position to

welcome such fine optometry businesses with such wide-reaching industry respect to our company … with strong local community working relationships and teams who are enthusiastic about optical care and customer service,” Mr Colin Kangisser, CEO of The Optical Company and Healthia director said.

TOC said it has a proactive approach to identifying potential stores, supported by Healthia for both outright purchase and partnership models.

“With a 30-year commitment to servicing the eyecare needs of Central Victorians, we are very proud of the reputation we have established and naturally there was a lot of interest as we started looking at succession,” Mr Edward Kosmac, optometrist and founding partner of Kosmac & Clemens, said.

“When considering the options, Healthia and The Optical Company represents the right ethos to be the ideal custodian of our business, carrying on our legacy well into the future, and is well equipped for the support of our teams as Kosmac & Clemens enters a new chapter.”

For TOC, in addition to multi-site acquisitions such as LensPro and now Kosmac & Clemens and Vision Eye Health, it has been a productive 12 months with extensive refurbishments of well-established stores in Townsville and the flagship Kevin Paisley Optometrists & Hearing in Geelong.

In late 2022 the first multi-discipline site, with a redesigned The Optical Co Charlestown store, re-opened in an extended retail space shared with NaturalFit Footwear & Podiatry – a retail group that is part of the Feet & Ankles division of Healthia.

“Health and wellbeing continue to be important for Australians,” Mr Wes Coote, Healthia CEO and director, said.

“As a leader in this space the ability to offer clients even more options within our broader network with new purchases of existing clinics plus our unique position to develop new sites that combine multiple complimentary disciplines, reflects the demand by clients for great care, familiar faces and continued trusted presence in the local community.”

Colin Kangisser, The Optical Company/ Healthia.

The latest acquisitions bring the company’s total footprint to 59 stores.

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MYOPIA PROGRESSION IN CHILDREN CONFERENCE RETURNING MID-2023; SPEAKERS REVEALED

Sydney-based paediatric ophthalmologist

Dr Loren Rose, who founded Myopia Australia in 2022, is planning the organisation’s second Myopia Progression in Children (MPIC) Conference for June 2023 following the success of the inaugural event last year.

Through Myopia Australia, Rose is aiming to increase public and industry awareness about myopia in children in an Australian context. This includes acknowledging and assisting in further education on best management.

After hosting MPIC 2022 in Sydney in September last year, plans are under way for another full-day conference on Saturday 10 June 2023 – also in Sydney – offering Optometry Australia quality-assured CPD content.

“MPIC 2022 provided a day conference with interactive components and was registered for CPD points from Optometry Australia,” Myopia Australia stated.

“MPIC 2023 will have a similar format. However, we are excited to announce joining last year’s panel: Dr Rose, Dr Shanel Sharma and Dr Trent Sandercoe will be

Ms Mariella Coluccio and Ms Homma Ebrahimi, both Sydney-based optometrists who will share interesting case studies as part of our panel.”

MPIC 2023 will continue to address the current treatment options in a sequential safe program. It will be an all-day event with industry participation and open interactions.

Eye health professionals are invited to learn and interact with the latest research-proven methods for monitoring and intervening in myopia progression in children.

A comprehensive management plan for myopia progression in children, an extended panel discussion of difficult cases and guidelines on referral recommendations for other tests and imaging will also be included.

Rose is a Clinical Senior Lecturer at Macquarie University and an Associate Professor at the University of Canberra. She has been an advocate for myopia management in children as a member of the Australia and New Zealand Child Myopia Working Group since 2018 and conducted multiple talks in 2022 on myopia

management as a guest speaker for Optometry Australia and Specsavers and provided updates for RANZCO (NSW) and RANZCO annual conference. She is also involved in ophthalmic registrar training in her public VMO position at Bankstown hospital and the Burwood Private rooms.

EVENT AND SPEAKER OUTLINE:

8.30 - 9.00am – Registration

9.00 - 9.30am – Welcome

Dr Loren Rose – Myopia: in an Australian context

9.30 - 10.45am – Overview and update of current research regarding intervention Dr Shanel Sharma and Dr Loren Rose –Lifestyle, refractive and pharmacological, Q&A

10.45 - 11.00am – Morning tea

11.00 - 12.15pm – Management of childhood myopia

Dr Loren Rose – Q&A

12.15 - 1.30pm – Lunch and interactive trade

1.30 - 3.00pm – Presentation and discussion (open forum)

Dr Loren Rose, Dr Trent Sandercoe, Dr Shanel Sharma, Ms Mariella Coluccio and Ms Homma Ebrahimi – Difficult cases and troubleshooting, two cases each Q&A and Assessment

3.00pm – Closing remarks

FDA APPROVES APELLIS PHARMACEUTICALS' SYFOVRE MARKING FIRST GEOGRAPHIC ATROPHY TREATMENT

In a historic first, the US Food and Drug Administration (FDA) has approved SYFOVRE (pegcetacoplan injection), manufactured by global biopharmaceutical company Apellis Pharmaceuticals, for geographic atrophy (GA) secondary to age-related macular degeneration (AMD).

SYFOVRE is the first and only FDA-approved treatment for GA, with the therapy also being tested at trial sites in Australia.

According to Dr Eleonora Lad, director of ophthalmology clinical research at Duke University Medical Center and lead investigator for the Phase 3 OAKS study, the approval of SYFOVRE is the most important event in retinal ophthalmology in more than a decade.

“Until now, there have been no approved therapies to offer people living with GA as their vision relentlessly declined. With SYFOVRE, we finally have a safe and effective GA treatment for this devastating

disease, with increasing effects over time,” Lad said.

Apellis co-founder and CEO, Dr Cedric Francois, said the granting of FDA approval marks an extraordinary milestone for patients, the retina community, and Apellis.

“With its increasing effects over time and flexible dosing, we believe that SYFOVRE will make a meaningful difference in the lives of people with GA,” he said.

“GA is a complex disease that the field has spent decades trying to address, so we are humbled and proud to bring forward the first-ever treatment. Thank you to all who helped make this moment a reality.”

The approval of SYFOVRE is based on positive results from the Phase 3 OAKS (n=637) and DERBY (n=621) studies at 24 months across a broad and representative population of patients.

SYFOVRE is approved for GA patients with or without subfoveal involvement and provides dosing flexibility for patients and

physicians with a dosing regimen of every 25 to 60 days.

In the OAKS and DERBY studies, SYFOVRE reduced the rate of GA lesion growth compared to sham and demonstrated increasing treatment effects over time, with the greatest benefit (up to 36% reduction in lesion growth with monthly treatment in DERBY) occurring between months 18-24.

In a statement announcing the FDA approval, Apellis said the safety profile of SYFOVRE is well-demonstrated following approximately 12,000 injections. The most common adverse reactions (greater than or equal to 5%) reported in patients receiving SYFOVRE were ocular discomfort, neovascular AMD, vitreous floaters, and conjunctival haemorrhage.

Apellis hosted a webcast on 17 February to discuss the FDA’s approval of SYFOVRE. A replay of the webcast was available for 30 days following the event.

The safety profile is demonstrated following 12,000 injections.

Dr Loren Rose, Myopia Australia.

PROVISION BOOSTS RECRUITMENT EFFORTS AFTER SURVEY CONFIRMS COMMON CHALLENGE

ProVision is boosting recruitment efforts on behalf of its members, after more than half identified staff recruitment and retention as their top challenge in a recent membership survey.

According to Survey Matters, which conducted the survey on behalf of ProVision, 57% of respondents highlighted it as their biggest concern.

To assist with short- to medium-term optometrist placement, ProVision has welcomed two new referral partners, Locumly and Eyecare Recruitment, to the network.

“These partners offer preferential rates for members and will help attract strong candidates to practice teams,” the membership-based network said.

ProVision said the tight labour market last year meant it was challenging to attract applicants to key optometry positions, but the network is now seeing a shift in the number of skilled and unskilled applicants for roles in the first few months of 2023.

The trend was also shared by several

Matching highly skilled roles to relevant experience remains a challange in recruitment. major retailers at the Australian Retailers Association (ARA) Leaders Forum held last week (22 February) in Sydney, which ProVision attended.

ProVision people and culture manager Ms Leanne Jackson said the network is pleased to see a real lift in the number of applications and is not necessarily finding that metropolitan areas are more attractive than regional offerings.

“However, the challenge remains currently for highly skilled roles being matched to relevant experience”.

To help overcome the challenge, ProVision is actively posting job openings through industry and broader market recruitment platforms, interviewing and shortlisting candidates, and referring candidates with relevant transferable skills and cultural fit.

ProVision also provides members with position descriptions across several practice roles, as well as interview techniques and suggested interview questions, and communicates with applicants through the recruitment process to keep them informed about their progress.

Complimentary ARA membership, which is granted to all ProVision members, further helps with creating compliant employment contracts.

“As part of their recruitment efforts, practices are advised to refine their Employee Value Proposition (EVP). An EVP outlines the benefits and rewards an employee can expect from the practice, and is a helpful tool in retaining staff and making the practice more appealing to potential new hires,” ProVision said.

MYOPIA PROFILE LAUNCHES ONLINE COURSE ON MANAGEMENT WITH SPECTACLES

Myopia Profile has launched a first-of-itskind online course on myopia management with spectacles to help deliver treatment to more children worldwide.

It said the ‘Myopia Management with Spectacles’ online course is designed to support and accelerate spectacle-lens adoption and clinical success. It built the course to introduce the latest research on myopia management lens designs and share evidence-based foundational knowledge on prescribing spectacles for children of all ages.

Myopia Profile co-founder Dr Kate Gifford said the new course compliments a growing cache of Myopia Profile resources aimed at combating the global myopia epidemic.

“Spectacle lenses are a hot topic in the field of myopia management, with the potential to help a vast number of children worldwide who may not have access to or be candidates for other treatment options,” she said.

“We know that managing myopia early can provide kids with more stable vision over time and help head off serious eye health issues that can develop in adulthood. Myopia Profile created the ‘Myopia Management with Spectacles’ course to equip more eyecare practitioners with the information they need to confidently adopt this emerging technology, wherever they may practice.”

The two-hour course covers all aspects of spectacle lens prescribing for myopia, from first corrections in very young children to progressive addition and bifocal lenses through the latest technologies and next generation lenses for myopia control.

Learning objectives include the clinical rationale for specific use of single vision spectacles in children with myopia, the evidence for various myopia control spectacle interventions, a simple comparison of spectacle lenses to other treatments based upon scientific evidence, understanding the latest technology lenses for myopia control, and practical aspects of spectacle lens prescribing including frame fitting and parent communication.

Continuing professional education approval is pending for North America (COPE), with qualification achieved for the United Kingdom (GOC CPD) and underway for Australia and New Zealand.

GLAUCOMA AUSTRALIA SEEKS NEXT 'QUINLIVAN’ FUND RECIPIENTS

Applications for the annual Glaucoma Australia (GA) ‘Quinlivan’ Research Grants will open 1 May, with successful recipients being announced on World Sight Day, 13 October 2023.

“We are very proud to fund Australian glaucoma research through our Quinlivan Research Grant program,” GA CEO Mr Richard Wylie said. “Research is an area which I am personally very passionate about. I have spent many years leading various not-for-profit organisations who have had a strong medical research focus. One of the things I admire most about Glaucoma Australia is the organisation’s ongoing commitment to supporting local research. Nowhere is this more evident than Glaucoma Australia’s Quinlivan Research Grant which is awarded annually to Australia’s leading glaucoma researchers.”

The William A Quinlivan Research Fund was established in 2006 by the late Mr Marcus Quinlivan in honour of his father. Since its creation, GA has committed over $1.5 million towards glaucoma research.

GA will invest up to $200,000 in this funding round and anticipates between one

and four grants will be awarded. All projects are to be completed within three years of grant allocation and seed fund grants can be used to apply for further funding with NHMRC or other agencies.

Glaucoma Australia supports research in the following four domains:

1. Increasing the rate and reliability of early detection of glaucoma

2. Improving the treatment and care experience

3. Improving the quality and experience of monitoring progression

4. Providing management tools to improve quality of life .

The ‘Quinlivan’ Research Grants are awarded following rigorous evaluation, based largely on the NHMRC process, along with peer review, to ensure that the successful applicants meet high standards. Submissions are reviewed by the Glaucoma Australia Independent Research Panel consisting of internationally recognised experts in glaucoma research.

Applications close at 5pm (AEST) Friday 9 June 2023.

OPTOMETRY AUSTRALIA SUPPORTS STRENGTHENING MEDICARE TASKFORCE REPORT

Optometry Australia has welcomed the new Strengthening Medicare Taskforce Report and Minister for Health Mr Mark Butler’s recent commitments to ensuring best use of Australia’s skilled health workforce.

However, the peak body has highlighted the “inadequacy of Medicare rebates” that are disincentivising optometrists from performing more complex care within the community setting.

Developed by primary health care leaders and experts in their fields, the report was released on 3 February and sets out a recommended pathway for significant reforms to strengthen Medicare and rebuild general practice.

The Strengthening Medicare Taskforce Report recommends supporting new blended funding models, integrated with the existing fee-for-service model, allowing teams of GPs, nurses, midwives,

and allied health professionals to work together to deliver the care people need.

Optometry Australia interim CEO Ms Skye Cappuccio said the peak body was committed to working with governments and stakeholders to explore how the contribution of optometry can be maximised to improve the health outcomes of all Australians.

“The recommendations in the report broadly align with our vision to support optometrists practising to their fullest scope and to enhance local integration of specialists and hospitals with primary care,” she said.

“However, a key issue that remains unaddressed, is the inadequacy of Medicare rebates for optometric care. The gap between the rebate and the cost of providing quality primary eyecare continues to grow.”

Skye Cappuccio, Optometry Australia.

Richard Wylie, Glaucoma Australia.

ARTIFICIAL

TEARS LINKED TO BLINDNESS AND ONE DEATH RECALLED IN THE US

The US drug regulator has issued an alert to immediately halt use and importation of an artificial tears eye drops manufactured in India that has been linked to permanent vision loss and one death.

On 2 February, the Food and drug Administration (FDA) said Global Pharma Healthcare was voluntarily recalling its Artificial Tears Lubricant Eye Drops, distributed to consumers as EzriCare Artificial Tears and Delsam Pharma’s Artificial Tears, due to possible contamination.

The Centers for Disease Control and Prevention (CDC) alerted FDA to an investigation of a multi-state cluster of infections possibly linked to the use of the artificial tears manufactured by the Chennai-based firm, which was alleged to have breached manufacturing standards.

The alleged contamination involves “carbapenem-resistant Pseudomonas aeruginosa”, a rare strain of extensively drug-resistant bacteria.

“The FDA recommended this recall due to the company’s current good manufacturing practice (CGMP) violations, including lack of appropriate microbial testing, formulation issues (the company manufactures and distributes ophthalmic drugs in multi-use bottles, without an adequate preservative), and lack of proper controls concerning tamper-evident packaging,” the FDA stated.

“FDA is collaborating with the CDC and state and local health departments to investigate a multi-state outbreak involving a rare, extensively drug-resistant strain of Pseudomonas aeruginosa bacteria. As of January 31, 2023, CDC identified 55 patients in 12 states with infections that have been linked by epidemiologic and laboratory evidence to use of EzriCare Artificial Tears.

“Associated adverse events include hospitalisation, one death with bloodstream infection, and permanent vision loss from eye infections.”

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Drops were allegedly produced in multi-use bottles, without an adequate preservative.

The FDA also placed Global Pharma Healthcare on import alert “for providing an inadequate response to a records request” and for not complying with CGMP requirements. The import alert prevents these products from entering the US.

“Global Pharma Healthcare is notifying the distributors of this product, Aru Pharma Inc. and Delsam Pharma and is requesting that wholesalers, retailers and customers who have the recalled product should stop use.”

Global Pharma Healthcare says it has provided a wide range of pharmaceutical formulations in several therapeutic forms to markets in Southeast Asia, Central America, LATAM, CIS, and Africa for more than two decades. It manufacturers products for 17 therapeutic areas, including eyecare. The company posted the recall to the homepage of its website, stating that “this recall is being conducted with the knowledge of the US Food and Drug Administration”.

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On the move

WITH AN EQUIPMENT TECHNICIAN

Whether installing new equipment, diagnosing a fault, or advising on consulting room layout, equipment technicians are often the unsung heroes of the ophthalmic world. Insight discovers how they keep the industry ticking over.

Askilled ophthalmic equipment technician knows what questions to ask – and how to ask them – to draw out relevant information to diagnose a fault. It’s a skill set that technical consultant Mr Joseph Justo, who joined Australian ophthalmic equipment distributor BOC Instruments in 1997, has honed over 26 years working in the field.

As one of eight technicians scattered across Australia servicing BOC customers, his primary role is installing new equipment, and providing after sales service, including repairs, in parts of New South Wales and Queensland.

He says it’s a role that involves different engineering-based skill sets –including electrical, electronic, and mechanical – merged with optics as well as communication skills. Alongside this is the continual advances in manufacturing technology, where equipment can be quickly superseded.

“I’ve noticed over the years that sales of a particular product will slow and then suddenly stop altogether when a newer equivalent product reaches a tipping point among eyecare practitioners. Word gets around – it can happen so quickly,” Joseph says.

Competing equipment manufacturers are continually introducing more features which adds a level of complexity to his role as technician. BOC’s approach to managing customer reports of defective equipment – sometimes caused by simple human error – is to try to resolve as much as possible over the phone. It becomes even more important due to the geographic spread of practices in Australia.

“An experienced technician can provide remote support and it benefits the customer if we can resolve it on the spot. They have their problem resolved quickly, efficiently, and that improves customer satisfaction,” Joseph explains, highlighting the value of being able to recall product codes and software protocol from memory.

“When speaking with customers over the phone, we’re working off memory of the product, and unique to this industry is the large variety of equipment

and instruments that can be found in the consulting room. There can be up to 30 different pieces of equipment in any one practice.”

Sometimes his role involves providing advice over the phone to a practice or clinic staff member, such as a locum, who is unfamiliar with a piece of equipment and needs quick instruction on how to use it. Other times, Joseph is skilfully extracting the information he needs from customers to diagnose a problem.

“Customers often have preconceived ideas or a misperception as to what the problem is. When a piece of equipment is not working, you don’t want to ask leading questions. You need to structure questions in such a way that you get as many objective answers as possible,” he says.

“As a technician, you get to know products well; you know what tends to break down or what same issues tend to arise. If a customer is reporting a defect that you’ve never heard of and it is uncharacteristic, you can start having doubts as to the veracity of what they’re telling you, or perhaps it’s a problem you haven’t encountered before.”

When assistance over the phone doesn’t resolve the problem, Joseph then needs to visit the practice in-person.

“Safety is paramount, so when we’ve got to the point where we need to remove protective covers to open machinery, that’s when we tell the customer we’ve gone as far as we can over the phone, we need to come and have a look at it,” he says.

“Then we need to judge the urgency of the problem and take into consideration how much it is going to impact their business. For example, some practices may have multiples of the same equipment which they can use while we repair a fault; other times it’s a critical instrument and their whole testing room is down because of it.”

Visiting a practice requires careful consideration. Joseph’s role is made more challenging by the large distances he needs to travel, and the rural

location of some customers.

“We courier spare equipment to customers in rural areas who have a business to run – similar to a courtesy car service at a panel beater –because we can’t service their equipment at the drop of a hat. Loaning equipment puts a lot of risk on us because sometimes it gets damaged in transport but it’s a risk that we factor in and undertake as part of the business,” he says.

“Sometimes, when we have a complex repair and need to order an obscure part –because it’s not sustainable to stock every component for the 200-300 pieces of equipment we’ve got out in the field – we loan equipment to keep the customer going if they need it, while we wait for a part that can take two or three weeks to arrive from overseas.”

When he goes out to a practice, Joseph is equipped with specialised tools, spare parts, trolleys and dollies to safely lift and move heavy equipment – and a computer.

“In the past, you never needed to touch a computer to do diagnostics on an instrument. Now, you need to be computer literate, and know how to set up networks because customers want to be paperless and want their equipment to ‘talk’ to each other and be linked and networked,” he says.

KEEPING UP WITH MANUFACTURERS

Like Joseph, national sales and service engineer Mr Carl Dutoit has accumulated a catalogue of technical knowledge gained over 28 years of selling, installing and servicing ophthalmic equipment with BOC.

“After I got past 25 years, I lost count,” says Carl, who initially began his engineering career with a pharmaceutical company before joining BOC.

“I knew nothing about optics when I came to this game. When I started [in 1995], everyone had an edger in their practice. It has slowly phased into more highly technical products, but my technical skills have evolved as new products came along.”

During his career at BOC, Carl has learned how equipment can improve efficiencies for optometrists and ophthalmologists, and like Jospeh, has learned that when a piece of equipment breaks down, it’s wise not to jump to conclusions.

“More than 80% of problems are minor. I get calls from WA at 10 o’clock at night, because they’re three hours behind, to tell me a device has stopped working,” he says.

“Mentally, you’ve got to work through all the pieces of the puzzle from scratch. Has it been turned off? Has it been bumped? Rather than thinking it’s a major part failure, we have to walk through all these mental steps to ensure it’s not the blindingly obvious. Then we go through a record of issues or problems associated with that particular piece of equipment that we’ve learned over the years, such as fatigue points, and it’s a process of elimination.”

When Carl visits a practice to repair equipment, he keeps an accurate record of what parts have been replaced in case the same equipment breaks down again.

“If there’s another fault or a problem later on, we can check the record and see what we replaced, and when, so we know either there is an inherent issue here, or it won’t be ‘that’ problem because we only recently replaced ‘that’ part. It’s going to be the next piece of that puzzle,” he explains.

When he started in the industry, most equipment was mechanical; now, most is PC-integrated and has a shorter life span.

“Electronics were very basic – I could see if an integrated circuit (IC) had failed. I could literally take a faulty part off and solder a new one on. Now, everything has laminated boards – you cannot see components which have failed; you can only assume a part has failed, but you’re replacing entire boards,” he says.

“Everything is connected to a computer; you’re dealing with customers’ networks and PCs. I get phone calls from customers on a Monday morning after Microsoft has done an update on a Sunday saying their machinery has stopped working.”

Carl says manufacturers are now reducing their life expectancy on machinery because components are no longer available for older products. Some pieces aren’t even reaching their five- or seven-year moratorium on parts anymore.

He continues: “Now, with so many buyouts from different companies, they don’t want to deal with old products, and COVID basically wiped out many small part manufacturers around the world. Manufacturers are drawing a line in the sand and saying we will only keep parts from ‘this time’ onwards.”

DESIGNING SPACE FOR EQUIPMENT

Joseph and Carl also provide a design service that helps eyecare practitioners visualise their consulting room to ensure equipment fits, is safely positioned, accessible, and functional, down to the placement of power outlets and data points.

Carl says architects who design optometry practices or ophthalmology clinics don’t necessarily know what’s required in a consulting room.

“They don’t know how many data points or how much power consumption that particular room needs,” he explains. “If you include a chair and stand with two or three instruments and four or five other devices, all of a sudden that room is dragging more power than your living room.”

He recalls an unusual problem in a Westfield shopping centre that BOC was able to diagnose and resolve.

“Two optometry practices – on separate floors – had exactly the same

An example of a consulting room layout, showing where to position an optometrist’s desk and chair, and patient chair and stand, allowing room for an ideal refraction length.

“AS A TECHNICIAN, YOU GET TO KNOW PRODUCTS WELL; YOU KNOW WHAT TENDS TO BREAK DOWN OR WHAT SAME ISSUES TEND TO ARISE.”

– JOSEPH JUSTO

BOC Instruments technician Joseph Justo installing an OCT.

roof would fire up, it would cause a voltage spike on level two of the shopping centre, and that was interfering with the equipment,” Carl says.

“We had to put big line filters in to protect the power supply to the practice on level two. Some products manufactured in Europe are designed for 220 volts, not 240 volts. Even though they function fine in 240-volt environments, a voltage spike of 260 or 270 will cause disruptions and malfunctions, as it did in this case.”

A poorly planned consulting room can mean equipment is ill-positioned or wiring and cords are exposed, leading to trip hazards, or worse.

That’s why BOC’s technicians work with customers to design a consulting room that meets their business needs today as well as where they want to be over the next five years, effectively futureproofing so they can add additional equipment later.

“We understand customers use this equipment every day – and humans do the strangest things. It never ceases to amaze me how an autorefractor can end up on the floor. That’s a 26kg item that someone’s knocked off a table,” Carl says.

“That happens. I once received a call from a customer saying: ‘my fundus camera got knocked off the table. I don’t know how it happened’. When I got to the practice, I put the fundus camera back, repaired it, and then swung the customer’s ergonomic chair around – and the handle on the back of the chair hit the chinrest on the camera. Ever so slightly it hit the chinrest and each time it slowly moved the fundus camera towards the edge of the table. This repeated action for six or seven months knocked it off the table.”

When it comes to installing and repairing ophthalmic equipment, Joseph and Carl, two of BOC’s longest-serving employees, have seen (and heard) it all. One would be hard-pressed to find two technicians who know more about the hundreds of products in their field, inside and out.

BOC Instruments technician Carl Dutoit.

INDEPENDENTS ARE TURNING TO Tokai Optical

Two independent practice owners are unanimous in their appraisal of the premium multicoating technology behind – or rather, in front – of Tokai Optical lenses.

Aconsultation with an unfamiliar patient in a practice where he was locuming provided optometrist Mr Seok Lee his first encounter with Tokai lenses – and it left a lasting impression.

“I was astonished at the condition the patient’s lenses were in because they were near pristine with no scratches, despite being a few years old. Usually, you would expect to see some marks and scratches – normal wear and tear –on lenses of that age,” Lee said.

The thickness of the lens – or rather the lack thereof – also made Lee sit up and take notice.

“Her prescription was around -10.00D, but the lens looked like -6.00D, it was so thin,” he says.

Intrigued, Lee quizzed the patient and discovered the lensmaker behind the thin, clear lens was Tokai Optical. Since setting up a subsidiary in Australia in 2019 – after previously using a distributor – the Japanese ophthalmic lens company has been cementing its position in the independent optical market with premium lens and unique multicoating technologies.

For Lee, the encounter remained in the back of his mind. After working in more than 100 optometry and ophthalmology practices across Australia and New Zealand, and dealing with several different lens suppliers, he opened his own full-scope independent practice in Queensland last year.

When Lee took over the lease of a former giftware shop in The Village, in the Brisbane suburb of Upper Mount Gravatt, and transformed it into STUDIO OPTOMETRY, he also sought the support of a buying group. As part of the buying group, Lee initially used the group’s preferred lens supplier as his main supplier, and Tokai as his secondary supplier, but a second encounter with Tokai lenses gave him pause.

“Lens suppliers often give practice owners a complimentary pair of glasses fitted with their lens, so you can see for yourself, so to speak,” he says.

despite frequent contact with the slit lamp.”

It’s that first-hand experience of superior quality coating that makes recommending Tokai lenses to his patients easy, says Lee.

“Unlike some other lensmakers, who have two or three different coatings on a scale of ‘good, better, best’, Tokai has six varieties of coatings, but they don’t vary in quality, they vary in application, to suit each patient individually,” he says.

Tokai’s specially designed coatings include USC (Ultra Shield Coat), ESC (Eternal Skin Coat), BDC (Blue light Damage Control), and NRC (No Reflection Coating), to name a few.

BREAKING NEW GROUND

For Mr Justin Chiang, a trained optical dispenser who heads up the company’s Brisbane-based subsidiary, Tokai Optical Australia, quality multi-coat is vital.

“To ensure wearers have the best vision possible and the lens lasts as long as it should, Tokai Optical sees multi-coat as essential instead of optional,” he says. “Therefore, every single Tokai lens comes with a premium multi-coat as standard.”

Tokai Optical's origins date back to 1939 and have been focused on producing superior-quality ophthalmic lenses. The Optical Division established in 1998 helps improve the coatings on ophthalmic lenses.

“The division produces high-performance optical coating products needed in high-end medical, bioengineering and nanofabrication instruments. Many of them require very high-precision coatings and can be up to 160 layers,” Chiang explains.

“For example, Tokai developed a light concentrator that contains 2000 mirrors with 2.5m in diameter that is used to effectively concentrate Cherenkov radiation. The concentrator is attached to a large-diameter telescope used in the Cherenkov Telescope Array project, one of the world’s largest gamma-ray

Harnessing this advanced technology, Tokai Optical can produce some of the industry’s the most premium quality and durable multi-coats in ophthalmic

“There are many benefits of having multi-coats on ophthalmic lenses but the key function most people know about is to reduce the reflection produced from the lens surface,” Chiang says.

“This type of multi-coat is known as anti-reflective coating. An ophthalmic lens without an anti-reflective coating can reflect from 8% and up to 17% of light depending on the lens’ refractive index.”

In other words, wearers can lose clarity by up to 17%. But with anti-reflective

First-hand experience with Tokai Optical lenses led STUDIO OPTOMETRY in Brisbane to make the manufacturer its primary lens supplier.

“TOKAI’S SCRATCHRESISTANT COATING IS SUPERIOR – MY LENSES AREN’T SCRATCHED DESPITE FREQUENT CONTACT WITH THE SLIT LAMP.”

SEOK LEE STUDIO OPTOMETRY

coating, the reflectance rate can be reduced to 0.8%.

“Tokai Optical has taken it further and reduced it to 0.19%, which is the lowest reflectance anti-reflective coating in the world,” Chiang says.

Known as No Reflection Coating (NRC), Tokai developed the multi-coat in response to increased reliance on screen-based communications and with an emphasis on two factors: reflectance and relative luminous efficacy.

As an optometry practice owner, it’s another quality performance characteristic that astonishes Lee.

“Tokai’s NRC is exceptional. My practice is located near an office building, so I get a lot of walk-ins, and I often recommend NRC for this patient cohort. When they pick up their new glasses, many remark on how clear the lens is,” Lee notes.

Apart from reducing the reflection on the lens, Chiang says multi-coats seal the lens surface and protect the lens material from moisture, acid or other chemicals that can possibly damage the lens.

“All Tokai multi-coat is high scratch-resistant, stain resistant, anti-static and super hydrophobic. In fact, Tokai Optical is the first lensmaker in the world to introduce hydrophobic (water repellent) coating,” he says.

With in-house R&D and strict quality control protocols, Tokai Optical can claim to effectively reproduce the most durable multi-coats in the industry.

“Tokai Optical developed a unique two-pronged lens coating test method comprising a scratch resistance test and a weathering test,” Chiang explains.

“The scratch test machine applies a 2kg weight on steel wool and runs through the lens surface 150 times. The weathering test method is to test the lens usage in reality and not only against scratch but also with other conditions.”

He continues: “The lens goes through the scratch test, soaks in sodium water over three days, and then goes into a machine with UV light, continuing with the splash of water, at a temperature of 39 degrees over 240 hours. This weathering test simulates the lens wear and tear as in real life for over three years.”

A LENS TO COMPLEMENT A PREMIUM SERVICE

For optical dispenser Mr Ethan Ong, supplier support, relationship and product quality determine which suppliers he and his business partner Mr Ivan Au, also a dispenser, chooses to work with.

Ethan is a co-owner of independent practice Eyemax Optical, a mainstay of Hopkins Street in Footscray in Melbourne’s west, for the past 18 years.

“What we look for in a lens supplier/manufacturer is the quality of the lenses, the breath of their products and the innovative coatings and tinting options a manufacturer can produce and apply to their lenses. Tokai satisfies our requirements by exceeding our expectations in providing an exceptional quality product for our patient’s needs,” he says.

Another facet of their business decision on selecting lens suppliers is how lenses integrate with their frame selection.

“Tokai produces the world’s thinnest resin lenses (index of 1.76) and also has

an exceptional tint offering, which covers the full range of their lenses. A unique offering which we are very fond of is the ability to tint their 1.76 index lens up to an 85% tint, which is a game changer for people who have high prescriptions and are sensitive to thickness. The combination of aesthetics and quality optics are now achievable for our patients,” Ong says.

Ong and Au say they have been “very fortunate” to have had the opportunity to visit the manufacturing plant in Japan where they saw first-hand Tokai’s full in-house production.

“We were in awe of their meticulous production process, their dedication to innovation and research and development. Their uncompromising high-quality standard could be seen in every station and stage of manufacturing. The factory is immaculately clean and their unwavering attention to detail on every aspect of production is palpable. This reaffirmed our view on Tokai’s commitment to quality in which they have carved a niche for themselves as a bespoke manufacturer of lenses,” Ong says.

The fact that all Tokai lenses are manufactured in Japan is an additional selling point, Ong says.

“We have noticed that Tokai coatings are also superior, notably on their scratch resistance (USC) coating, where we have seen a significant reduction in complaints on fine scratches on lenses.

"Tokai’s non-reflective coating (NRC) is also very impressive as it has less visible reflections than that of other brands, making the lenses seem more transparent and clearer; our customers have commented on how much clearer their lenses are.”

Ong and Au also say their experience with the Tokai team in Brisbane has been “overwhelmingly positive” where support is always provided when needed.

“We sell more mid- to high-end frames and we want a lens product that complements our range. We look for an exceptional quality product which has a story to tell, and Tokai offers that product. Our patients rely on our expert opinion to recommend the best for them, and when it comes to lenses, our customer feedback for Tokai has always been exceptional,” Ong says.

Special coating that separates colour, made by Tokai Optical Thin Film Division.

Optical dispensers Ethan Ong (right) and Ivan Au co-own Eyemax Optical in Footscray.

“TOKAI OPTICAL DEVELOPED A UNIQUE TWO-PRONGED LENS COATING TEST METHOD COMPRISING A SCRATCH RESISTANCE TEST AND A WEATHERING TEST.” JUSTIN CHIANG TOKAI OPTICAL AUSTRALIA

Offer accepted WHAT GRADS WANT FROM THEIR EMPLOYER

As one of Australia’s largest employers of graduate optometrists, EssilorLuxottica has developed a comprehensive program to ensure its budding optometrists can succeed at this important career juncture within its OPSM and Laubman & Pank stores.

When Ms Tansy Barr sat down with Insight to discuss why she chose OPSM to kickstart her optometry career, she had just got off the phone from EssilorLuxottica’s ANZ head office with unexpected news.

Barr – only 18 months into her two-year graduate contract at OPSM Garden City Booragoon in suburban Perth – learned she had been promoted to the role of managing optometrist across town at OPSM Carousel. It’s a big responsibility granted to around 50 passionate and influential optometrists who coach in-store optometrists and galvanise the store team to deliver high quality eyecare.

Her story is one example of the opportunities available to optometrists within the EssilorLuxottica network of 430 OPSM and Laubman & Pank stores across Australia and New Zealand. It’s been a quick and unexpected rise through the ranks for Barr, after only graduating from Deakin University in 2021 before honing her skills in a busy store, with access to mentors, high-tech diagnostic technology and a network of likeminded optometrists.

Graduates like Barr are vital to OPSM and Laubman & Pank – and EssilorLuxottica’s growth plans for the network. With more than 100 grads expected to join the business in 2023 – many whom will provide much-needed eyecare in regional communities – the company’s graduate program is highly sought-after, which is perhaps testament to the unique opportunities on offer.

“There are countless opportunities for optometrists to excel in various ways, whether at a store level in positions such as managing optometrist, or even within the head office,” she says.

“If you’re someone who is passionate about your work and has a clear idea about where you want to be in the future, OPSM is a great company because they’ve got the backing of a global company and they will readily provide the support to help progress your career.”

When Barr was coming to the end of her studies she had several

options, but OPSM stood out for various reasons. She had done her placement at OPSM Midland Gate and ended up staying for six months instead of the three she originally planned. The network also offered longer consultations (up to an hour for fresh new grads before working down to 30 minutes), career support including the EyeLaunch induction event, and access to iconic eyewear brands – a drawcard for Barr who once worked in the fashion industry.

“I liked how the optometrist side of OPSM operated. The placement was the ideal stepping stone and from there I was convinced OPSM would be the place to progress my career,” she says.

“The thing I’ve loved most about my journey with OPSM is the support. I have a personal, in-store mentor who’s looking out for me, and there’s

Garson Chin (fourth from right) at the EyeLaunch event in Sydney in February 2023.

Tansy Barr began her career at OPSM Garden City Booragoon, Perth, 18 months ago, and has already been promoted.

MYOPIA MANAGEMENT MATTERS

The flexibility to become an expert in an area of clinical interest is a major drawcard for many graduates when choosing their employer. In addition to dry eye, presbyopia and contact lenses, myopia is one area where young optometrists can make a significant difference in the communities OPSM and Laubman & Pank serve.

Recently the network reinforced its commitment to myopia management through its partnership with EssilorLuxottica by introducing the Essilor Stellest lenses in its practices. The lenses were launched locally in October 2022 and have been shown to slow down myopia progression in children by 67% on average, compared to single vision lenses, when worn 12 hours a day after two years.1

Essilor Stellest lenses are now rolling into an all-encompassing myopia program to better support younger OPSM and Laubman & Pank patients. The program includes OCTs with optical biometry for axial length measurements – and a comprehensive protocol to support optometrists to elevate their myopia management practice.   At the global level, EssilorLuxottica has established several partnerships with a focus on advancing myopia education, awareness and advocacy.

EssilorLuxottica collaborates with the International Myopia Institute (IMI), Global Myopia Awareness Coalition and Myopia Profile, founded by Australian optometrists Dr Kate Gifford and Dr Paul Gifford. The partnership with Myopia Profile since 2020 aims to empower eyecare practitioners with clinical knowledge, skills, and practical resources in managing childhood myopia. The company is also a platinum sponsor of IMI, a consensus body of global myopia experts. In April 2021, IMI released the 2021 edition of white papers on myopia, sponsored by EssilorLuxottica and other leading industry players. Essilor also pledged its support for the first series of the landmark IMI white papers published in 2019 and is a co-author of one of the white papers titled, ‘Industry Guidelines and Ethical Considerations for Myopia Control’.

In future, EssilorLuxottica wants to continue investing in myopia research, to understand the reasons behind myopia onset and work on additional solutions. The group will also keep expanding its partnerships globally to better understand and share its findings about myopia onset and progression, advance innovative solutions, and educate all healthcare professionals to better manage myopia.

checking in and seeing how I’m feeling, anything exciting that I’ve seen or things I’m not sure about. I’ve never felt pressured and they’ve provided the space to learn how to practise properly as an optometrist. And then over time we’ve been building my skills and confidence to the point now that I’ll become a managing optometrist.

“It was somewhat unexpected. Even though I’m a grad, they advised if I felt ready they’d give me full support – we can take it month by month until I’m comfortable stepping away and letting me do my own thing.”

WHY GRADS CHOOSE ESSILORLUXOTTICA

Ms Elizabeth Kodari is the eyecare operations director at EssilorLuxottica ANZ, overseeing all aspects of the eyecare strategy for OPSM and Laubman & Pank. She joined the company in 2015 and is a former optometrist at OPSM George St, Sydney.

She says the field of optometry has evolved, and today’s graduates are seeking employers who are responsive to change and attentive to their needs.

The support EssilorLuxottica provides to a graduate’s career starts from their time in university. Optometry students can start their career with OPSM or Laubman & Pank as an optical dispenser or part of the highly sought-after Cadetship Program.

“Our cadets are awarded financially throughout their final years of university and upon graduation, receive a guaranteed role in one of our regional stores across Australia and New Zealand,” Kodari explains.

“We are proud to support a vast number of clinical placements each year, where students have the opportunity to learn and refine their clinical skills alongside our experienced optometry mentors. From being a placement student, to an optical dispenser, to a cadet, being part of our EssilorLuxottica retail family as an optometry student can fast-track inclusion in our annual graduate intake.”

Graduates that join EssilorLuxottica can access a wide range of opportunities for ongoing professional growth while joining forces with thousands of colleagues globally, united by the company’s mission of helping the world “see more and be more”.

“Whether you aspire to be an exceptional clinical optometrist or a future business leader, the possibilities are limitless. We continuously invest in the newest technologies to keep our graduates up-to-date with the latest advancements in the optical industry. With more options, and more opportunities to provide comprehensive optometry services, both OPSM and Laubman & Pank are an attractive choice for many optometry graduates starting their careers,” Kodari explains.

One of the most important aspects of the graduate journey is EssilorLuxottica’s EyeLaunch event. It’s a two-day induction program and marks the start of the company’s two-year Graduate Development Pathway. The event equips graduates with tools and resources to start their careers and an opportunity to network with colleagues.

During EyeLaunch, graduates learn about the EssilorLuxottica business, its cutting-edge technology, premium eyewear portfolio and the philanthropic initiatives led by Onesight EssilorLuxottica Foundation. They also hear from industry experts on various topics including myopia control, dry eye, and contact lenses. The induction program also equips graduates with the skills to handle different situations and techniques to build a cohesive work environment.

“For many, the DISC (Dominance, Influence, Steadiness, and Conscientiousness personality type) communication workshop is a highlight, a llowing graduates to understand their own behavioural style as well as ways to improve teamwork and communication in the workplace,” Kodari says.

YOUNG MYOPE BECOMES GRADUATE OPTOMETRIST

One of the graduates to emerge from the 2023 EyeLaunch induction in February was Mr Garson Chin. He became an OPSM optometrist at the Carindale store in Queensland in January 2023, but his ties to the network hark back a few years earlier.

“GRADUATES HAVE REGULAR PROTECTED TIME WITH THEIR MENTOR TO BUILD ON THEIR EXPERIENCE AND CORE COMPETENCIES.”

ELIZABETH KODARI, ESSILORLUXOTTICA

1. Compared to single vision lenses, when worn by children at least 12 hours per day every day Bao, J., Huang, Y., Li, X., Yang, A., Zhou, F., Wu, J., Wang, C., Li, Y., Lim, E.W., Spiegel, D.P., Drobe, B., Chen, H., 2022. Spectacle Lenses With Aspherical Lenslets for Myopia Control vs Single-Vision Spectacle Lenses: A Randomized Clinical Trial. JAMA Ophthalmol. 140(5), 472–478. https://doi.org/10.1001/jamaophthalmol.2022.0401.

capacity for four years (2018-2022) while completing his optometry studies at Queensland University of Technology.

Chin was always interested in a healthcare career, but growing up as a young myope – the only among his siblings – he had a natural curiosity about eyecare. Like Barr, he had plenty of options when deciding his employer out of university, but his experience with OPSM as a dispenser cemented his decision.

“There were several reasons why I chose OPSM. In terms of the optometry, I preferred the length of appointment times, but also the potential for me to practise high quality optometry and take a special interest in different fields, like orthoK, dry eye and contact lenses,” he says.

“I also appreciated their approach to innovation, and how they integrated it with the Essilor lens products. The best example of this is the new Clarifye patient journey, which is allowing us to refine the prescription with the new Essilor Vision-R 800 auto phoropter with 0.01 D increments.”

When Insight spoke to Chin, he had only been in the role for two weeks, but he appreciated the time and space his mentors allowed him, while also acting as a sounding board for more complex cases.

Kodari says as Chin and other graduates grow into their roles as part of the Graduate Optometrist Development Program, they will have access to several initiatives including the mentorship program, leadership training and professional development opportunities.

The two-year graduate program provides four main pillars of support.

“All our graduates start on one-hour appointments and are supported by an optometry mentor. Graduates have regular protected time with their mentor to build on their experience and core competencies. Our graduates also receive professional guidance from our dedicated team of eyecare leaders including professional services managers, and area eyecare managers,” she says.

“Secondly, we provide opportunities for networking and development. Our optometrists are part of one big family, and we host various in-person networking and CPD events throughout the year where graduates can engage with local allied health professionals and connect with their peers.

“We also support our graduates with further education to elevate their expertise. We provide a large range of CPD modules through our learning platform Leonardo, and award LEDA (Luxottica Eyecare Development Award) scholarships to financially support further studies in an area of interest, which encourages our graduates to pursue their passion.”

Finally, Kodari says EssilorLuxottica helps build a graduate’s profile as an optometrist in the community. The organisation can leverage their profile through health practitioner platforms and support their engagement with allied health professionals by providing tools such as collaborative care packs.

“Our graduates can also take part in something bigger through our local vision screening clinics and OneSight EssilorLuxottica Foundation outreach program,” Kodari states.

“With our vast network of talent and resources available, we can tailor the development program for each graduate based on their career aspirations.”

Kodari says it’s an example of EssilorLuxottica’s structured p ipeline of opportunities and career development initiatives.

“There is robust support for your professional development, whether your passion is to become an expert in an area of clinical interest or to become a future leader in eyecare. With more than 430 stores across our ANZ network, combined with our global footprint, the opportunities are endless with both OPSM and Laubman & Pank.”

EssilorLuxottica’s graduate 2023 intake at the company’s ANZ headquarters in North Sydney.

Garson Chin recently became an OPSM optometrist at the Carindale store in Queensland.

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– MYOPIA

At the completion of this article, the reader should be able to improve their myopia managament c are.

Including

• Know the systemic conditions related to high myopia

• Develop a clinical evaluation protocol for high myopia

• Know the pathological complications associated with high myopia

• Understand the elevated risk of sight-threatening complications in myopic patients

PUTTING HIGH MYOPIA HIGH ON THE AGENDA

As the consequences of myopia rise globally, high myopia retinal complications will only become more common. Optometrists will increasingly be called upon to provide the solutions, explanations and education to a growing number of patients in search of answers.

The International Myopia Institute (IMI) defined myopia where the spherical equivalent refraction of an eye is ≤ -0.50 D. High myopia is defined as an eye with spherical equivalent refraction of at least -5.00D or -6.00 D, depending on clinical or research settings.

Historically, low and moderate myopia were termed ‘physiologic,’ but in 2019 the IMI asserted that the terminology of ‘physiologic myopia’ was misleading, as myopia cannot be implied to be “devoid of any adverse consequence”. Similarly, high myopia and pathologic myopia are not synonymous, as the latter is defined by structural complications in the posterior segment which are related to excessive axial elongation, not necessarily to a dioptric threshold.1

The prevalence of myopia and high myopia has dramatically increased worldwide, 2-4 particularly in countries within East Asia such as China, 5 Japan,6 Singapore,7 and South Korea8 where myopia prevalence is already high. It has been projected that almost five billion individuals of the world’s population will suffer from myopia by 2050, with almost one billion people suffering high myopia. 9

Myopia is an emergent public health concern, and a large body of evidence now points to the necessity of prescribing interventions to slow myopia progression in suitable patients. The World Council of Optometry affirmed this position in mid-2021, indicating that eyecare practitioners (ECPs) worldwide must work to increase awareness and ensure effective myopia management strategies are implemented to achieve better patient and public health outcomes.10

HIGH MYOPIA IN CHILDREN

High myopia in young children is a red flag for systemic complications. Examples include connective tissue disorders such as Stickler syndrome and Marfan syndrome, and developmental syndromes such as Noonan and Down syndrome. A retrospective study of children under 10 years of age with myopia ≤ -6.00 D showed only 8% had ‘simple high myopia’ without other ocular or systemic associations, while 54% of children had an underlying systemic condition.11 These children require referral to, or

co-management with ophthalmology. Accurate and early diagnosis facilitates educational planning, and provides the patient and their family with an understanding of the condition and its consequences.11 Furthermore, diagnosis of a heritable ocular or systemic condition may encourage the screening of the condition in other family members.

A simple approach may be to initiate referral and/or co-management with a paediatric ophthalmologist for:

• Children under age 10 with high myopia who have not yet seen an ophthalmologist

• Children whose dioptres of myopia exceeds their age in years

• Where referral and/or co-management is necessary for strabismus, amblyopia, or ocular disease findings.

CLINICAL EVALUATION

Evaluation of visual function in patients with myopia involves measurement of distance and near visual acuity, subjective and/or objective refraction, and evaluation of binocular and accommodative function.12 The IMI defines myopia as ‘when ocular accommodation is relaxed1 which points towards cycloplegic assessment where possible and available. Cycloplegic refraction is a necessity in research studies, and undertaking the same in clinical practice allows for maximum accuracy; however it is not a necessity as both cycloplegic and standard clinical techniques can control accommodation. For example, non-cycloplegic retinoscopy in children with contralateral fogging of +6.00D yields results within 0.25D of cycloplegic testing.13

Structural assessment of myopic eyes should include anterior eye health slit-lamp assessment, intraocular pressure measurement, corneal topography (on indication), axial length measurement (where available), fundus examination and imaging.12 Measurement of axial length can be integral in measuring progression in younger myopes, and identifying risk of pathologic myopia in patients of all ages.

Axial lengths exceeding 26 mm show correlation with escalating risk of pathology and eventual

Clinical educator - Myopia Profile Pty Ltd

Dr Kate Gifford

PhD BAppSc(Optom)Hons GradCertOcTher.

FBCLA FIACLE FCCLSA FAAO GAICD

Optometrist, professional

educator and clinician-scientist Co-founder and lead educator – Myopia Profile Pty Ltd

vision impairment.14 Regardless of the refractive level of myopia, patients of all ages with axial lengths approaching this value are also reasonably defined with ‘high myopia’ from the point of view of their additional clinical care requirements.12

PATHOLOGICAL COMPLICATIONS

High myopia is associated with various pathological findings, particularly those manifesting in the posterior segment. ‘Pathologic myopia’ refers to the structural changes in the posterior eye as a result of excessive axial elongation, such as posterior staphyloma, myopic maculopathy and optic neuropathy.15 While most pathologic myopia occurs in eyes with high myopia by refractive definition, individuals with low or moderate myopia can also suffer pathological sequelae. Numerous studies in adult or elderly populations have shown that around half of adults with high myopia are likely to develop pathologic myopia.15

MYOPIC MACULOPATHY

Myopic maculopathy is one of the most prevalent disease complications observed in high myopia.

It is characterised by slowly progressive retinal pigment epithelial (RPE) and chorioretinal atrophy, and sometimes accompanied by choroidal neovascularisation (CNV), lacquer cracks or Fuchs spot. Macular retinoschisis, lamellar macular hole and foveal retinal detachment are other potential complications. The META-PM Classification of Myopic Maculopathy provides a simple five category system (Figure 1 and Table 1).

Myopic maculopathy is one of the leading causes of blindness in several countries around the world, including China, Ireland, Israel, Japan and the United Kingdom.16-20 The Blue Mountains Eye Study in Australia reported the overall prevalence of myopic retinopathy in 1.2% of the population. 21 However, prevalence increased dramatically to over 50% for myopes ≤ -9.00 D compared to 0.42% of myopes < -5.00 D, representing a 60-fold increase in risk of myopic retinopathy.

Sadly, atrophic forms of myopic maculopathy are untreatable. At best, the established first-line treatment for secondary myopic CNV is intravitreal anti-VEGF therapy.15

RHEGMATOGENOUS RETINAL DETACHMENT (RRD)

Rhegmatogenous retinal detachment (RRD) is another potential sight-threatening complication of myopia, with an incidence estimated to be between 6.3 and 17.9 per 100,000 individuals. 22 RRD

arises when fluid from the vitreous cavity enters via full-thickness retinal defect into the subretinal space, inducing a separation of the neurosensory retina from the underlying RPE.

RRD may occur in non-myopic eyes, but as the Eye Disease Case-Control Study in the US suggested, a substantial proportion (55%) of idiopathic RRD cases can be retraced to myopia. 23 The risk of developing retinal detachment increases significantly with severity of myopia and greater axial length.

Compared with non-myopic eyes, lower levels of myopia (up to 3.00 D) attract a four-fold increased risk of RRD; while higher levels of myopia have an eight to 10-fold increased risk of detachment. 22,24 Numerous studies have also found eyes with axial length > 26 mm had a significantly elevated risk of RRD in both phakic and pseudophakic patients. 25,26 The intrinsic risk may be related to the architecture of myopic eyes, which are more likely to have a thinner retina and a predisposition to premature vitreous liquefaction and subsequent posterior vitreous detachment. 27,28

PRIMARY OPEN ANGLE GLAUCOMA

Many studies have implicated an association between myopia and primary open angle glaucoma (POAG), increasing with degree of myopia. The Blue Mountains Eye Study reported a relationship between glaucoma and low myopia

(odds ratio (OR) 2.3) as well as moderate-to-high myopia (OR 3.3). 29 This was maintained in a recent meta-analysis which found those with moderate-to-high myopia (OR 2.46) and low myopia (OR 1.65) have an increased risk of developing open-angle glaucoma. 30

The pathogenesis of POAG itself is still poorly understood, let alone the link between myopia and POAG. Accuracy of diagnosis is complicated by the fact that retinal nerve fiber layer (RNFL) thinning is characteristic of both myopic structure-function changes as well as ‘true’ glaucomatous optic neuropathy. 31 The prevailing theory is that highly myopic eyes are more susceptible to optic nerve head damage by elevated intraocular pressure (IOP), which may be related to the structure and arrangement of connective tissues in the posterior segment.

CATARACTS

High myopia is known to be associated with cataract development. The Blue Mountains Eye Study showed that early onset myopia (before 20 years of age) was strongly associated with posterior subcapsular cataract (PSC) (OR 3.9) and that hyperopia appeared to be protective of PSC (OR 0.6). 32 Consistent with the conditions described above, a dose-dependent relationship was found; the risk of PSC is greater in high myopia (OR 5.5) than low myopia (OR 2.1). The

FIGURE 1: Fundus imaging illustrating the META-PM Classification of Myopic Maculopathy, from the open-access paper by Ohno-Matsui et al.15 Image panel (A) shows a tesselated fundus, category 1. (B) and (C) show diffuse chorioretinal atrophy, category 2. (D) shows patchy chorioretinal atrophy, category 3 (arrows). (E) shows myopic macular neovascularization with associated atrophy, category 4 with ‘plus lesion’. (F) shows macular atrophy, category 4.

aetiological link between myopia and cataract is unclear, although it has been suggested that incident cataract is more common in myopia due to the increased oxidative susceptibility of myopic crystalline lenses. 33

MANAGING HIGH MYOPIA

Ultimately, while myopia control options should be communicated to the patient and their family, managing expectations regarding their efficacy is equally important.

SPECTACLES

The first line of management for patients with high myopia is prescribing a refractive correction. For patients young and old with high myopia, control of vertex distance in both refraction and optical dispensing is crucial for best acuity. High myopes approaching 10 D and beyond can suffer reduced visual acuity 34 and contrast sensitivity 35 compared to lower myopes, and impaired quality-of-life similar to that of patients with keratoconus. 34

Optimum vision can be achieved by measuring vertex distance in refraction, checking acuity in a trial frame, and then attempting to match this vertex distance with the spectacle frame. High index spectacle lens materials improve optical quality and cosmesis by minimising peripheral distortions in a thinner lens profile.

CONTACT LENSES

Contact lenses can provide a superior correction option for paediatric and adult high myopes,

META-PM Classification Visual Impairment Pathologic Myopia

Diffuse chorioretinal atrophy (category 2)

Patchy chorioretinal atrophy (category 3)

Parafoveal scotoma Yes

Macular atrophy (category 4)Central scotoma Yes

‘Plus’ lesions

Myopic macular neovascularization (including Fuch’s spots)

Cen tral scotoma, distorted vision Yes

Lacquer cracks Temporal scotoma owing to simple haemorrhage, distorted vision (in some cases) Yes

orthokeratology (orthoK) and low-concentration atropine. Conventionally, orthoK lenses have been used to treat low-to-moderate myopia, and fitting for high myopia may result in complications such as corneal staining and lens decentration. 38

Partial orthoK correction may be useful. In one small study, myopes with between 6.00 and 8.00 D spherical equivalent underwent partial (4.00 D) correction of myopia in conjunction with single vision spectacle daytime wear for the residual refraction. This resulted in 63% reduction in axial

“PRESCRIBING INTERVENTIONS TO SLOW MYOPIA PROGRESSION IN CHILDREN AND TEENS IS IMPORTANT, AND THE LONG-TERM IMPACT CAN ALSO BE SIGNIFICANT. REDUCING A PATIENT’S FINAL LEVEL OF MYOPIA BY ONE DIOPTER REDUCES THE RISK OF MYOPIC MACULOPATHY BY 40% REGARDLESS OF THE LEVEL OF MYOPIA.”37

overcoming the limitations of spectacles. Contact lenses may improve visual acuity compared to spectacles by reducing the minification effect caused by differences in vertex distance. Field of view is improved, and there are obvious aesthetic and functional advantages.

When fitting from spectacles to contact lenses, though, watch for any issues with near vision. High myopes have less accommodative and convergence demand in spectacles, compared to contact lenses, due to vertex distance and intrinsic prismatic effects. This can lead to asthenopic symptoms during near work in individuals with near exophoria, incipient presbyopia, or a habitually close working distance. 36

Prescribing interventions to slow myopia progression in children and teens is important, and the long-term impact can also be significant. Reducing a patient’s final level of myopia by one diopter reduces the risk of myopic maculopathy by 40% regardless of the level of myopia. 37 The evidence base for applications in high myopia is limited, though, as most studies include only participants with low-to-moderate myopia.

ORTHOK

For high myopia, there is a small amount of evidence for myopia control efficacy with

elongation over two years, 39 comparable with the efficacy of orthoK for control of low and moderate myopia. 40

ATROPINE

Topical atropine has established myopia control efficacy for children from four up to 15 years of age. Among the lower concentrations, atropine 0.05% currently appears to provide the best balance of efficacy with minimal side effects, slowing axial elongation by around 50%. 41 This is a similar efficacy to the best available spectacle and contact lens interventions. 42

The landmark Low-Concentration Atropine for Myopia Progression (LAMP) study did not report specific outcomes for high myopia, but did not exclude them from the study criteria. As atropine alone does not provide visual correction of myopia, it is generally preferred as a first-line treatment where optical interventions (spectacle and contact lenses) are not available or suitable. This could be the case for high myopia, where there may be wider prescription availability in single-vision spectacles and contact lenses.

Atropine 0.01% can be combined with orthoK to increase short-term myopia control efficacy, but again this evidence is limited to those without high myopia. 43 There is no other evidence at this stage

It’s important to educate patients and any caregivers on the potentially sight-threatening conditions of myopia and that the risk is proportional to the severity of myopia. For patients with high myopia, of all ages, the IMI recommends annual retinal health examination through dilated pupils. Multimodal imaging such as fundus photography and optical coherence tomography (OCT) may be performed to document retinal abnormalities and changes. Patients and their families should be counselled on the symptoms of retinal break in order to recognise and appropriately respond to an ocular emergency.12

A CAREFUL APPROACH

Clinical management of high myopia requires a careful approach in addressing both vision needs and ocular complication risk. In young patients with high myopia, systemic health associations must be investigated, and co-management between optometry and ophthalmology can be required.

Prescribing an appropriate optical correction should be prioritised to provide best possible vision. Patients– and their caregivers in the case of children – benefit from education on the importance of lifelong ocular health assessment needs, and in setting appropriate expectations for myopia control.

NOTE: References are available in the online version of this article or can be provided upon request.

TABLE 1. The META-PM Classification of Myopic Maculopathy, adapted from Ohno-Matsui et al.15 Pathologic myopia is defined by at least category 2, or the presence of a ‘plus lesion,’ or the presence of posterior staphyloma. for the efficacy of atropine combined with other optical interventions for those with any level of myopia.

Proven by 7 years of clinical data to significantly slow myopic progression with no rebound effect

Supported by the Brilliant Futures™ myopia management program

Further information at childmyopia.com and coopervision.net.au / coopervision.co.nz

*95-100% of children expressed a preference for contact lenses over glasses at each visit over 36 months. †’How much do you like wearing your contact lenses?’ 87/97 (90%) Top box ‘I like contact lenses the best’ Subjective response at 60 months. ‡Compared to a single-vision, 1-day lens over a three-year period; rate of progression maintained out to 6 years. On average, there was no indication that accumulated treatment effect gained following 3 or 6 years of MiSight® 1 day wear was lost during a 12-month cessation study in children aged 8-15 at initiation of treatment. Instead, eye growth reverted to expected, age average myopic progression rates. References: 1. Sulley A et al. Wearer experience and subjective responses with dual focus compared to spherical, single vision soft contact lenses in children during a 3-year clinical trial. AAO 2019 Poster Presentation. 2. CooperVision® data on file, 2019. 3. Chamberlain P et al. A 3-year randomized clinical trial of MiSight® lenses for myopia control. Optom Vis Sci 2019;96:556–567. 4. Chamberlain P et al. Myopia Progression in Children wearing Dual-Focus Contact Lenses: 6-year findings. Optom Vis Sci 2020;97(E-abstract):200038. 5. Chamberlain P et al. Myopia progression on cessation of Dual-Focus contact lens wear: MiSight 1 day 7 year findings. Optom Vis Sci 2021;98:E-abstract 210049.

6. Hammond D et al. Myopia Control Treatment Gains are Retained after Termination of Dual-focus Contact Lens Wear with no Evidence of a Rebound Effect. Optom Vis Sci 2021;98:E-abstract 215130. For instructions for use refer to https://coopervision.net.au/patient-instruction. MiSight®, Brilliant Futures™ and CooperVision® are registered trademarks of the Cooper Companies, Inc. and its subsidiaries. EMVCOO0841 ©2022 CooperVision.

At the completion of this article, readers should be confident of the steps required to implement and monitor myopia management strategies for patients and their families.

Including

• An understanding of how low levels of outdoor activity affect myopia

• An understanding of the Australia and New Zealand Child Myopia Working Group recommended Standard of Care for myopia management

• Knowledge of the key elements of a myopia management plan, and how to implement them

• Knowledge of the key elements of an informed myopia referral

MYOPIA MANAGEMENT: IMPLEMENTING AN EVIDENCE-BASED STANDARD OF CARE

The recommended best practice Standard of Care from the Australia and New Zealand Child Myopia Working Group outlines the steps to prevent, manage and reduce the impact of myopia. Scientia Professor FIONA STAPLETON says the six-step model will help practitioners have informed discussions with parents to ensure every patient receives the best management option.

The understanding of myopia and myopia management continues to advance, with the latest evidence and data continually informing best practice. However, since 2018 and the release of the first Australia and New Zealand Child Myopia Report, we have witnessed a shift in trends, awareness and understanding of myopia.1

WHAT HAS CHANGED?

Few of us would have predicted a global pandemic in that time. The COVID-19 pandemic has had a significant impact on the progression of child myopia in those populations who endured extended lockdowns, bringing the issue to the attention of a wider audience than ever before.

Myopia prevalence rose significantly in young school children during the COVID-19 pandemic. According to one large Chinese study, prevalence increased almost 400 per cent in six- year-olds. 2 This substantial myopic shift (approximately −0.30 dioptres) has not been seen in any other year-to-year comparison, making the cause possibly due to the unusual concurrence of home confinement, online schooling and increased use of digital devices in 2020.

Researchers also hypothesised that the impact was greater for younger children, those aged six to eight years old, as they are more sensitive to environmental change, given they are in an important life stage for the development of myopia. The findings of this research have global implications; children have completed months of home and online schooling during the pandemic, including in Australia and New Zealand where schools were closed and sports cancelled.

ENVIRONMENTAL INSIGHTS

The evidence of the protective effect of time outdoors, on myopia, continues to grow. Low levels of outdoor activity may influence

the development of myopia, 3 so balancing screen time with green time for children is imperative. Spending time outdoors, with or without requiring physical activity or direct sunlight exposure, appears to have a protective effect against myopia onset. 4

According to Optometry Australia, children need to spend at least 90 minutes per day outside to help prevent myopia from developing and progressing. 5 Ethnic and geographical differences in terms of myopia prevalence also need to be acknowledged as influencing factors, as does the urban or rural environment in which an individual resides. 6

It is estimated that children living in predominantly urban environments have 2.6 times greater chance of developing myopia than those living in rural environments.7 Regions that have undergone rapid economic transition, south and east Asia for example, have also experienced a rapid rise in rates of myopia.7

The challenges reported above and reported impact on myopia during the pandemic, provide the evidence for changing how myopia is managed with intervention starting as soon as possible.

For Australia and New Zealand, the forecast rate of myopia by 2050 is projected to be 55%. Currently 36% of the population is estimated to be affected by myopia. 8 Furthermore, Australia is expected to have 4.1 million high myopes and New Zealand over 600,000 high myopes by 2050, unless myopia management is widely implemented.

These forecasts (from 2016) highlight the scale of the problem that is facing the eyecare profession given Australia in 2020 had an estimated 1.1 million, and New Zealand more than 200,000, high myopes. 8

WHAT NEEDS TO BE DONE?

It’s vital that eyecare professionals have an agreed-upon, updated Standard of Care

that reflects the recent evidence. It’s equally important to ensure that this information is widely disseminated. Myopia management must move from a service offered by a minority of eyecare practitioners to being universally available.

The Standard of Care offers accessible strategies for practitioners to work comfortably within their competency. Only with widespread uptake, will the full public health benefits of reducing the prevalence and impact of myopia be achieved.

The Australia and New Zealand Child Myopia Working Group recommended Standard of Care for myopia management

For the practice setting, it is recommended that the following key elements should be included when managing a patient’s myopia:

1. Use a myopia management program for patients with pre-myopia or myopia based on the best available evidence.

How: Understand the current research and literature available on myopia management to inform the chosen model of Standard of Care for your clinic and best protocol for management. Your myopia management program should support the vision and values within your practice.

2. Explain to patients and their parents or carers what myopia is and discuss the increased risks to long term ocular health associated with myopia.

How: Often visual cues such as an eye model or an online resource like the myopia vision simulator (https://www.childmyopia.com/vision-simulator-tool/) can help. Provide parents w ith take home educational material so they can refer to it out of the practice setting and can ask questions at the time or later.

Taking time to explain myopia carefully and address any concerns or worries will help enlist the patient and their family to support your recommended myopia management program. They need to be more than just ‘compliant,’ ideally, they are equal and active participants in the management and feel empowered in the treatment plan you have recommended.

Seek help with education resources for families of all types, (split families, for example, where parents have different views about the treatment of their child). Myopia educational material is also readily available in a range of languages.

Patient and parent education needs to include the broader impact of myopia, where increasing myopia means more than thicker glasses. It could mean more issues such as progression to high myopia and potentially serious eye health problems in the future, including myopic maculopathy, glaucoma, cataract and retinal detachment. These eye conditions can all potentially lead to reduced vision at best and blindness at worst. 9

3. Discuss, formulate, and implement an agreed management plan with the parent or carer and patient (child), including a discussion of the evidence-based available myopia management options to mitigate axial length elongation; the risks (lifestyle and family history) of myopia progression; the provision of verbal and written information describing the risks and benefits of treatment. Consider the use of consent forms, duration of treatment, review frequency, when to cease treatment and rebound effects.

How: The following management options all

have a role to combat child myopia to maintain better eye health:

• C ertain soft contact lenses featuring a special optical design which are worn during the day.

• O rthokeratology (orthoK) contact lenses which reshape the front surface of the eye during overnight wear and are then removed during daytime. Usually, this modality corrects myopia during the day after lens removal, as well as reducing progression.

• C ertain spectacle lenses featuring an optical design developed especially for myopia management.

• Low-dose unpreserved atropine eyedrops, of varying concentrations, which are usually instilled at night before bed.

Discuss the evidence supporting each option with the parents or carers and determine what may suit the patient best. Build in a discussion around the risks and duration of treatment and any potential rebound effects. Also address the cost of each management option as it will play a role in the decision-making process.

school years. Depending upon the profile of the patient (age, ethnicity, if parents are myopic etc), you may recommend three- to six-monthly visits to monitor progression.

Continue the discussion about lifestyle with less near work, increased time in natural light at every review and monitor for change.

5. Monitor the impact of treatment. How: If a patient’s myopia is significantly progressing, consider if the patient needs myopia management services that your practice cannot provide. Axial length measurement is the gold standard for assessing myopia progression. Where change in axial length and refraction do not match, other causes of myopia progression or systemic causes should be considered.

Be open with patients and their family and ensure they know they can report any adverse effects of a myopia management treatment (for example glare or blur) and intervene earlier if they feel that there is a significant problem.

Adopt an approach that would entail a discussion about lifestyle with less near-work and increased time in natural light.

4. Document a review/recall for patients with myopia that demonstrate progression. How: If axial length measurement is not available, using cycloplegic refraction to measure dioptric change over time to assess speed of myopia progression. Studies in both Caucasian and Asian populations generally define fast progression of myopia in children as more than half a dioptre (0.2 mm change in axial length) per year.10, 11 A recent evaluation of progression in the CLEERE study however has suggested that progression history may not be the best indicator of future progression.12

Monitoring myopia progression should occur regularly, and the effectiveness of treatment evaluated at regular visits throughout the

6. Recognise personal limitations and refer patients to a suitable optometrist or ophthalmologist if the required myopia management services cannot be provided. How: Write an informed referral to the optometrist or ophthalmologist as required. To optimise patient outcome, share the following information in the referral:

• Ag e and ethnicity of the child

• Patient history – visual, ocular and general health history (history of retinopathy of prematurity, collagen diseases, systemic syndromes); developmental and family history; use of medications and medication allergies; visual requirements; lifestyle and hobbies

• V isual acuity and unaided vision

• C ycloplegic refraction, axial length information, if available, and change over time

FIGURES 1-3. Vision at 0 Dioptres, -2 Dioptres and -6 Dioptres. Image: Myopia Vision Simulator – www.childmyopia.com.

“ONLY BY ENCOURAGING PARENTS AND CARERS TO ESTABLISH REGULAR AND ONGOING EYE EXAMINATIONS FOR THEIR CHILDREN, CAN WE IDENTIFY THE EARLY SIGNS OF MYOPIA, WORK TO DELAY ONSET, AND SLOW PROGRESSION.”

• B inocular vision and accommodation examination and treatment history

• D iagnosis – for example: simple myopia, pre-myopia, degenerative myopia

• P rior myopia management history and response to treatment including adverse events

• A nterior and posterior ocular health assessment

For shared care arrangements, clear protocols should be in place and agreed to. A myopia management Standard of Care is critical, given that each year of delay in developing myopia substantially reduces the chance of a child developing high myopia in adulthood.13

REDUCING THE PREVALENCE AND IMPACT OF MYOPIA

Good vision is essential for a child’s learning and development. With 80% of classroom learning being visual,14 early detection, especially in children with a strong family history of myopia and especially a family history of high myopia, is critically important. Early detection supports not only the educational development of a child but also their social, behavioural and physical development. There is therefore an urgent need for a greater focus on preventing and

managing myopia and increasing awareness of the importance of children having regular eye examinations. Only by encouraging parents and carers to establish regular and ongoing eye examinations for their children, can we identify the early signs of myopia, work to delay onset, and slow progression.

Expected increases in myopia prevalence are likely to cause increased future public health and economic problems unless action is taken using evidence-based approaches to prevent, delay and manage the condition.

Understanding the economic burden of vision impairment associated with myopia is therefore critical to addressing myopia as an increasingly prevalent public health problem. For example, the potential productivity loss associated with vision impairment and blindness resulting from uncorrected myopia is substantially greater than the cost of correcting myopia.15

Recent evidence also reveals that the prevalence of high myopia is growing at a faster rate than the prevalence of overall myopia.16 Advances since 2018 however should be recognised. The establishment of the Child Myopia Working Group has enabled the development of an industry-wide recommended best practice Standard of

Care for managing myopia and has driven much-needed awareness among Australian and New Zealand families. Technological advances are also paving the way for more effective options for managing myopia. But work needs to continue.

Adopting the new Standard of Care is critical to moving myopia management to a service offered by a wide range of eyecare practitioners. Only then will the full public health benefits of reducing the prevalence and impact of myopia be achievable.

NOTE: References are available in the online version of this article or can be provided upon request

To download a copy of The Australia and New Zealand Child Myopia Report 2022/23 –Reducing the Risk to Vision, visit www.childmyopia.com

Ms Mariella Coluccio Dr Trent Sandercoe

Dr Loren Rose Dr Shanel Sharma Ms Homma Ebrahimi

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

Taking

TWO BITES AT THE CHERRY

Almost immediately after HOYA Vision Care disrupted the myopia management landscape in Australia with its MiYOSMART defocus spectacle lens, optometrists began wondering what impact they could have on more rapidly progressing patients if this spectacle lens was combined with atropine.

There was little data to support this approach at the time, but since MiYOSMART – and its Defocus Incorporated Multiple Segments (D.I.M.S.) Technology – became available in Australia and New Zealand in October 2020, HOYA has been working with global experts to build an evidence base and consensus on how practitioners can combine the spectacle lens with atropine.

Mr Ulli Hentschel, national training and development manager for HOYA Lens Australia, says MiYOSMART has been a welcome addition to the expanding suite of myopia management treatments now available in Australia, acting as a gateway for many practitioners who began offering a proven intervention for the first time. Others have found this spectacle lens particularly useful for younger and/or newly diagnosed patients, as well as those wanting to avoid contact lenses.

In May 2022, eyecare professionals gained even greater confidence in the lens when six-year data was presented showing MiYOSMART’s myopia control effect was sustained over time.1 It marked the longest study on a myopia management spectacle lens and also reported a favourable outcome when measuring for rebound effect. This study built on the original two-year, double-blind randomised controlled trial, published in the British Journal of Ophthalmology, that concluded children aged 8-13 years wearing MiYOSMART had on average 60% less progression compared with single-vision wearers as measured by the axial elongation, and a 59% reduction in spherical equivalent refraction. 2

With the lens establishing itself in markets across the globe, Hentschel says it made sense for HOYA to facilitate a discussion around combination treatment with atropine.

“When we first launched MiYOSMART, every other week there would be an inquiry about whether it could be combined with atropine, but there was limited evidence to go by at the time,” he explains.

“That’s the reason behind HOYA setting up an advisory meeting in 2022 and developing a consensus document that we can provide to eyecare professionals without them having to go through the literature themselves to arrive at a conclusion about how and when they could combine atropine with MiYOSMART.”

He’s referring to a landmark virtual advisory meeting last November when five well-known experts in paediatric myopia discussed their opinions on combination treatment with atropine and optical inventions. The advisory group

comprised key experts from Europe and Asia, including Professor Hakan Kaymak from the Internationale Innovative Ophthalmochirurgie in Duesseldorf, Germany, who shared insights based on their clinical experience and research.

They discussed their experience with MiYOSMART, including clinical application of the lens in combination with 0.01% atropine drops in European myopic children and adolescents when the expected goal using the spectacle lens alone was not achieved. They noted “a better control effect” with the combination treatment and, importantly, reported no significant changes in visual acuity or binocular vision between the use of MiYOSMART spectacle lenses alone or in combination with low dosage atropine.

A key outcome of the advisory meeting was the group reaching consensus on combining MiYOSMART with atropine, helping practitioners make informed decisions about their myopia management.

KEY FINDINGS

According to Hentschel, the consensus document helps practitioners distinguish whether patients can continue being prescribed monotherapy (MiYOSMART), or if they’d get greater benefit by combining the lens with atropine.

“This is largely centred on whether patients are achieving their treatment goal: is their myopia progressing at a normal rate based on emmetropic eye growth, in which case they are recommended to continue with MiYOSMART monotherapy,” he explains.

“Or if the patient is not achieving that, it’s about educating eyecare professionals about the additive effect of introducing atropine for a combination treatment – both interventions are using different mechanisms of action to reduce myopia progression, they’re complementary.”

Much of the consensus document is underpinned by whether patients are meeting their treatment goals. The five experts, led by Kaymak, noted that the idea of using emmetropic/physiological eye growth as a target for axial length progression has been described in several papers but was yet to be widely established.

However, they said increases of 0.1 mm/year have been shown to be associated with normal eye growth3 , while a progression of more than 0.2 mm/year indicates the achievement goal hasn’t been met. It’s important to note normal eye growth is age dependent, with one Dutch study showing an average of 0.09 mm in 10–13-year-old emmetropes but 0.19 mm in 6-9-year-old emmetropes.4 But treatment targets can also vary by region.

“The goal of treatment is different between Asian and Caucasian children. Success in Asian children is considered to be an annual progression of refraction less than -0.80 D. In Caucasian children, European advisors

The latest six-year data shows MiYOSMART’s myopia control effect was sustained over time.

HOYA broke new ground with its defocus myopia management spectacle lens, and the company is continuing this trend by educating eyecare professionals about the ideal time to introduce atropine as a combination therapy in higher risk patients.

ASSESSMENT TIMELINE FOR CHILDREN ON COMBINATION TREATMENT

visual functions are not adversely changed, even in combination therapy with atropine,” he concluded.

In an even more recent study led by Zhu Huang et al at Zhejiang University in Hangzhou, China, and published in December 2022, the research team looked at the treatment effects of DIMS spectacle lenses and 0.01% atropine. To their knowledge, this study was the first to evaluate the additive effects of DIMS spectacles and 0.01% atropine on slowing axial elongation in children with myopia.6

The retrospective study of 107 children aimed to determine whether the combined approach could slow myopia progression compared with DIMS spectacle lenses or single vision (SV) spectacle lenses alone.

“After a one-year follow-up, myopia progression and axial elongation were lower in participants receiving a combination of 0.01% atropine and DIMS spectacles than in those receiving DIMS spectacles alone and SV spectacles alone, indicating an additive effect in the combined treatment,” the authors reported.

recommend a threshold of -0.50 D or less progression per year,” the experts summarised.

When it comes to initiating treatment, the expert advisory panel recommended that older children with less risks of high myopia should start with optical options only. If the child is young and has high risk profile with myopia progression of >-0.50D in the previous six months, then combination treatment can be initiated immediately.

But what concentration of atropine is appropriate? The experts said they usually adapted the dosage individually depending on myopia control and side effects.

They referred to the LAMP study in Chinese children, in which dosages of 0.01%, 0.025%, and 0.05% were studied over a three-year period. A dose-dependent myopia control effect was observed, meaning the higher the dosage, the better the myopia control. While the side effects with 0.05% dosage was well tolerated in Asian children, the same was not reported in Caucasian children who have light coloured eyes.

“The experts see no significant changes in visual acuity or binocular vision between MiYOSMART spectacle lens alone or in combination with low dosage atropine,” the consensus document said.

“Contrast sensitivity was measured with MiYOSMART spectacle lens alone and in combination with atropine 0.01%, no difference was found. 5 If the expected treatment goal is not achieved only with MiYOSMART spectacle lens, the experts noted a better control effect in combination treatment.”

Another important consideration is the regional variance between how practitioners prescribe atropine.

Currently, in Asia 0.01% to 0.5% atropine is prescribed to children, but this depends on the country and individual prescriber preferences. In some countries health insurance reimbursement has an influence such as in Taiwan where only concentrations of 0.125% and higher are covered and are therefore prescribed more often compared to lower dosages.

In many European countries, atropine is not reimbursed by health insurances and the most common dosage is still 0.01%, but, according to the consensus document, ophthalmological societies now tend to recommend the higher dosage of 0.02% to 0.05%.

WHAT THE STUDIES SAY

Alongside the consensus document, the literature is beginning to build around combination spectacle lens and atropine treatment.

In October 2022, Kaymak published his own study assessing the safety of combining MiYOSMART with atropine 0.01%. 5 In a small trial involving 12 young adults, he investigated combination therapy in terms of traffic safety. Each person recruited was evaluated for corrected distance visual acuity (CDVA), contrast sensitivity and glare sensitivity under the influence of DIMS spectacle correction alone and combination therapy with 0.01% atropine.

“DIMS glasses do not represent any risk to road safety. The safety-relevant

“In this study, axial elongation over one year was dramatically slowed by 0.13 mm in participants treated with a combination of 0.01% atropine and DIMS spectacles compared with DIMS spectacles alone.”

LIFTING STANDARDS

With the emergence of new research and a consensus on combination therapy, Hentschel says HOYA is aiming to remain at the forefront of myopia management , ensuring practitioners can make clear, informed decisions about providing evidence-based care.

It forms part of a broader effort to lift myopia management standards globally, which includes HOYA’s partnership with Haag-Streit and Device Technologies to provide a pathway towards optical biometer ownership (Lenstar Myopia).

“Since announcing this in October 2021, we’ve been pleased with the uptake of this program. As more optometrists open practices or look to elevate their myopia management offering, they are realising that optical biometry is where they need to be in order to provide that gold standard level of myopia management,” he says.

“Being able to provide objective measurements such as axial length ties back to the consensus document, and knowing whether patients are reaching their treatment goals with MiYOSMART alone, or whether atropine might need to be added to the equation.”

Atropine can be combined with MiYOSMART when patients are progressing beyond the treatment target.

REFERENCES:

1. L am CSY, Tang WC, Zhang A, Tse D, To CH. Myopia control in children wearing DIMS spectacle lens: 6 years results. ARVO 2022 Annual Meeting, May 1-4, Denver, US.

2. L am CSY, Tang WC, Tse DY, Lee RPK, Chun RKM, Hasegawa K, Qi H, Hatanaka T, To CH. Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomized clinical trial. British Journal of Ophthalmology. Published Online First: 29 May 2019. doi: 10.1136/bjophthalmol-2018-313739

3. G ifford KL, et al. IMI – Clinical Management Guidelines Report. Invest Ophthalmol Vis Sci. 2019;60(3):M184-M203.

4. R ationale for Intervention. MYOPIE.NL. Available from: https://www.myopie.nl/en/ professionals/rationale-for-intervention/

5. M attern A.-I., Kaymak H., Verkehrssicherheit von DIMS Brillengläsern und Atropin in der Kombinationstherapie zur Hemmung der Myopieprogression, DOG 2022 poster PDo11-01, https:// d og-kongress.de/programm/poster-sessions/ (accessed: 5.10.2022)

6. H uang, Z., Chen, XF., He, T. et al. Synergistic effects of defocus-incorporated multiple segments and atropine in slowing the progression of myopia. Sci Rep 12, 22311 (2022). https://doi. org/10.1038/s41598-022-25599-z

Source: HOYA data on file. Consensus: Combination Treatment for Myopia Management.10/2022

MASTERINGyour myopia service

With more proven treatments coming to market to slow myopia progression, DR JIM KOKKINAKIS says configured optical biometers are becoming a must-have device for Australian primary eyecare professionals.

Prominent Sydney optometrist Dr Jim Kokkinakis has a philosophy to retire an old piece of equipment each year and install something new in its place. Without this approach, he’d struggle to provide the highest standard of care for the four key areas that differentiate his practice: myopia management, dry eye, specialty contact lenses and ocular therapeutics.

In the case of myopia management, this was a service Kokkinakis started offering almost by accident in the mid-1990s. His business – The Eye Practice located in Sydney’s CBD – began by prescribing orthokeratology (orthoK). Back then, this approach was used for vision correction purposes, with the literature in the proceeding years confirming orthoK’s myopia controlling effect. Newer contact lens and spectacle-based interventions, as well as atropine, round out his suite of treatments today.

Like many Australian optometrists, Kokkinakis had monitored progression by changes in the patient’s prescription, but as the industry moves towards the more objective, gold standard measure of axial length, it was imperative to make an optical biometer his latest investment. Recently, the practice installed the OCULUS Myopia Master, distributed by Designs For Vision, with the device having an immediate impact.

“Initially, I thought the Myopia Master would complement my myopia control but I think it’s taken over that part of my practice – it’s that impressive. It’s an old cliché that you don’t know what you don’t know, but it applies in here,” he says.

“Technology like this is what’s kept me in this profession, without it I would have been gone a long time ago.”

While the German-engineered device prides itself on accurate auto-refraction and keratometry combined with axial length measurement (using dual partial coherence interferometry) – it is the normative database collated by and in collaboration with the Sydney-based Brien Holden Vision Institute (BHVI) that sets the Myopia Master apart.

The software works in three ways, being: diagnostic, managerial and educational. Its analysis draws on a combination of measurement data, behavioural variables and genetic links to provide a holistic picture and approach to myopia control in an individual.

Being an inner-city practice, The Eye Practice doesn’t see the volume of children a suburban optometrist might. But Kokkinakis cares for a high number of adult myopes who often bring in their children for a second

opinion, many whom have been prescribed a pair of single vision lenses. “And that’s where the Myopia Master is so powerful with its ability to present visual graphs and projections into the future to show where a child might end up without treatment; it’s sobering to see, but it gets people motivated to take action,” he says.

“Previously, I had no concept of myopia progression risk going forward, other than looking at the parents and/or if the child spends a lot of time indoors reading or on an iPad. I’d only be able to go off the refraction, but now with the Myopia Master, I’m able to get ahead of the curve. We’re able to know what level of risk the child faces, all the way through to how much intervention is needed.”

OPTICAL BIOMETRY CEMENTING ITS PLACE

Kokkinakis believes his new optical biometer has potential implications beyond myopia control. He says the longer the axial length, the stronger the likelihood of a patient developing a retinal detachment or other diseases. This helps him inform his eyecare for adult myopes, even if they have stopped progressing many years earlier.

“Refraction to measure myopia is an issue because you can have a zero prescription, but with a long eye. You are, in fact, anatomically myopic with all the associated risks, so refraction can only tell part of the story,” he says.

“But from the perspective of accurate management, if I was in the suburbs and seeing a large volume of kids, there’s no ifs or buts about the need for an optical biometer. Soon every second child that’s coming in is going to have some myopia: it’s like saying I’m going to practise without a refractor head, it’s insane.”

In fact, myopia is approaching, if not already at, epidemic proportions among youth. While more than 30% of the world’s population is currently myopic, by 2050 it is estimated that more than 50% will have myopia and 10% – or almost one billion people – will have high myopia.1

The increasing incidence is thought to be largely due to lifestyle factors with children spending less time outdoors and more time indoors doing near sighted tasks on phones, tablets and screens. 2,3,4 This essentially makes it a by-product of the technological revolution, resulting in increasingly more children presenting to health practitioners,

The OCULUS Myopia Master performs auto-refraction and keratometry combined with axial length measurement.

and at younger ages, 5 often identified by difficulty seeing in the classroom.

It means primary eyecare professionals like Kokkinaks have been thrust into the fight to counter this rising problem.

Furthermore, research indicates that myopia is most commonly caused by increased axial length of the eye. 6 The higher the degree of myopia, generally the longer the axial length, and with that comes increased future risks of serious complications like glaucoma, retinal detachment and myopic maculopathy.7

Early intervention is therefore recommended to minimise axial elongation, with various treatments now approved in Australia, including atropine drops, orthoK, distance-centre multifocal soft contact lenses, and new spectacle lens technology. 8

But these interventions can’t be prescribed well without accurate diagnostics, hence why configured biometers like the Myopia Master have become an important tool for optometrists to both diagnose and manage progressing myopes.

Mr Malcolm Sketcher, from Designs For Vision in Queensland, explains that diagnostically the device takes raw data from the patient’s eye and compares that to a population of their peers, including specific BHVI data sets for Caucasian and Asian eyes.

The practitioner, patient and parent can then easily observe where the child is currently placed with relation to axial length and subsequent myopia compared to normative values.

“In managing known myopes, projected percentile growth curves provide accurate information on current status and future progression. The level of myopia in adulthood can be predicted, highlighting the consequences if intervention is not implemented and adhered to,” he says.

“Likewise, the effect of any intervention already undertaken is easily evaluated and explained to patients and their parents.”

Myopia Master also has an optional module called GRAS (Gullstrand Refractive Analysis System), which Sketcher says is proving popular among eyecare professionals.

It compares the patient’s measured data to a theoretical emmetropic eye, modified to match their age using BHVI’s extensive data.

It then identifies how much myopia is being caused by each component of the eye: axial length, keratometry and the crystalline lens/ accommodation.

“When axial length is the major contributing factor, GRAS is invaluable in explaining to parents why treatment is so important,” Sketcher explains.

“This ‘educational value’ of the OCULUS Myopia Master should not be underestimated. The culmination of a complete exam is a take-home report for each patient and parent to aid in their understanding of the disease itself, whilst highlighting the importance of adherence to treatment and attendance at follow up appointments. The result is that a higher proportion of patients accept recommendations for initiating, continuing, or increasing treatment. In a world with billions of myopes, that can only be a good outcome for eye health.”

GETTING PATIENTS INVESTED IN THEIR CARE

Kokkinakis agrees. When weighing up which optical biometer to invest in, he says Myopia Master’s educational software and BHVI projections was the clincher.

“Once I was sold on the software, I then knew it would be easy for me to explain the benefits to parents,” he explains.

“As you’re going along, it plots new data points as the individual child is progressing. It projects from their age, when initiating treatment, all the way through to an adult, and where they will end up plus or minus some prescription. And then you can plot data points along as you capture more data and, hopefully, you’ll see the patient’s not progressing as fast as the graph is estimating.”

With around 40 years’ experience, Kokkinakis says he has learned to communicate effectively, believing patients respond better to several mediums.

“It’s not a matter of sitting down, grunting a few words and flicking them out the door with a bit of paper, saying here’s your new glasses. The way I explain it is that optometrists will differentiate themselves by appealing to the senses. The patient needs to see, hear and preferably feel something throughout their visit,” he says.

“With technology, of course, you can support that approach. The lights are flashing, the sound of the equipment, the puff of air when measuring for pressure – these all give the patient a very unique experience and hopefully get them to return and remain invested in their care.”

NOTE: References available upon request.

“I THOUGHT THE MYOPIA MASTER WOULD COMPLEMENT MY MYOPIA CONTROL BUT I THINK IT’S TAKEN OVER THAT PART OF MY PRACTICE." – DR JIM KOKKINAKIS, THE EYE PRACTICE

The device and its corresponding software takes raw data from the patient’s eye and compares that to a population of their peers, including specific BHVI data sets for Caucasian and Asian eyes. Projected percentile growth curves then provide accurate information on current status and future progression.

AP PLY THE BRAKES TO SLOW DOWN

MYOPIA IN CHILDREN

WITH THE FIRST REGISTERED LOW-DOSE ATROPINE EYE DROPS *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:

Made to measure

Three practitioners with a special interest in myopia management discuss why their colleagues should be prioritising axial length measurement, the importance of using software and data, and what lies ahead in optical biometry.

Assessing refractive error alone in managing myopia may have once been the norm, but the limitations of this method are now being acknowledged. Simultaneously, there is a growing awareness of the association between axial elongation and risk profile.

To this end, measuring axial length using biometry is emerging as the standard of care – and optical biometry technology, typically used for cataract surgery work-up, has advanced with manufacturers making modifications for myopia management.

Improved technology means optical biometers have significantly better resolution than their predecessors, a high degree of accuracy and repeatability, and produce results quickly – an advantage when assessing young children with short attention spans.

Integrated software also alleviates the manual work of comparison and extrapolation, and allows optometrists to draw comparisons between their patient against normative data and growth curves.

And as experts in the field have pointed out, there are evidence-based reasons why measuring axial length may soon become an indispensable part of effective myopia management.

SUBJECTIVE VERSUS OBJECTIVE

Optometrist and clinic director of Eyecare Concepts, incorporating Myopia Clinic Melbourne, Dr Philip Cheng says the main limitation of not having a biometer to measure axial length is inaccurate monitoring of myopia progression and treatment response.

“Subjective refraction has a high degree of variability between tests, and subject to practitioner technique, equipment, vertex distance, patient response, accommodation – factors that can easily lead to differences in refraction of plus or minus 0.50 dioptres,” he says.

“The variability in subjective refraction can be greater than the actual myopia progression that we are trying to measure. Atropine treatment can affect accommodation, which can appear to slow progression in refraction while axial length is still progressing. Optical biometry, as an objective measure, gives a reliable and consistent metric for monitoring eye growth and progression across all treatment modalities, eliminating guesswork and doubt.”

“OPTICAL BIOMETRY, AS AN OBJECTIVE MEASURE, GIVES A RELIABLE AND CONSISTENT METRIC FOR MONITORING EYE GROWTH AND PROGRESSION ACROSS ALL TREATMENT MODALITIES.”

DR PHILIP CHENG EYECARE CONCEPTS

In addition, Cheng, a Fellow of the International Academy of Orthokeratology and Myopia Control and board member of the Orthokeratology Society of Oceania, says the only method of properly assessing progression in orthokeratology (orthoK) patients is to measure axial length, as the true refraction status cannot be measured due to corneal changes.

“Without biometry, myopia progression in OrthoK patients may be masked until their daytime unaided vision is reduced from significant progression, delaying further intervention in these cases of fast progressors. Practitioners fitting OrthoK for myopia management but not monitoring their axial length changes are missing the full picture and are potentially not managing the patient as well as they should,” he says.

It’s a view shared by Ms Rebecca Dang, optometrist and UNSW lecturer, and Ms Zeinab Fakih, lead optometrist in paediatric services at Australian College of Optometry.

“The two main outcomes of myopia are refractive error and axial length,” Dang says. “Compared to refractive error, axial length has the advantage of being an objective measurement (therefore more repeatable in children) and directly related to the anatomy associated with sequelae of high myopia such as degenerative retinal changes.”

Dang, who is completing a PhD in factors affecting the adherence of

multifocal contact lenses used for myopia control, says any change in refractive error is very small compared to the equivalent change in axial length, estimated to be approximately 0.25 D to 0.1 mm.

“Considering these factors, a clinic without access to a biometer which instead relies on refractive error changes for myopia management will only be able to reliably detect larger changes in myopia progression before amending treatment,” she says.

Fakih adds that axial length has been found to be critical in a patient’s risk of ocular pathology.

“Axial lengths greater than 26mm, irrespective of the dioptric myopic correction, have been shown to have a 25% chance of vision impairment by age 75. Without having access to a biometer, practitioners may miss these high risk myopes who, on refraction alone, may pass as having only mild-moderate myopia,” she says.

Furthermore, tracking axial length offers another metric with which the effectiveness of a myopia control therapy can be tracked.

“It is not affected by how relaxed a patient’s accommodation is or on the type of myopia control being administered,” Fakih says.

“It is invaluable in the monitoring of progression in patients undergoing orthoK. In the absence of axial length measurements, the clinician is reliant on over refraction, which can be variable, and requires the patient to attend with their contact lenses.”

Cheng, Dang and Fakih represent a profession moving towards more sophisticated myopia management, and their views highlight why the use of axial length measurement is growing in importance.

“I think eyecare practitioners are starting to see the limitations of assessing refractive error alone in managing myopia,” Cheng says.

“There is growing awareness that axial elongation in progressive myopia is associated with increased lifetime risks of uncorrectable visual impairment. [JWL] Tideman’s 2016 paper showed a 25% risk for axial length greater than 26 mm, so it is vital to measure the length of the eye to understand the individual’s risk profile and urgency of treatment.”

Recently published population studies from the Netherlands and China on axial length in emmetropic and myopic children are providing normative data and growth curves in Caucasian and Asian children.

“This data will allow us to determine whether a child’s axial length and rate of elongation falls within a normal range or whether they may be at risk of becoming myopic, even before they develop symptoms and refractive changes. Preventing the onset of myopia, not just slowing progression, is set to be an important part of myopia management in the future,” Cheng says.

Cheng acknowledges optical biometers are a significant investment for a practice, with cost of entry of around $30,000 to $50,000, but takes a long-term view in regard to return-of-investment in practice technologies.

“When we purchased our first biometer five years ago, as one of the

early adopters in measuring axial length for myopia management in private practice, we did so to provide the highest level of comprehensive myopia care to our patients. Investing in our patients’ care has been instrumental to our clinic’s success and growth, and today we are proud to be looking after well over 2,000 children across Melbourne for myopia management as a leader in this space,” he says.

Dang also notes early myopia control studies used refractive error as the preferred primary outcome, as optical biometers had limited resolution which proved refractive error superior.

“However, improved technology means optical biometers have significantly better resolution making them the outcome of choice especially in addition to the factors I mentioned previously,” she says.

SOFTWARE AN EFFECTIVE COMMUNICATION TOOL

Hardware, in terms of optical biometers, is only part of the solution. Of equal importance is easy-to-use, integrated software to help optometrists assess, but also extrapolate, patient data for parents.

“Hardware should be easy and quick to use, especially on younger kids with short attention spans who are unable to sit still for long,” Cheng agrees. “It needs to have a high degree of accuracy and repeatability – but software is important to help eyecare practitioners understand the data and to communicate this to parents.”

Cheng believes software should be customisable to the practitioner's needs to communicate the message and be able to show changes clearly, in terms of the raw data and in the trend of axial elongation.

“Practitioners need to have confidence in the data provided to make the best management decisions for the patient. The changes can be small (0.1 to 0.2 mm between reviews) and it’s important to visualise trends to act promptly in changing or adding treatments as required to best control an individual’s progression. Incorporation of growth curves and normative data helps with interpretation of results and guide management,” he says.

“Software is also an effective communication tool to show parents why their child needs myopia management as well as demonstrating treatment results, so they can understand how their child’s treatment is working, and why changes in treatment strategy might be made. Software should ideally be developed in consultation with experienced myopia management eyecare practitioners to understand their needs in a clinical setting.”

Dang, at UNSW, goes one step further and highlights the importance of integrated databases.

“Axial length measurements should be analysed in context of the patient by comparing to normative databases, which allow clinicians to stage for risk,” she says.

“A certain axial length could represent an eye of average length in a female child of European ethnicity but could represent an above average eye length in a male child of East-Asian ethnicity. A change of 0.1 mm axial length in one year may be high for a 15-year-old, but below average for a 5-year-old.”

“A CLINIC WITHOUT ACCESS TO A BIOMETER WHICH INSTEAD RELIES ON REFRACTIVE ERROR CHANGES FOR MYOPIA MANAGEMENT WILL ONLY BE ABLE TO RELIABLY DETECT LARGER CHANGES ... BEFORE AMENDING TREATMENT.”

Zeinab Fakih, lead optometrist paediatric services, in a consult in the Australian College of Optometry’s recently opened Myopia Clinic.

a myopia clinic, also says having clinician-friendly software is critical to ensuring that optometrists can promptly measure a patient’s axial length and also compare the result to previous records.

“Software that allows trend analysis to monitor rates of changes or stability would certainly be advantageous,” she says.

INNOVATION TO BE EXPECTED

Last year alone, Essilor’s Stellest myopia control lens launched in Australia and New Zealand, CooperVision released its MiSight 1 day contact lenses in higher prescriptions, low-dose atropine EIKANCE secured the first myopia TGA approval, and a three-way alliance between Haag-Streit, its Australasian distributor Device Technologies and HOYA Vision Care offered Australian optometrists greater access to the Lenstar Myopia optical biometer. In 2023, Rodenstock has entered the race with its MyCon lens with peripheral defocus areas.

This is in addition to HOYA’s MiYOSMART defocus lens launched in October 2020, and contact lens based interventions from Visioneering Technologies and mark’ennovy introduced in recent years.

If these advances are any indication, many would agree the myopia management space is ripe for yet more innovation, and Cheng, Dang and Fakih share in the anticipation of what's ahead.

For Fakih, having a system that more easily plots axial lengths over a particular time frame would allow the practitioner to monitor change more easily.

“Changes greater than the expected yearly growth of 0.1 mm each year would be flagged and require follow ups. It would also allow parents to visualise a trajectory if no myopia control was initiated,” she says.

“Having the ability to also plot a child's axial length against age-normal would allow easier visualisation of a child’s risk of myopia and long-term risk of ocular pathology.”

INTRODUCING RODENSTOCK MYCON

A NEW LENS DESIGNED TO HELP MYOPIC CHILDREN

Fakih continues: “Myopia is increasingly being recognised as a true public health issue, and no longer considered as merely a refractive concern. As the importance of myopia control gains traction, it is hoped that partnerships with industry will make biometry more specific to myopia and increase accessibility in the profession.”

Cheng and Dang also believe industry is on the cusp of further change.

“Many manufacturers now have optical biometers with integrated myopia management software, such as Oculus Myopia Master, Lenstar Myopia, Myopia Expert 700. With the successful integration of these into clinical practice, I’m sure other manufacturers will follow and expand on the support they offer,” Dang says.

Cheng agrees: “I think we will see more manufacturers enter the biometry space for myopia management, perhaps some using their existing, proven biometers for cataract pre-op and adding specialised software for myopia management.”

But he cautions “all-in-one partnerships” may potentially create bias towards one particular treatment.

“There is no one-size-fits-all approach in myopia management – each child’s situation is unique and should be managed individually, with a discussion on all available treatment options taking into account many different factors including progression risk profile, compliance, child/parent preferences and lifestyle,” he says.

“Practitioner decision making is still the most important part in myopia management, which takes skill and experience, and no machine can replace that, but having good data from a reliable biometer certainly helps with this process. Optical biometry is one of the most valuable tools we have in our clinic; such is the importance that we have not one but two biometers to ensure we capture reliable and repeatable data for all our patients, and I certainly can’t imagine practising myopia management without one.”

For more

information, speak to your local Rodenstock Account Manager. Rodenstock MyCon lenses are built to correct myopia, controlling its progression in children while ensuring sharp vision.

67% on average*

Essilor® Stellest™ lenses slow down myopia progression by 67% on average*, compared to single vision lenses, when worn 12 hours a day.

A SLEEK LENS DESIGN THAT HELPS ALL MYOPIC CHILDREN

Rodenstock says it has always strived to create the sharpest vision possible for all, including children. With the company’s new MyCon myopia control lens, peripheral defocus areas are placed to the sides of the lens, where they slow the progression of myopia the most, leaving the main vision zones of the lens undisturbed for sharp vision.

“An independent clinical study examining myopia progression in Caucasian children over a period of five years has shown that myopia control lenses built on the principles of Rodenstock MyCon are effective in reducing the progression of myopia,” the company says.

“Whether a child is slightly myopic or highly myopic, Rodenstock MyCon lenses help prevent further myopia progression. Rodenstock MyCon lenses are available in index 1.5, 1.6, 1.67, and 1.74, which make the lenses both thinner and sleeker than many other myopia lenses on the market and well suited to high prescriptions.”

For enquiries contact a local Rodenstock account manager.

Contact: (02) 9748 0988

MYOPIA EXPERT 700 – A TRUSTED PARTNER FOR MYOPIA MANAGEMENT

With axial length being the critical measurement in myopia management, the Myopia Expert 700 delivers a gold standard, non-invasive axial length measurement to help guide myopia management solutions and provide ongoing control.

Additionally, the instrument has a complete set of measurements for all myopia solutions. Covering the full spectrum, the Myopia Expert 700 captures key measurements necessary for the application of different myopia solutions, allowing the practitioner to recommend the optimum control solution to the patient.

These include: corneal topography, keratometry, fluorescein, pupillometry and white-to-white measurement.

Myopia Expert 700 is manufacturered by Essilor Instruments and is supplied to Australian practitioners through OptiMed.

Contact: sales@optimed.com.au

MASTER ORTHOK WITH THE MEDMONT MERIDIA

The Meridia advanced corneal topographer generates high-quality, reliable and precise topography maps – the key to successful orthokeratology (orthoK) design and fitting. Unlike other topographers that extrapolate data, it provides the practitioner with real topography data from limbus-to-limbus.

Proprietary composite topography capture provides users with a complete view of the cornea for utmost confidence in your orthoK lens design.

“Achieve the perfect fit in the way that suits you best with the Meridia’s convenient lens design options. Use the effortless contact lens simulator, integrate with custom lens design software such as EyeSpace and WAVE, or send your data to your contact lens lab so they can design the lens for you,” manufacturer Medmont states. “Assess and document fit at a glance with the Meridia’s easy-to-interpret subtractive map function and powerful fluorescein imaging and video.”

The Meridia is considered an indispensable tool for determining orthoK candidacy, designing lenses, evaluating fit and achieving quick orthoK lens success for myopia patients.

Contact: info@medmont.com

START OFFERING GOLD STANDARD MYOPIA CARE

Eyecare professionals can introduce or expand their myopia control capabilities with precise measurements of The Lenstar Myopia by HOYA. Whether it’s for early detection of disease onset or offering state-of-the-art management, this instrument utilises Automated Positioning Technology for fully automated measurement capture process, combined with the latest graphical data from Erasmus University to detect and track progression and communicate treatment pathways effectively with patients and parents.

Derived from Haag-Streit’s ophthalmology-facing Lenstar for cataract planning, the device is said to be highly accurate and repeatable, averaging multiple individual measurements for axial length measurement, enabling practitioners to identify true progression from deviation. Networkable with existing practice IT ecosystems, and chair and stand compatible, it enables easy practice integration even for those who are space conscious.

The device is distributed by Device Technologies in Australia, and is also accessible to HOYA customers thanks to a global preferred partnership agreement between Haag-Streit and HOYA.

Contact: 1300 338 423 (Device Technologies)

Myopia products

NIDEK LAUNCHES AL-SCAN M OPTICAL BIOMETER

Nidek has introduced its AL-Scan M Optical Biometer with MV-1 Myopia Viewer software.

The AL-Scan M measures axial length, considered a key parameter for predicting and monitoring myopia progression, according to clinical and scientific literature. As most facilities already have an auto refractometer, clinicians can immediately begin myopia management with the AL-Scan M and the MV-1.

“The AL-Scan M incorporates 3D auto tracking and auto shot functions for easy operation and quick measurement. This is especially important for measuring young children and ensures smooth patient flow. The accuracy of axial length measurements is the same as the current Nidek AL-Scan that is used in cataract practices worldwide,” local distributor BOC Instruments says.

“Measurements over time can be monitored and compared with the growth curve. Additionally, the MV-1 presents a history of treatment and patient behaviour in a convenient summary. The history is important for clinical decision-making and the intuitive displays are helpful for patient and parental education.”

BOC is the exclusive Australian distributer for the device. Contact: sales@bocinstruments.com.au

MASTERING MYOPIA MANAGEMENT WITH CONFIDENCE

The OCULUS Myopia Master measures three key parameters to help make myopia detection and management easier and more reliable. Measurement of refraction, axial length and keratometry in a stylish unit, delivered with a comprehensive myopia software suite, helps provide clarity of diagnoses.

Myopia Master, available through Designs For Vision, is described as the only device to incorporate the latest Brien Holden Vision Institute (BHVI) data for estimating future myopia progression, enabling personalised reports detailing a child’s current myopia status and their likely outcome in adulthood.

BHVI’s data sets, with diverse strata of age, gender and ethnicity, improve modelling in a wider patient cohort and enhance parent counselling – giving practitioners confidence without compromise.

Contact: 1800 225 307 (Designs For Vision)

DIOPTER EXTENSION FOR COOPERVISION MYOPIA CL

CooperVision MiSight 1 day contact lenses are now available in higher prescriptions. The expanded range covers -0.25 D to -10.00 D (0.50 D steps after -6.00D) – which means that MiSight 1 day now covers 99.97% of prescriptions for Asian children, and 99.97% for Caucasian children – who have myopia and less than 1D of astigmatism.1

The diopter extension for this innovative, specially designed lens will allow even more children to benefit from myopia management.s

MiSight 1 day contact lenses are backed by the longest-running soft contact lens study among children.

Contact: hello@au.coopervision.com

References

1. CVI Data on file, 2022. SERE coverage of childhood myopia prescriptions with MiSight® 1 day for 104,810 eyes in Asia (China, Korea) and 116,336 eyes in Europe and USA aged 8-18 years.

THE LONGEST MYOPIA CONTROL SPECTACLE LENS STUDY

The results of a six-year clinical study conducted on 90 children in Asia looked at the progression of myopia in children who wore the HOYA Vision Care’s MiYOSMART spectacle lens.

The results enhanced a previous three-year follow-up study 1 , a continuation of a two-year randomised control trial (RCT) 2 , which was published in the British Journal of Ophthalmology, demonstrating strong evidence of the lens’ effectiveness in slowing down the progression of myopia in children ages 8-13.

The findings of the six Year MiYOSMART Follow-up Clinical Study proved:

• T he myopia control effect of MiYOSMART spectacle lens was sustained over six years

• C hildren that wore MiYOSMART for the duration of the study 3 of six years had:

- Average cumulative myopia progression of less than -1.00 D (-0.92 D or -0.15 D/year)

- Average axial elongation

0.60mm (0.10 mm/year)

• C hildren who stopped wearing MiYOSMART spectacle lenses show no rebound effect

Contact: ulli.hentschel@ hoya.com

(References available upon request)

ESSILOR BRINGS SPECTACLE-BASED INTERVENTION TO MARKET

Essilor® Stellest™ lenses slow down myopia progression by 67% on average*

Myopia products

BIOMETRY OCT DELIVERS PRECISE RESULTS

To help give children a brighter future, Essilor has launched Essilor Stellest, a new myopia control lens that slows down myopia progression in children. Essilor Stellest is an innovation for optometrists wanting to correct myopia and help fight its progression. Clinical trial results show that after two years, Essilor Stellest lenses slow down myopia progression by 67% on average, compared to single vision lenses, when worn 12 hours a day.*

With more than 30 years of research and development experience in myopia control, Essilor says it is proud to be at the forefront of myopia management. Essilor Stellest is the company's best solution to slow down myopia progression in children and doesn’t compromise on the aesthetics of the lens. Available from plano to -10.00 D sph and plano to -4.00D cyl, it covers a broad prescription range. Made in Airwear, Essilor Stellest also provides the safety a child needs in the rough and tumble of the playground.

Ask an Essilor account manager for more information.

* Reference available upon request.

Contact: marketing@essilor.com.au

B-OCT is an innovative method of using the Optopol REVO OCT device to measure ocular structure along eye axis. OCT biometry provides a complete set of biometry parameters: axial length, central cornea thickness, anterior chamber depth and lens thickness.

B-OCT is a software licence feature for the ‘REVO’ OCT available through OptiMed. It is considered an ideal tool for myopia control, with many Australian myopia management key opinion leaders successfully using this technology. All measurement callipers are shown on all boundaries of OCT images provided by REVO.

Now, practitioners can visually verify, identify and, if required, make corrections as to which structure of the eye has been measured. With a simple cursor shift, it is possible to precisely set boundaries for every

From now, eyecare professionals can eliminate the common uncertainty as to how most optical biometers classify the boundaries in non-typical can allows precise evaluation of retinal conditions esolution gives the highest level of detail.

The REVO Biometry licence will have an update in Q1 to include progression analysis (retrospective data enabled) to provide practitioners with a powerful management software package that includes normative database.

Contact: sales@optimed.com.au

Put your best-fit forward with the medmont meridia™

Gold-standard topography for winning ortho-k

Increase first-fit success by designing your lenses using accurate, limbus-to-limbus topography.

Lens design options for every practitioner

Use Medmont’s contact lens simulator, integrate with custom lens design software or export data directly to contact lens labs.

Multi-modal functions for multi-service offerings

Access exceptional topography, vast contact lens applications, detailed anterior capture, fluorescein imaging and video, and a broad dry eye suite.

Email sales@medmont.com for more information.

Myopia products

MYOPIA INDICATION FOR LOW-DOSE ATROPINE

Pack image not to scale.

Just over a year ago, Aspen Australia launched Eikance 0.01%, the first pharmacotherapy registered on the Australian Register of Therapeutic Goods to slow the progression of myopia in children aged 4 – 14 years1#. Atropine treatment may be initiated in children when myopia progresses ≥-1.0 D per year.1

EIKANCE 0.01% single-use ampoules are sealed in foil pouches and are available in packs of 30 x 0.3 mL ampoules. The ophthalmic solution is sterile and preservative-free. EIKANCE 0.01% is a private, prescription only medicine available at community pharmacies across Australia.

For the Minimum Product Information and PBS status, turn to page 42.

Contact: customerservice@aspenpharmacare.com.au

References:

1.Eikance Approved Product Information

# Australian Registered of Therapeutic Goods. Accessed 10 Dec 2021. Aspen Australia, St Leonards NSW 2065. Prepared: Feb 2022 ASP 2696 AF 06355

HP-OCT CAPTURES ALL BIOMETRIC PARAMETERS FOR MANAGEMENT

The Cylite HP-OCT is an Australian-made OCT with an industry-leading scanning speed of over 300,000 scans per second. It realises this by scanning the eye with 1,008 simultaneous and parallel beamlets in a series of snapshot captures, which the company says effectively neutralises eye motion artefacts for each snapshot, and in doing so, producing true volume 3D images of the anterior and posterior segments.

“With one click of the button, the HP-OCT Biometry scan captures all biometric parameters required for comprehensive myopia management, including axial length, keratometry, anterior chamber depth, central corneal thickness, lens thickness, white-to-white and pupil diameter,” Cylite states.

“And since the HP-OCT is acquiring an image of the entire anterior segment at the same time, this scan also produces anterior and posterior corneal topography maps, plus a pachymetry map. All of these parameters are then displayed on a single biometry report, giving clinicians a greater understanding of the m yopic eye.”

Contact: info@cyliteoptics.com

SEE MORE, TREAT MORE

INTEGRATED OPTICAL BIOMETRY FOR MYOPIA MANAGEMENT

The OCULUS family of Pentacam anterior segment, total-corneal tomographer continues to expand on its diagnostic capabilities, with the addition of the Corneal Scleral Profiling module for 3D corneal planning of scleral contact lenses, and updates to keratoconus screening and progression analysis.

The Pentacam AXL expands on its hi-resolution anterior segment capabilities with the addition of integrated optical biometry for total corneal IOL calculation and myopia management and monitoring.

The latest Pentacam AXL WAVE model builds on the Pentacam AXL with the addition of retro-illumination of the lens, to highlight lens opacities and defects, and integrated wavefront aberrometry and autorefraction of the entire eye. The result is a comprehensive diagnostic system offering a complete, objective, visual assessment from anterior cornea to the retina. The extensive abilities of the Pentacam AXL WAVE and its analysis modules is said to be an indispensable tool for screening, diagnosis and management of refractive and corneal disease, the lens, anterior chamber and cataract, more accurate optical prescriptions, surgical planning and myopia management.

Contact: 1800 225 307 (Designs For Vision)

Optos says its Daytona device produces a 200° single-capture optomap retinal image of unrivalled clarity in less than ½ second. This fast, easy, patient friendly, ultra-widefield (UWF) imaging technology was designed for healthy eye screening and has been shown to improve practice flow and patient engagement.

Enhances Clinical Decision-making: Evaluation of the peripheral retina is critical for optimal patient management. optomap imaging is ideal for peripheral examinations. Published studies comparing field-of-view and clinical utility of various widefield imaging systems confirm optomap captures the widest clinically usable field of view and the most retinal pathology, Optos says.

Improves Practice Efficiency and Economics: Studies show that optomap images are faster to capture and easier to review than traditional patient examination techniques. optomap enables practitioners to differentiate their practice and add an additional revenue stream.

Contact: auinfo@optos.com

IOL PROVIDES CATARACT PATIENTS with daily range of vision

New generation intraocular lenses are changing the game for patients seeking more spectacle independence, with reduced visual disturbances. Insight speaks to two surgeons with early access to a new Bausch + Lomb platform now available in Australia.

Whether they are motivated to prolong an active lifestyle or wish to no longer wear glasses for most tasks, patients are increasingly demanding more from their cataract surgeon beyond what’s possible with a monofocal intraocular lens (IOL).

For this reason, Adelaide ophthalmologist Dr Paul Athanasiov has made it a priority to embrace IOL innovations, a trend currently being spearheaded by the resurgence of lenses offering extended range of vision, sometimes referred to as enhanced depth of focus (EDOF) IOLs.

“Even though there are excellent lenses around, they all have slightly different good and bad points – and if you don’t try something else, you don’t know what you’re missing out on,” he says.

“When I was approached by Bausch + Lomb (B+L) to begin implanting its newest IOL platform, I was interested because I’d seen it had performed well in Europe and could be used on most patients. I wanted to try something different and the early results have been impressive. You can base a decision on whether you’re going to continue with a lens after the first 10 implants –then refine your approach from there – and now I’ve performed more than 150 surgeries with this lens.”

The lens Athanasiov is referring to is B+L’s new LuxSmart Preloaded, a premium hydrophobic IOL of which he was the first to implant in Australia. A toric version will follow soon.

The premium IOL was a feature at the RANZCO Congress in Brisbane in October 2022, offering a range of vision required to cover the major needs of

cataract patients in their daily activities. Essentially, surgeons report the lens provides distance and intermediate continuous vision with some spectacle dependence for near tasks. Some patients can reportedly read unaided in many cases, especially with mini monovision .

Importantly, LuxSmart offers a potentially similar dysphotopsia profile as a monofocal – an issue that traditionally held back premium posterior chamber IOLs (PC-IOLs). In Clinical Ophthalmology, Campos et al reported the LuxSmart achieved higher performance for uncorrected intermediate and near vision compared with a conventional monofocal IOL, without increasing the risk of photic phenomena, concluding the LuxSmart “may be an attractive and safe option for patients who desire spectacle independence for distance and intermediate vision”.

B+L has achieved this with a lens that is based only on refractive profiles (Pure Refractive Optics Technology – PRO Technology), meaning there are no diffractive areas.

For Athanasiov, it’s been fascinating to see the PC-IOL landscape change dramatically in recent years. In his practice, Eye Surgeons SA, which recently joined Vision Eye Institute, so-called EDOFs were infrequently considered, but are now being offered in up to 90% of patients with private health insurance or seeking a lens exchange.

Bausch + Lomb’s new LuxSmart Preloaded is a premium hydrophobic IOL.

Bausch + Lomb’s LuxSmart IOL features Pure Refractive Optics Technology, meaning there are no diffractive areas.

logMAR) remained wide for the 2 mm and 3 mm pupil. This effect seems to indicate that the central part of the lens, with the combination of fourth and sixth orders of spherical aberration (SA) of opposite signs, still has a noticeable effect when the pupil widens to 3 mm. As the pupil enlarges further, the aberration neutral periphery of the lens takes part, which may explain the shorter focus extension for a 4.5 mm pupil.”

Further, several studies have demonstrated LuxSmart achieves a “useful range of vision” of 2.3 D for a 2 mm pupil size, 1.7 D for 3 mm and of 0.8 D for 4.5 mm.

In terms of dysphotopsic phenomena, when patients consent to surgery with LuxSmart, Athanasiov is careful to advise they may encounter haloes at night.

“But I haven’t had anybody with LuxSmart who’s seen those yet. It doesn’t mean they won’t occur, but I’ve been specifically telling them in advance

and asking afterward, and zero out of the more than 150 surgeries I have

Additionally, B+L has designed LuxSmart so that it is only available in a preloaded system. The company says this potentially means less risk of IOL damage and mishandling, while producing faster and more predictable delivery

For Athanasiov this will provide some convenience for his ophthalmic nurses who are already well-trained in IOL loading, but he expects the pre-loaded system to have benefit in states like Victoria – where nurses don’t always load IOLs – as well as regional parts of Australia where there is variability in the skills

Ask any surgeon why there is increased demand for PC-IOLs, and they will explain there are myriad reasons. Some believe new IOL technology is driving greater awareness, while others say patients are becoming more engaged in their care. Or perhaps both factors are feeding one another.

In his experience, Athanasiov puts it down to word-of-mouth referrals with patients wanting some spectacle independence much like their friend, neighbour or clubmate at lawn bowls.

Another factor could be increased demands on the vision system for near and intermediate tasks. Research cited by B+L shows the use of digital devices by Australian seniors in the near and intermediate visual range has increased in recent years, with senior internet use also increasing from 68% to 93% from 2017 to 2020.

In Europe – where the world’s first LuxSmart was implanted by Czech ophthalmologist Dr Pavel Stodulka in 2020 – people over 55 years spend at least six hours daily on activities such as games and computer use, reading, TV, socialising, exercise, recreation, and travel.

“It was a great honour from B+L to trust me and the Gemini Eye Clinic team to perform the first LuxSmart implantation,” he explains. “It’s very rewarding to be able to push the bar higher in eye surgery especially with such a great device.” After implanting the lens in a significant number of patients, Stodulka has been impressed by the LuxSmart’s ability to achieve stable intraocular position thanks to its four-point fixation haptic design and material.

“This is very important for every premium IOL with complex optic design,” he says.

“In terms of the visual performance, after assessing patients post-operatively, the lens provides high quality distance vision, and at the same time, a lot of patients can read unaided especially with mini-monovision, which I really like.”

During surgery, Stodulka says the surgeon needs to show some patience for complete lens unfolding, but he recommends pushing both IOL optic edges apart by bi-manual cannulas to speed up the process.

“The lens centres reliably and the fully pre-loaded system makes the life of the surgeon easy,” he says.

“For Australian surgeons who will begin implanting the LuxSmart IOL soon, my advice would be not start on myopes and patients with dry eye. I would aim for -0.5 D or -0.75 D of monovision to increase the depth of focus. And stick to the old rule: under-promise, over-deliver.”

“I WAS INTERESTED BECAUSE I’D SEEN IT HAD PERFORMED WELL IN EUROPE AND COULD BE USED ON MOST PATIENTS. I WANTED TO TRY SOMETHING DIFFERENT AND THE EARLY RESULTS HAVE BEEN IMPRESSIVE.”

DR PAUL ATHANASIOV OPHTHALMOLOGIST

Intermediate vision has become more important for older Australians due to lifestyle changes.1 (Reference available upon request).

WHY PATIENT REPORTED

outcomes matter

Incorporating patient reported outcome measures (PROMs) into my cataract assessment has led to better outcomes and increased patient satisfaction. Here, I will outline my reasoning for changing my practise and some of my clinical pearls.

TIMES ARE CHANGING

The paternalistic days of medicine are behind us and it is no longer acceptable for IOL selection to be based on the “doctor knows best” philosophy. The days of leaving every patient presbyopic after cataract surgery are over too; they have wised up about their IOL choices and wish to make autonomous decisions. Our role as cataract surgeons is to guide them in the right direction. With recent technological advances, there are many more options available for presbyopia correction at the time of cataract surgery, including monofocal, multifocal and extended depth of focus (EDOF) IOLs.

We are constantly being told to “choose our patients carefully” when it comes to presbyopia-correcting IOL selection. But what does this really mean and how do we do it? I have developed a simple line of questioning, based on statistically validated cataract questionaries, that can help with this process.

WHAT ARE PROMs?

The ‘patient’s view’ is increasingly recognised as a key measure in health service delivery. PROMs are tools that ask questions about people’s health. They gather information from patients about symptoms, condition and overall quality-of-life.

Some PROMs can be used for any condition, while other PROMs can be condition specific. There are hundreds of PROMs that have been developed for ophthalmic conditions from glaucoma through to cataract.

PROMs IN CATARACT SURGERY

Visual acuity provides a poor indication of visual difficulty in a complex visual world. Patients’ self-reported visual difficulty related to cataract can be reliably measured using questionnaire instruments such as Cat-PROM5 (UK) and Catquest-9SF (Swedish). These questionnaires are used before and after cataract surgery.

Cat-PROM5 measures the self-reported impact of cataracts on vision and quality-of-life. It comprises five items:

1. Whether vision overall has been affected by the “bad” eye

2. The extent to which eyesight has interfered with life in general

3. A rating of vision overall

4. The frequency with which vision prevented usual activities

5. D ifficulties in reading normal print in books or newspapers.

When asking patients these questions, the recall period for each is “the last month”.

The Cat-quest-9SF has nine questions. Two general questions about whether their sight causes difficulty with their everyday life and whether they are satisfied or dissatisfied with their vision overall.

There’s then seven questions about specific visual scenarios including reading newspapers, recognising faces, seeing prices when shopping,

seeing to walk on uneven surfaces, seeing to do handicrafts, seeing subtitles on the TV and seeing to engage in hobbies. I have adapted this particular questionnaire for my cataract patients and updated it to the modern era.

So which of these PROMs should we be using?

Luckily there was a study that answered this question. It was entitled: ‘A head-to-head comparison of the Cat-PROM5 and Catquest-9SF self-report questionnaires’ and was published in 2018 in Eye, the peer-reviewed official journal of the Royal College of Ophthalmologists.

This study used a Rasch-based performance to assess 822 typical NHS cataract surgery patients across four centres in England. Rasch modelling is a tool used by the social sciences to quantify unobservable human conditions. Both questionnaires demonstrated excellent performance for all metrics assessed including; Reliability Indices of 0.90 (Cat-PROM5) and 0.88 (Catquest-9SF) and responsiveness to surgery (1.5 SD improvement from baseline for both).

The two tests were highly correlated with each other (R = 0.85). Both questionnaires were acceptable to patients, but they preferred the shorter CatPROM5, which allowed them to map their own issues to the questions as opposed to the more specific scenarios of Catquest-9SF.

HOW DO I USE PROMs TO GUIDE IOL SELECTION?

I start with open ended question like: “What are your hobbies?”. Then ask specific questions including:

• D o you drive? Do you intend to drive at night?

• D o you play golf/tennis?

• D o you watch much TV? With subtitles?

• D o you use a desk-top computer?

With implantation of presbyopia-correcting IOLs becoming more commonplace, Melbourne ophthalmologist DR LANA DEL PORTO says patient reported outcome measures in cataract surgery can improve results and patient satisfaction.

“THE PATERNALISTIC DAYS OF MEDICINE ARE BEHIND US AND IT IS NO LONGER ACCEPTABLE FOR IOL SELECTION TO BE BASED ON THE 'DOCTOR KNOWS BEST' PHILOSOPHY.”

DR LANA DEL PORTO OPHTHALMOLOGIST

• D o you have/use a smart phone?

• D o you read newspapers/books?

• D o you knit/sew?

Next, I ask how much time they spend doing each activity. Finally, I ask how important it is for them to be spectacle independent for each of these activities.

For patients who want it all, I distil it down to this simple yet valuable question: “Please prioritise what is more important to you, driving at night or reading a book without glasses.”

Once I have asked the patient these questions it generally becomes obvious whether they would be best suited to a monofocal, EDOF or multifocal IOL.

Of course, not every patient is suited to an EDOF or multifocal IOL from an ocular pathology standpoint. I steer away from these lenses in patients with amblyopia, macular pathology, corneal pathology, including dystrophies and those with optic neuropathy. These eyes need all the contrast they can get and I don’t want to degrade that contrast by giving them one of these presbyopia correcting lenses. I still describe all three lens types to patients with ocular pathology with an explanation of why certain lenses will not suit them. Most patients know someone who is now glasses independent following cataract surgery and will want to know why they have been left with reading glasses.

HOW TO USE PROMs TO JUDGE PATIENT SATISFACTION

PROMs can also be used to judge patient satisfaction. Post-operatively, I ask my patients whether they can perform the following tasks without glasses (listed from least to most near vision requirement):

• D rive?

• Watch TV including subtitles?

• Use a desk-top computer?

KEY POINTS

• Patients have wised up about IOL choices, the days of leaving every patient presbyopic after cataract surgery are over.

• Pa tient Reported Outcome Measures (PROMs) are increasingly recognised as a key measure in health service delivery and cataract surgery is no exception.

• W ith recent technological advances there are now many more options available for presbyopia correction at the time of cataract surgery.

• T here are cataract specific questionnaires such as Cat-PROM5 and Catquest-9SF that can be personalised for your practice.

• T hese questionaries can be used before cataract surgery to help guide IOL selection and after cataract surgery as a measure of patient satisfaction.

• C ook/eat a meal?

• Read a restaurant menu?

• Read a book/newspaper?

• Read food labels?

• Thread a needle?

Answering these questions makes them realise how far they have come and what a good job you, the surgeon, have done.

A patient centred approach to cataract surgery outcomes is needed in our modern world. PROMs are likely to become a measure of cataract surgery success in the near future. This is especially important in the setting of rapidly progressing IOL technology such as presbyopia-correcting IOLs. Surgeons may wish to develop their own style of questioning preoperatively in order to help guide IOL selection and post-operatively to gauge patient satisfaction.

IOL landscape HOW VIVITY IS DISRUPTING THE

It’s been almost 18 months since Alcon altered the presbyopia-correcting IOL market with the AcrySof IQ Vivity IOL. NSW ophthalmologist DR ARMAND BOROVIK discusses how the lens fits into his armamentarium today and real-world insights from an international registry.

It was at an overseas ophthalmology conference in 2019 when NSW cataract, corneal and refractive surgeon Dr Armand Borovik first got wind of the AcrySof IQ Vivity IOL, touted as a ground-breaking presbyopia-correcting intraocular lens (PC-IOL) from Alcon with a monofocal-like visual disturbance profile.

Borovik knows “there’s no free lunch in optics”, but to him Vivity and its wavefront-shaping technology presented a clear advance in the premium IOL category by offering excellent distance, intermediate and functional near vision. Importantly, the majority of patients had reported being unbothered by starbursts, haloes and glare: it was the type of PC-IOL many surgeons had been waiting for.

When the lens first became available in Australia in 2021, it was

described as a first-of-its-kind, non-diffractive extended depth of focus IOL underpinned by Alcon’s proprietary non-diffractive X-WAVE technology, which stretches and shifts light without splitting it.1-3 Borovik, who practises privately at Southern Ophthalmology/Lasersight located in Kogarah, Miranda and Wollongong, made it a priority to gain early access to the lens once it became available in Australia. He realised the disruptive technology could fill a gap for eye surgeons seeking a PC-IOL for patients who weren’t suitable for a diffractive IOL, but desire some spectacle independence.

Today, the Vivity IOL is implanted in more than 90% of his private patients – achieving increasingly better outcomes as he has refined his technique.

It’s a far cry from 2017, when Borovik started out in private practice after completing his fellowship in Toronto. Back then, there were plenty of PC-IOL options available, but he was surprised to see how few ophthalmologists implanted them.

“I came into it cautiously because people were concerned PC-IOLs led to side effects and unhappy patients, but I think that’s the case in only a small percentage of patients. Our lives are on our phones, screens and beyond now, so I think we’re doing patients a disservice if we don’t utilise some of the great presbyopia-correcting technology at our disposal, and leave them with spectacle dependence for tasks they perform regularly,” Borovik explains.

“As my practice has evolved, I started out using a mix of predominantly monofocals then multifocals. The patients were generally very happy, but there were some who were unhappy for no good reason with traditional diffractive multifocal-style lenses – and it doesn’t take many unhappy patients for you to change and seek a different solution – and that’s when Vivity entered the equation.”

After speaking with Alcon, Borovik became an early-adopter of Vivity in Australia. In addition, he joined Southern Ophthalmology colleague Dr Alan Flax in becoming an investigator in a global registry analysing the real-world performance of Vivity in 757 patients from Australia, New Zealand, the UK and Europe.

They presented their sub-analysis at the Australian Society of Cataract and Refractive Surgeons Conference in 2022, focusing on post-operative assessments at three and six months. They measured: binocular uncorrected visual acuity (UCVA) at distance, intermediate (66 cm), and near (40 cm), patient-reported spectacle independence, patient-reported satisfaction, and patient-reported visual disturbances. 4,5

They found patients demonstrated good binocular UCVA, with a mean UCVA (± SD) of 0.016 logMAR (6/6) for distance, 0.088 logMAR (6/7.5) for intermediate and 0.253 logMAR for near (6/9.6). Further, more than 80% of patients reported never or rarely needing glasses to see at intermediate or distance. 4,5

Most patients reported no haloes (92.3%), glare (93.1%) or starbursts (95.5%) at three to six months, as well. 4,5

Ultimately, their study found patients had good UCVA outcomes from distance to functional near, high rates of spectacle independence for intermediate and distance, high levels of patient satisfaction, and low occurrence of visual disturbances. 4,5

REAL WORLD USE

For Borovik, the findings represented a major step forward in PC-IOLs where previously there had always been a trade-off for achieving an extended range of vision.

“Those trade-offs were always glare and haloes around lights – and in the right patient I still use multifocal IOLs today, but if someone is happy to not have as much near vision up-close at 30-40 cm – which is the majority of my patients because they can still function without glasses in their day-to-day life – then Vivity is a great option in that regard,” he says.

“It works differently. Because it doesn’t split light it tends not to have the same side effects of traditional PC-IOLs, and that was translated in the registry data (cited above). The vast majority of patients are very satisfied

Dr Armand Borovik, form Southern Ophthalmology/ Lasersight in NSW.

and it suits their needs nicely with very few side effects – even in patients I’ve seen two years post-surgery.”

As a result, Vivity has become “an easy go-to lens” in Borovik’s private clinic.

“I call it the refractive lens for non-refractive cataract surgeons because it’s easy to use. I think what stops people from using a multifocal lens is the fear of having to deal with an unhappy patient, which is understandable, but Vivity is much more forgiving. That’s why I suspect Alcon has had so much success with it,” he says.

“There’s a few factors to that, including counselling. The patient knows what to expect with their vision afterwards. I inform them they’re going to need reading glasses and if they’re not happy with that, then we’ll look at another option, or I’ll consider implanting the Vivity in their non-dominant

IMPLANTED A PC-IOL, BUT AFTER TALKING TO ME ABOUT VIVITY AND SEEING HOW STRAIGHTFORWARD IT IS TO LOOK AFTER PATIENTS AND HOW HAPPY THEY GENERALLY ARE, THEY’VE STARTED USING IT AS THEIR GO-TO LENS.”

eye for some residual myopia; the nice thing about that is you don’t need as much residual myopia as with traditional monovision, so it works well for most of our patients.”

For Borovik, his refractive outcomes have become more predictable as he has made refinements to his approach with Vivity. When the lens first came out, he recalls concerns about some patients not achieving 6/6, but he believes that has decreased over time.

“That’s likely due to patient selection, but also a refinement of the refractive target. We worked out that we need to aim for slight hyperopia to maximise their distance vision. I like to target a slight plus in their dominant eye and the first minus in their non-dominant eye to maximise both far distance and near vision, otherwise patients can be left with some residual myopia, which they’re not happy with in their dominant eye.”

While Vivity is a versatile lens, Borovik says there are some outliers and pathologies that he realised required more caution as he has grown more familiar with the lens.

These include people with co-existing corneal pathology, like scars, keratoconus or Fuchs’ endothelial dystrophy, but it ultimately comes

down to each case.

“There’s no free lunches – it’s still premium optics and the modulation transfer function is not the same as a monofocal so they may lose some quality of vision. Anecdotally in my practice, I haven’t had anyone with a bad experience, but some [of these corneal pathology patients] haven’t quite achieved outcomes as good as their visual potential may have been with monofocal optics,” Borovik says.

“In saying that, in patients where I’m performing a combined cataract and DMEK (descemet membrane endothelial keratoplasty), Vivity is still my go-to because I know their endothelial will normalise once their cornea recovers.”

GREATER UPTAKE

Innovations like the Vivity IOL are also driving greater use and access to premium IOL technology. Patients are becoming more aware, and more surgeons that were once apprehensive about PC-IOLs due to visual disturbances are beginning to embrace the technology.

This is something Borovik has witnessed first-hand. What’s more, is the relatively small learning curve for surgeons familiar with Alcon’s platforms.

“There’s almost no learning curve. The lens is akin to an AcrySof IQ lens (model SN60WF) with a central elevated plateau in the centre. This is something that is very familiar to most ophthalmologists – and the surgery is no different in that regard,” he adds.

“Some colleagues in my practice had never implanted a PC-IOL, but after talking to me about Vivity and seeing how straightforward it is to look after patients and how happy they generally are, they’ve started using Vivity as their go-to lens as well. They haven’t turned back.”

REFERENCES:

1. h ttps://www.alcon.com/media-release/alcon-announces-launch-acrysof-iq-vivty-firstand-only-non-diffractive-extended

2. A crySof IQ Vivity® Extended Vision IOL Directions for Use

3. A lcon Data on File, TDOC-0056718. 18-Jun-2019

4. A lcon Vision LLC. ILE871-P001 clinical study report. Data on file. 2019

5. A lcon Vision LLC. ILE871-P001 second interim database lock. Data on file. 2022

A study conducted by Dr Armand Borovik found patients had good UCVA outcomes from distance to functional near. Source: Dr Armand Borovik and Dr Alan Flax, AUSCRS 2022.

The AcrySof IQ Vivity IOL first became available in Australia in 2021.

“SOME COLLEAGUES IN MY PRACTICE HAD NEVER

– DR ARMAND BOROVIK

Hospital optometrist role

A CLINICAL AND PERSONAL CHALLENGE

Early-career

optometrist CLAIRE ONG is pursuing her passion in paediatric care in a newly created role at the Women’s and Children’s Hospital in Adelaide.

Ms Claire Ong was nearing the end of her first full year in the workforce and keen to pursue her area of clinical interest when a former lecturer alerted her to an intriguing role.

The Women’s and Children’s Hospital in Adelaide was seeking an optometrist for a newly created role as part of a six-month pilot, commencing in January 2023. One of the main goals of the role is to reduce the current long waiting periods for tertiary eyecare.

“I’ve been wearing glasses since I was young, and I’ve always been interested in optometry in terms of what an optometrist can do and how they can problem-solve,” Ong says. “Working with children and learning to manage and diagnose very specific children’s eye problems really caught my interest while studying at Flinders.”

Ong was looking for ways to expand her skills in the paediatric optometry field when one of her former lecturers – Ms Jacqueline Warren from Flinders University – notified her about a new position.

“Jacqueline was involved in a similar pilot at Modbury Hospital a

couple of years ago. The Women’s and Children’s Hospital in Adelaide role was advertised on the ‘I Work for SA’ government website, and the job description was perfect, so I applied and here I am.”

When Insight spoke with Ong in January, mere weeks into the role, it was already proving to be a significant departure from her previous workplace experience.

An optical assistant at Specsavers for three-and-a-half years while studying at Flinders University, Ong then joined the company full time as a graduate optometrist in 2021 at its Norwood Place store.

She is now working at the Women’s and Children’s Hospital three days a week, and at Specsavers in Sefton Park two days. Ong is also undertaking the Australian College of Optometry’s Advanced Certificate in Children’s Vision this year to complement her hospital role.

“It is definitely a new experience going from corporate primary eyecare to a tertiary setting. It’s been a steep learning curve,” she

Optometrist Claire Ong has been exposed to uncommon paediatric pathology in her pilot role at the Women’s and Children’s Hospital in Adelaide.

says. “But it’s a good balance; Specsavers gives me the opportunity to serve the general community in primary eyecare and the hospital allows me to focus on a more targeted demographic in a tertiary care setting.”

It is the first time since the Modbury Hospital pilot that SA Health has introduced an optometrist into a hospital environment.

In 2020, Optometry Victoria South Australia backed a joint ophthalmology and optometry pilot at Modbury Hospital, costed at $50,000. Data from the pilot showed that 40-60% of the non-urgent waitlist could be effectively managed by optometrists in a collaborative care setting.

Warren, lead optometrist on the Modbury pilot, said that the pilot showed there is a solution.

“The Modbury pilot proved that wait times can be reduced with only a small amount of investment. It showed that by putting in place a system of collaborative care with optometrists, the number of patients unnecessarily waiting to see an ophthalmologist was reduced,” Warren said.

Similarly, the main goals for Ong’s role at the Women’s and Children’s Hospital are to reduce patient wait times, improve GP and community optometrist relationships, and set up outpatient clinics external from the hospital.

THE ROLE

As the sole optometrist at the Women’s and Children’s Hospital, Ong is part of a highly-qualified specialised team comprising consultant ophthalmologists, registrars, junior doctors, orthoptists and nurses.

Because the position is a six-month pilot and funding is not yet secured for a permanent position, the hospital’s ophthalmology department is collecting data about the kinds of patients she is seeing, so it can provide numerical proof of the value of having an optometrist on staff.

The Women’s and Children’s tertiary eyecare median waiting time is 15 months, with the longest patient waiting 45 months to be seen as of 30 September 2022, according to the hospital.

“Most new referrals come from community optometrists and GPs, but we also get a lot of referrals from within the hospital. For example, kids with systemic diseases that can have ocular effects, they get sent through the ophthalmology department in the hospital, so there’s a lot of patients to see,” Ong says.

Her role has been created to explore how optometrists can be incorporated into the ophthalmology department which is heavily centred around a multidisciplinary care approach. It’s intended to resolve the sticking points in the system.

“At the moment in the hospital, the patient is given a referral, an orthoptist will do the initial workup, and then when it’s time for refraction and ocular health, they’ll send that off to the registrar or the consultant [ophthalmologist],” Ong explains.

“But sometimes the referrals that get sent through, they’ve either been waiting a long time so the problem has resolved, or the referral

probably could have been sent through to a community optometrist.

“Therefore, some of the goals of incorporating an optometrist into the hospital are to see a higher volume of new patients so the department can start shaving down the waitlist and reduce the long wait times, and also increase the efficiency and the flow of the patient care within the hospital-based clinics and, being more resourceful of the consultants’ time.”

Ong described her role as having two main objectives.

“The first objective is clinical, so being able to increase the efficiency, and see some of the more routine patients or some of those patients that are an emergency walk-in. The second objective is more of an advocacy-based role. There was an emphasis in the job description about advocating for the optometrist to deliver high quality, evidence-based paediatric care and to assist the Women’s and Children’s Hospital in their pursuits to expand,” she says.

“At the moment, there’s talk of setting up an external outpatient clinic in the northern suburbs of Adelaide. There’s a lot of kids in the suburbs who need eyecare attention. Unfortunately, a lot of those children and their families don’t present to their appointment at the hospital due to the distances involved, and a general lack of understanding of how important eyecare is for young people. Hopefully taking the clinic to them will allow them to be seen, and also take the more routine or stable cases out of the hospital so that it frees up consultant time to see more new patients or more urgent cases.”

While the hospital is well-equipped with imaging technology and a slit lamp in every consulting room, Ong brings personal equipment to make her more comfortable assessing young patients.

As well as improving efficiency, she will be critical to improving the relationships between intersecting health professions.

“There’s an emphasis on creating more robust and more efficient interpersonal relationships between GPs and the hospital, community optometrists and the hospital, and GPs and optometrists, because the hospital ophthalmology department is a multidisciplinary care model designed to maximise patient outcomes, proving high quality evidence-based care to patients. However we recognise that GPs and optometrists in the community have first-rate skill sets – we want to further bridge the gap about how they can inter-refer to each other and how they can help and educate each other more.”

Ong says the Women’s and Children’s Hospital is envisioning more connection with community optometrists, educating them about what

“WE WORK IN A DYNAMIC SPACE WHERE CONSULTS HAVE TO BE ADAPTED TO SUIT VERY YOUNG CHILDREN, PATIENTS WITH DEVELOPMENTAL DELAYS, AND PHYSICAL DISABILITY.”

CLAIRE ONG WOMEN’S AND CHILDREN’S HOSPITAL

Women’s and Children’s Hospital in Adelaide.

the ophthalmology department does, and finding ways to empower optometrists to help them manage their own paediatric patients.

“Sometimes optometrists don’t feel comfortable managing a paediatric patient even though it is within their scope to manage them. But they don’t feel comfortable, or they feel like they don’t have the equipment to manage, so they send the patient to the hospital,” Ong says.

“Perhaps in the future, when we have a larger network of optometrists who feel confident and comfortable in managing paediatric patients, other optometrists can inter-refer to these paediatric optometrists to see whether hospital referral is necessary. It’s about promoting and empowering community optometrists to be more involved in paediatric care.”

For Ong, her new role is proving not only to be clinically challenging but personally challenging too, learning to find her way in a wider healthcare setting.

“It’s really highlighted to me the different ways the team work together. It’s a very symbiotic environment. In terms of an optometrist, and where we sit in the community, we’re quite used to working independently, but as a hospital department, we’re trying to figure out where an optometrist sits in terms of the end goal – increasing efficiency – and what kind of patients I’ll eventually see independently,” Ong says.

Perhaps the steepest part of her learning curve has been the exposure to a range of pathology she didn’t experience during her first year working at Specsavers.

“I’ve learned a great deal in a short time – there is a broad range of ocular pathology that affects a paediatric population that wouldn’t ordinarily be seen in the community because of ongoing management

within the hospital. One condition I’ve seen is retinopathy of prematurity (ROP). At the hospital, the ophthalmology consultants check the retinas of the premature babies because their retinas are underdeveloped. Sometimes premature babies can have blood vessels where they’re not supposed to be. Ophthalmologists then continue to monitor children that have been identified as having ROP, whether they require treatment or not, due to their high risk of developing future complications such as strabismus or high prescriptions,” Ong says.

“I have the opportunity to screen a lot of patients with juvenile idiopathic arthritis – this is particularly important because uveitis caused by this condition may be asymptomatic, and has detrimental consequences if left untreated. There is strabismus of many types caused by cranial nerve palsies and eye movement disorders that are rare to come by in community practice. Children with genetic disorders such as rare mitochondrial or muscular diseases also come through the clinic to be screened or managed for associated eye complications. There are children affected by retinoblastoma being managed, and ophthalmology play a role in co-managing those affected by brain tumours and other forms of cancer. We work in a dynamic space where consults have to be adapted to suit very young children, patients with developmental delays, and physical disability. It’s a very mixed bag with pathology and patient types that I wouldn’t normally see.”

Ong’s role within a hospital ophthalmology department is indicative of how optometry’s scope-of-practice has changed and become more integral to eye health – but she will have to wait until July to know if she will be a permanent member of the multidisciplinary team at the Women’s and Children’s.

PIVOTING TO A DISPENSING CAREER PAYS DIVIDENDS

DISPENSER DETAILS

Name: Chris Cunningham

Position: Senior optical dispenser

Location: Eyedentity, Carnegie & Elsternwick, Victoria

Years in industry: 8

1. What initially attracted you to a career in optical dispensing, and how did you enter the profession?

My career in optical dispensing started as a happy coincidence. Having left a busy job following a change of company ownership, I found myself longing for a change, but feeling limited as my skills and experience were exclusively in retail. One afternoon I was at a café, thumbing through the local paper when I saw an advertisement for a sales assistant. I thought I’d enquire and was surprised to learn it was with an optometrist. I’d worn glasses since I was a toddler, so I thought “why not?”. The optometrist saw value in my business management skills and customer service experience and took me on as a trainee.

2. What are your main career highlights?

Joining the team at Eyedentity was a career highlight. Eyedentity value you for who you are and invest in you both personally and professionally. They encouraged me to undertake the Australasian College of Optical Dispensing (ACOD) Cert IV in Optical Dispensing, even though I hadn’t sat an exam in 40 years. Graduating is a highlight and something I never thought possible. Prior to starting my dispensing career, I worked my way up to an area manager for a retail chain.

3. What are your strengths as an optical dispenser and what excites you about your job?

An optical dispenser is so much more than the person handing out glasses. I help people express their personality through frame selection, sometimes challenging their perceptions of what glasses need to be. How their glasses make them feel is just as important as improving their vision. I particularly get excited about helping children, and reassuring their parents. I recently had father come in with his six-month-old baby, devastated that she had to wear glasses. Initially I reassured him, but when it came to fitting the glasses, he became distressed at his baby’s cries. Then she opened her eyes and fell silent, with a huge smile as she saw her world in a new way. Dad was smiling too.

Chris Cunningham says helping people express their personality through frame selection excites her as a dispenser.

4. If you could give some advice to yourself at the beginning of your optical dispensing career, what would you say?

Be kind to yourself. There is so much to learn, and you don’t need to know it all on day one. It’s OK to ask questions and allow the team to support you.

5. What do you see as the key opportunities and challenges facing the future of optical dispensing in Australia?

Unlike optometrists, optical dispensers do not need to be registered or qualified, leading to inconsistent practices and people dispensing lenses with inadequate training and support. Ultimately this impacts patient outcomes and reflects poorly on the industry. Professional associations such as ODA have a huge role to play, both in uplifting the skills of current optical dispensers and in promoting it as a career.

6. How do you ensure your skills and knowledge stay up to date and current in such a fast-moving industry?

It’s important to keep in contact with your sales reps to be aware of new products, when they will be released and the training available to ensure you remain at the top of your game. Sales reps can also assist to broaden your knowledge through experiences, such as when CR Surfacing Laboratories hosted a day where we observed how lenses were made. ODA is also a great source of ongoing training through newsletters, library resources and webinars on everything from lenses and frames through to new industry practices.

7. Why did you become a member of Optical Dispensers Australia, and what value do you see in the organisation?

I saw great value in joining a professional association. ODA provides me with a community to discuss problems and find solutions or learn by following other discussions. I also get access to a host of tools I can use in our practice. I wouldn’t use an accountant that wasn’t a CPA, so why wouldn’t I join ODA?

8. What would you say to others thinking of joining Optical Dispensers Australia?

Stop thinking and join! There is a wealth of resources available to members that will benefit your patients, your practice and your career.

www.odamembers.com.au

Founded in 2022, OPTICAL DISPENSERS AUSTRALIA’S mission is to transform the optical dispensing industry by creating a community where optical dispensers and their associates can feel supported and inspired through education, events, networking, and employment advice, plus more. Visit:

Insight Dry Eye Directory returning in 2023

The October 2023 issue will feature the Insight Dry Eye Directory, Australia’s most comprehensive source for dry eye care.

Back by popular demand, this all-in-one resource is a valuable purchasing guide for practices, showcasing available Therapies and Diagnostics in Australia. It will also feature a comprehensive list of dedicated Dry Eye Clinics.

It’s FREE and EASY for you to list your products or services.

If you operate a dry eye clinic, or are a supplier of dry eye products, scan the QR code to organise you listing, or visit insightnews.com.au/dry-eye-directory-2023

Scan HERE to arrange your listing.

To amplify your product via advertising, contact Insight BDM Luke Ronca: 0402 718 081 or luke.ronca@primecreative.com.au

www.insightnews.com.au

WHEN AN EMERGENCY IS AN EMERGENCY

EFFICIENTLY RUN OPTICAL PRACTICES OFTEN RELY ON DISPENSERS TO DELINEATE WHEN A TRUE ‘OCULAR EMERGENCY’ PRESENTS. CHEDY KALACH OFFERS SOME TIPS TO CUT THROUGH THE NOISE.

Ocular emergencies tend to be rare in optometry practices, particularly in metropolitan practices. However, when one does occur, there needs to be clear guidelines and protocols.

Firstly, you need to consider whether the problem is with their eyes, glasses or contact lenses and whether it is an emergency. Some patients may think breaking their -0.50 DS in both eyes is an emergency, while others may have severe pain and not define it this way. It’s the role of the eyecare professional to triage and manage patients’ needs. To ensure this is performed most effectively, questions are the key. Having a good combination/flow chart of open and closed questions is vital.

Before going further, it’s a good reminder to look at your practice’s policies. The policy should be reviewed regularly, and staff updated on the procedures. It’s just like first aid – vital to have the knowledge and skills, but ideally not required to use it. The policy should cover the basics, like who handles the calls (receptionist, lab technician, optometrist, optical dispenser, practice manager), what to do if the relevant staff member is with a patient/ customer or at lunch, what questions need to be asked and how to record the information.

Also, it’s good to remember, S.O.A.P: S – subjective data is what the patient tells you, O – objective data is what you find, A –stands for Assessment and P – the plan for management or treatment.

Initially, you only have the subjective data from your patients, so the better you are at eliciting the right information the easier it will be. This step becomes even more important if you’re only able to communicate with them over the phone. Australian Family Physician Vol. 37, No. 7, July 2008, mentions assessment of ocular emergencies can be made difficult. However, a concise patient history, general observation and basic ocular tests can lead to a firm diagnosis and thereby appropriate management and referral.

When asking questions remember:

• not to draw conclusions and note information, not opinions

• do not draw to conclusions too quickly

• don’t diagnose

• don’t promise anything out of your control

• avoid technical words

• don’t divulge patient confidentiality

• don’t compare your practice’s skills to those of others

• remain calm and concise

A few simple questions to ask:

1. did it happen recently?

2. a ny sudden vision loss?

3. a ny pain?

These questions are a good start to figure if it is a true emergency. For example, if it just happened and there’s vision loss and extreme pain, that will suggest they’ll need to be seen by an ophthalmologist immediately. Furthermore, if they’re describing a situation that suggests a foreign body in the eye, they should be still seen the same day. However, if they are suggesting they need a form to be filled out, then that could wait till the next available appointment. Use judgement based on the information presented. After asking your questions, the patient essentially has one of five options:

1. take immediate action at home

2. go to hospital and ophthalmologist

3. c ome to the practice immediately

4. c ome to the practice within a day or so

5. b e referred to another type of specialist/professional

Before making any recommendations, ensure you have gathered all relevant information and recorded it correctly and liaised with the relevant protocols or personnel in your practice.

Some examples of very urgent situations that will require optometrist advice:

• su dden loss of all/part of the vision

• su dden double vision

• red eye

• pain

• su dden onset of flashes or floaters

• injury to the eye

It is important to delve deeper into their situation to propose the best plan. For example, if they have a red eye, that could be a symptom of a number disorders, like a sub-conjunctival haemorrhage, allergic conjunctivitis, corneal ulcers, corneal abrasion, iritis, scleritis, acute angle-closure glaucoma, entropion or trichiasis to name a few. As you can see from the list, some are less urgent than others and many will have other symptoms present to distinguish.

The purpose of triage is to sort of patients’ allocation of care or treatment according to the urgency of their need and not to diagnose.

ABOUT THE AUTHOR: CHEDY KALACH is a director of the Australasian College of Optical Dispensing. Since 2009 he has lectured throughout Australia and New Zealand across a variety of topics such as ophthalmic optics and business management. He is also the advisory board secretary of new dispensing network Optical Dispensers Australia.

“INITIALLY, YOU ONLY HAVE THE SUBJECTIVE DATA FROM YOUR PATIENTS, SO THE BETTER YOU ARE AT ELICITING THE RIGHT INFORMATION, THE EASIER IT WILL BE.”

Patients with vision loss or extreme pain will require immediate care from an ophthalmologist.

STUDENTS WILL BENEFIT FROM EXPANDING SERVICES AT LA TROBE EYE CLINIC

NOW ENTERING ITS THIRD YEAR, THE DIVERSE RANGE OF SERVICES PROVIDED BY THE LA TROBE EYE CLINIC GIVES ORTHOPTIC STUDENTS THE OPPORTUNITY TO ASSESS AND MANAGE A VARIETY OF PATIENTS, WRITES CLINIC COORDINATOR KYLIE GRAN.

he La Trobe Eye Clinic was established in 2020 in response to the COVID-19 pandemic. It was formed as a student-led clinic overseen by experienced orthoptists to allow successful completion of clinical placements whilst density limits were in place in eye clinics throughout Victoria and there were restrictions on travel interstate and

The La Trobe Eye Clinic initially partnered with the Royal Children’s Hospital, Melbourne, that were experiencing growing wait lists due to the COVID-19 pandemic. A co-managed service where eligible children are referred to the clinic for intermediary or ongoing care was created. The relationship continues to benefit patients and their families.

Since then, the clinic has created a relationship with local maternal and child health nurses. Maternal child health centres refer children most commonly for strabismus, ptosis, a failed vision screening, abnormal head posture, or where an underlying condition prevents a vision screening from being undertaken.

The clinic provides paediatric orthoptic eyecare by practitioners with extensive experience with children from newborns onwards. La Trobe also contributes to the continued education of maternal child health centres located in the north-eastern and eastern suburbs of Melbourne.

Over 90% of maternal and child health nurses when recently surveyed reported that families referred to the clinic were always satisfied with the clinical care provided. Families, in particular, appreciate the professional service delivered, the low cost of the service and ease of access.

More recently, a multidisciplinary clinic has been established which includes optometrists. This clinic is focused on co-managing refractive error in children, myopia progression and other paediatric ocular conditions. It also provides an opportunity for optometrists to be involved in the clinical education of orthoptic students.

In addition to providing specific co-management and collaborative clinics, the La Trobe Eye Clinic receives referrals from general practitioners, ophthalmologists and optometrists, primarily for children with ocular motility

disorders and amblyopia.

Adults are often referred for diplopia, strabismus, and abnormal ocular movements, with underlying conditions such as Graves ophthalmopathy, a neurogenic palsy or accommodative spasm.

With the diverse range of services provided by the La Trobe Eye Clinic, orthoptic students are given the opportunity to assess and manage a variety of patients. The clinic provides placements for orthoptic students throughout all years of the course, with final year consisting of an extended block placement. It offers an environment for students to observe, undertake a comprehensive clinical assessment and to consider their findings and apply evidence-based practice.

Patient appointments are structured to provide students with ample opportunity to practise their clinical skills and discuss cases with their fellow students and clinical educator. Through this approach the clinic helps students to consolidate their knowledge and put theory into practice. Motor and sensory disorders are often challenging subject areas for students, and hands-on experience is essential to their understanding and attainment of competencies in this sub-specialty and provides students with unique skill development that is vital for their careers, locally and internationally.

been a great way to put theory into practice with real life cases. I am grateful for the opportunity to improve my clinical skills in an environment where student learning is in focus,” final year orthoptic student Ms Kali Evans said.

As the La Trobe Eye Clinic enters its third year of operation, the university aims to expand on current services and to further diversify the clinical experience for orthoptic students. Areas of growth will include low vision services, and stroke assessment and rehabilitation. Furthermore, beyond clinical placement, the clinic will offer greater opportunities for undergraduate and post-graduate clinical research.

Overall, the clinic aims to provide high quality, affordable orthoptic services to children and adults in the community and seeks to be a valuable collaborator with the Royal Children’s Hospital and external eyecare practitioners including ophthalmologists and optometrists.

The La Trobe Eye Clinic is based within the Health Sciences Clinic at La Trobe University in Bundoora.

ORTHOPTICS AUSTRALIA strives for excellence in eye health care by promoting and advancing the discipline of orthoptics and by improving eye health care for patients in public hospitals, ophthalmology practices, and the wider community. Visit: orthoptics.org.au

"ADULTS ARE OFTEN REFERRED FOR DIPLOPIA, STRABISMUS, AND ABNORMAL OCULAR MOVEMENTS, WITH UNDERLYING CONDITIONS."

Final year student, Lauren Vernon, assessing a patient at La Trobe Eye Clinic.

STARTING A PRACTICE – PHASE 2

Following last month’s article on starting a practice, we move to the next phase to ensure your clinic begins on the right note. However, to proceed with certainty, we must assume the following preliminary tasks have been performed to the owner’s satisfaction:

• Business plan & feasibility study: Aspiring owner/s have carefully analysed all ‘foundation’ steps to ensure a clearly documented ‘road map’ of their plans for the venture, including financial elements, and new owner/s are confident the venture will provide high quality healthcare and reasonable rewards (profits);

• Business structure: A well-defined structure has been created and can be used to secure premises and for applications to finance lenders;

• Area/premises selection: Owners are comfortable with the demographics of their operating area. A suitable premises has been selected, occupancy terms and conditions negotiated, and it is ready to be fitted out;

• Finance approval: An application has been submitted to a lender and ‘in principle’, if not formal, approval received. You are now ready and eager to move to Phase Two comprising:

• Design: Owners, with design specialists, must define the ‘look and feel’ of the premises. Room design speaks volumes about patients’ perception of healthcare and personalised attention they will receive.

• Fit out & construction: Apart from overarching project plans to establish the new practice, this component

deserves meticulous planning as several interdependent suppliers, including council/complying development certificate (CDC) approval, must be coordinated to ensure timely completion. Roles of external service providers must be performed in sequential order to ensure no stone is left unturned.

• Mid-term review: A project plan 'progress review' should identify delays in deliverables or missed targets. Remedial action must be taken along with suitable modifications to plans. If the delay will impact any milestone dates, possibility of a start date deferral may require consideration.

• Testing to go live: Probably the most critical activity to ensure all equipment and facilities function smoothly and that staff are familiar with technological aspects of their roles.

• Business insurance: The business must be insured against events that may negatively impact operations, including relevant professional insurances.

• Recruitment: Engagement of administrative/clinical employees are undertaken in parallel with aforementioned activities, including execution of various employee contracts. This critical task requires time and effort involving job advertisements online and other media, receipt and screening of resumes, interview appointments, interviewing. To recruit appropriately, position descriptions must be prepared and management structures, administrative and clinical, finalised so recruiting personnel (agents or owners) fully understand the type of person required for each role.

• O ther (practice & business management) plans: These background actions are undertaken so staff have clear reference sources for performance of tasks/jobs and that all necessary tools are accessible e.g. budgets, monitoring, risk management, supplier management, staff induction and assessments, records management, policy & procedure manual, meetings and board/owners’ management plans.

OTHER (SET-UP):

• Practice furniture: Usually selected by owners, should be colour coordinated and compatible with general office layout and branding;

• Logo design & business documents: Design specialists should develop a pictorial theme that depicts the business on all documents.

• Website & marketing: Creation of a meaningful, informative website is a modern day essential. It may also take patient bookings and other communications. Professional web designers are usually engaged.

• Technology – hardware & software: There are various software applications for practices and familiarity with more than one will help selecting the most appropriate.

• Medic al equipment/furniture/supplies: A clinical person should review available options and select the most suitable.

• Security: Engagement of a security firm is straight forward but internal facilities must also be installed to secure premises and alert the security firm if required. Purchase of an office safe may be necessary.

• Signage: An important aspect, displaying the practice name, as it advertises services offered and professionals administering them.

• Telephone system: Usually arranged by contract with a reputable supplier but may require knowledge of a few to select from.

• Maintenance contracts: Usually provided by suppliers but require careful scrutiny to ensure adequate cover e.g. after hours.

• Waste disposal: A facility secured through an experienced provider.

• Miscellaneous: Toys and TV may be some items necessary for a well-equipped waiting room.

SUMMARY

This particular phase is key to the practice’s start-up, ongoing operations and success. Engagement of an experienced organisation/s is essential to achieve a professionally coordinated effort. Our next article will cover implementation of the “go live” phase.

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

IN PART TWO OF HER SERIES ON SETTING UP A CLINIC, HEALTH PRACTICE LEGAL EXPERT KAREN CROUCH PROVIDES A COMPREHENSIVE CHECKLIST, INCLUDING MANY ELEMENTS THAT OFTEN SLIP THROUGH THE CRACKS.

KAREN CROUCH

“ROOM DESIGN SPEAKS VOLUMES ABOUT PATIENTS’ PERCEPTION OF HEALTHCARE AND PERSONALISED ATTENTION THEY WILL RECEIVE.”

Signage that communicates the practice’s services and operating hours is an important part of the set-up process.

WHAT TO DO ABOUT MEDICARE

Obeen subsidised by the Australian Government since Medicare (then Medibank) was first introduced in 1975. This has long been considered a significant win for the profession, and for population eye health, given the limited number of non-medical professions able to access subsidies for patient care without a referral from a medical practitioner.

Medicare rebates for optometric services have been critical in ensuring a breadth of Australians have access to affordable primary eyecare, and are arguably central to the high uptake of optometric care in Australia; in 2022 alone, 10.6 million optometry consults were billed to Medicare, suggesting a return to the steady pre-COVID growth trajectory. This not only helps to enhance or maintain quality-of-life for people with correctable vision, but in supporting early detection and treatment of eye conditions, it reduces the overall burden on the healthcare system.

Unfortunately, for well over a decade there has been an increasing misalignment between the true costs of providing optometric care and the Medicare rebates for these services. Medicare rebates for optometry –and for many other clinical services – were frozen from November 2012 to November 2014, reduced by 5% in 2015 and then further frozen prior to the reintroduction of indexation (after advocacy from Optometry Australia) in 2019. As a result of all these factors, Medicare scheduled fees for optometric services are now less in actual dollar terms than they were in 2012.

The fact that reducing the real value

of Medicare rebates is not an issue that is unique to optometry is cold comfort. Despite this, we have seen optometry retain some of the highest bulk-billing rates of any profession; they consistently hover around 94%. This is partly historical – prior to the removal of the cap on fees, optometrists could charge under Medicare after extensive association lobbying in 2015, and it was often considered that there were limited benefits in accepting the additional administrative burden to charge a marginally higher fee. Since the fee cap removal, bulk-billing rates have reduced only minimally, due to the increased level of competition in the sector and cross-subsidisation of clinical care with sales of glasses and contact lenses.

The combination of inadequate rebates, high bulk-billing rates and a (necessary) reliance on retail to cross-subsidise clinical care has multiple impacts. Whilst bulk-billing rates remain incredibly high, the likelihood of government recognising a need to increase rebates or employ fairer indexation is low. This system also builds in a disincentive to provide too many services not likely to be associated with a prescription for glasses or contact lenses, as it’s simply not a financially viable option when bulk-billing. This is problematic when, due to an ageing population and an over-burdened tertiary sector, the need to support optometrists to provide greater volumes of complex care and care for chronic eye diseases is increasing.

The current funding approach is not structured to support a readily accessible and robust primary eyecare system with optometrists working to their fullness of scope, and into the future. Optometry Australia will continue to call on the government to undertake a comprehensive, independent review of Medicare scheduled fees for optometric items, and join the call from a breadth of health professional associations for fairer Medicare rebates.

However, as a sector we also need to begin exploring alternate funding models, ones that also support optometrists to work to their fullness of scope and provide ongoing management of complex, and often chronic, presentations.

Across the country there are dotted,

costs remain an obstacle to accessing care.

It is encouraging to see the government recognising the limitations of the fee-for-service Medicare model, and exploring blended funding models that complement fee-for-service with other approaches. However, at this point, this conversation is primarily focused on GP care and supporting GP-led care with allied health care.

As a sector, it’s vital that we begin exploring what future funding models for a sustainable primary eyecare system look like. This should not mean abandoning Medicare – arguably the fee-for-service model, if funded adequately, remains a good fit for many presentations to optometry. But it should mean lifting our eyes from Medicare as the only possible approach to funding eyecare.

Name: Skye Cappuccio

Qualifications: BA, PgradDPH, GAICD

Affiliations: Optometry Australia

Position: Interim CEO

Location: Canberra

Years in industry: 10+ years

ARGUABLY THE FEE-FOR-SERVICE MODEL, IF FUNDED ADEQUATELY, REMAINS A GOOD FIT FOR MANY PRESENTATIONS TO OPTOMETRY.

2023 CALENDAR

APRIL

AUSTRALIAN VISION CONVENTION

Gold Coast, Australia

1 – 2 April

events@optometryqldnt.org.au

SILMO SINGAPORE

Singapore

12 – 14 April www.silmosingapore.com

ARVO 2023

New Orleans, US 23 – 27 April arvo.org/annual-meeting

OPTICAL DISPENSERS

AUSTRALIA CONFERENCE

Sydney, Australia

28 – 29 April odamembers.com.au/ odaconference

MAY

ANZSRS MEETING

Melbourne, Australia

20 – 21 May ranzco.edu/events/2023

SUPER SATURDAY –OPTOMETRY NSW/ACT

Sydney, Australia

21 May optometry.org.au/about-us/ our-organisation/optometry-nsw-act

NATIONAL ABORIGINAL AND TORRES STRAIT ISLANDER EYE HEALTH CONFERENCE

Sydney, Australia

24 – 26 May mspgh.unimelb.edu.au

JUNE

ASO EXPO 2023

Sydney, Australia

2 – 4 June asoeye.org

MYOPIA PROGRESSION IN CHILDREN CONFERENCE

Sydney, Australia 10 June myopiaaustralia.com.au

WORLD GLAUCOMA CONGRESS

Rome, Italy

28 June – 1 July worldglaucomacongress.org

JULY

AUSCRS 2023

Port Douglas, Australia

26 – 29 July auscrs.org.au/2023-conference

AUGUST

WORLD CONFERENCE ON OPHTHALMOLOGY & EYECARE

Rome, Italy

21 – 23 August eyecare.thepeopleevents.com

SEPTEMBER

ORTHOKERATOLOGY SOCIETY OF OCEANIA CONFERENCE

Gold Coast, Australia

1 – 3 September www.facebook.com/OrthoKSO/

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

O=MEGA23 & WORLD CONGRESS OF OPTOMETRY

Melbourne, Australia

8 – 10 September omega-event.org

EUROPEAN SOCIETY OF CATARACT & REFRACTIVE SURGEONS CONGRESS

Vienna, Austria

8 – 12 September congress.escrs.org/

SILMO PARIS

Paris, France

29 September – 2 October event.silmoparis.com/2023/en/

OCTOBER

RANZCO SCIENTIFIC CONGRESS

Perth, Australia

20 – 24 October ranzco.edu/events

Exciting Optometrist opportunity – Specsavers Porirua (Wellington), NZ

Fantastic opportunity for an optometrist to join a fun team. Porirua is a great location, in which you will see lots of pathology and paediatrics, whilst only being a quick trip to the bustling Wellington CBD. You will be able to utilise some very exciting equipment including an OCT. This is a chance to really develop your skills, work in a very supportive team including 2 experienced partners. So, if you want to know more about the further equipment and lucrative salary package, please reach out.

Optometrist Joint Venture Partnership Opportunity – Kings Meadows, TAS

We are currently on the lookout for expressions of interest for an Optometrist to join Specsavers as a Joint Venture Partner in our brand-new store opening in 2023 in Kings Meadows, Tasmania.

King’s Meadows is a suburb in the south of Launceston, Tasmania. The suburb offers a central location and is only a short 10-minute drive from the city centre. It is a well-developed suburb with a greater number of shops than any other suburb within Launceston making it the largest commercial district in Launceston outside of the CBD. It also has the largest indoor shopping centre within Launceston.

$30k Optometrist sign-on bonus to go with a Friend!

Looking for a lifestyle change but don’t want to make the move on your own? Specsavers has some

amazing opportunities across Australia to help you and a friend try somewhere new!

We can offer a $15k sign on bonus each, opportunities to work with market leading technology – including OCT free for EVERY patient and excellent career development opportunities –such as Pathway to Partnership, outreach programs and mentorships. Also offering competitive salaries with loads of extras, flexible rosters and can proudly say that Specsavers has been Great Place to Work certified for 3 years in a row.

Graduate program across Australia and New Zealand

Looking at starting your career with a dedicated mentor and graduate team to support you in your first steps? Specsavers are the largest employer of Graduate Optometrists across Australia and New Zealand and we have continued to develop our comprehensive two-year Graduate Program providing a support network and structured program to assist you in your development.

The Graduate Recruitment Team have competitive graduate packages for new graduates to join our teams in QLD, NT, and WA, along with generous regional salary and relocation packages.

LET’S TALK!

In a few short years, Specsavers has achieved market leadership in Australia and New Zealand with more people choosing to have their eyes tested and buy their prescription eyewear from Specsavers than any other optometrist. To learn more about these roles, or to put your hand up for other roles as they emerge, please contact us today:

Joint Venture Partnership opportunities enquiries: Kimberley Forbes on +61 (0) 429 566 846 or E kimberley.forbes@specsavers.com

Australia Optometrist employment enquiries: Marie Stewart – Recruitment Consultant marie.stewart@specsavers.com or 0408 084 134

Locum employment enquiries: Matthew Cooney matthew.cooney@specsavers.com or 0447 276 483

New Zealand employment enquiries: Chris Rickard –Recruitment Consultant chris.rickard@specsavers.com or 0275 795 499

Graduate employment enquiries: apac.graduateteam@specsavers.com

also the National President of Optometry Australia and the National Vice President of the Cornea and Contact Lens Society of Australia. She started her independent optometry practices, theeyecarecompany, in 2005, before later partnering with George & Matilda Eyecare where she also served as the company's Head of Professional Services.

Oculo co-founder and former CEO Dr Kate Taylor is starting a new position within iCare as Vice President Strategy and Business Development. Finnish ophthalmic diagnostics company Revenio –which supplies ophthalmic devices under the iCare brand – acquired Oculo in 2021. Taylor commenced as Vice President Eye Care Solutions at iCare in 2021.

Sales Consultant. The company says his extensive knowledge within the optical wholesale and retail markets, along with ongoing qualifications in optical dispensing, have him well-positioned to support and grow his Queensland customers’ businesses.

ex-practice manager, is well-versed in the needs of independent practices. His experience includes roles in regional operations at Big W Optical and three years as Head of Product and Partnerships at Bupa.

dispenser since 1988, he’s worked in corporate roles and independent practices during this time. He’s spent the past 18 years as a two-practice business owner with his wife, also a dispenser. He hopes to provide an experienced, relevant opinion to grow and support ODA and its members.

Your MIGS Choice Matters

The rst and only MIGS device to report clinical results from a pivotal trial at 5 years.1,2

1. Ahmed I, et al; HORIZON Investigators. Long-term Outcomes from the HORIZON Randomized Trial for a Schlemm’s Canal Microstent in Combination Cataract and Glaucoma Surgery. https://www.aaojournal.org/article/S0161-6420(22)00160-9/fulltext

2. Safety & Effectiveness Study of the Hydrus Microstent for Lowering IOP in Glaucoma Patients. ClinTrials.gov (NCT01539239)

Please refer to product direction for use for list of indications, contraindications and warnings. © 2023 Alcon Inc. Alcon Laboratories (Australia) Pty. Ltd. ABN 88 000 740 830. Phone: 1800 224 153. Auckland, New Zealand NZBN 9429047030480 Phone: 0800 809 189. ANZ-HDM-2300010