Insight June 2020 by Prime Creative Media

INSIGHT JUNE

2020

AUSTRALIAâ&#x20AC;&#x2122;S LEADING OPHTHALMIC MAGAZINE SINCE 1975

We're here for you!

Practice appointment books filling fast after government loosens restrictions.

COMPETING IN A LEAGUE OF THER OWN Eye and vision specialists discuss their work to help elite Aussie athletes gain an edge.

6/05/2020 3:52:59 PM

OPTOMETRISTS EMERGE FROM COVID CRISIS

June Front cover - We're here for you. 1.indd 1

WHERE ARE WE WITH GLAUCOMA SURGERY?

Re-defining the term MIGS and an exploration of current surgical interventions.

INSIGHT JUNE

2020

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

OPTOMETRISTS EMBARK ON ROAD TO RECOVERY AFTER EASING OF LOCKDOWN RESTRICTIONS

A sense of relief is reverberating across the eyecare sector as practices that were mothballed or reduced to urgent care at the peak of COVID-19 return to prepandemic levels of care. Following a challenging six-week period spanning the month of April and first week of May, corporate and independent optometry providers have reopened to a surge in appointment bookings in recent weeks. Purchasing data of lenses, contact lenses, frames and sunglasses are trending in a positive direction. Meanwhile, eyecare providers face a challenging task of prioritising a patient backlog and continuing the care of vulnerable patients without an approved Medicare item for

telehealth. They will have to do so while implementing infection controls and adhering to the relevant restrictions in each state and territory. Optometry Australia (OA) CEO Ms Lyn Brodie said many practices that closed or provided only urgent care are now starting to offer expanded services after the government began easing restrictions on 8 May. “We understand that as of 19 May there is no jurisdiction with restrictions that prevent practices, including those with a retail arm, offering extended patient care, provided social distancing and infection control requirements are appropriately addressed,” she said. “I think it’s fair to say that there is relief across the sector that

other colleagues in April, started to re-open last month.

Optometrists are returning to provide the full range of services.

pandemic restrictions are easing and that they can start to return to providing all the primary eye and vision care services that their communities need.” Mr Steven Johnston is the CEO of Australia’s largest independent optometry network ProVision. He told Insight several of its 460 members practices that closed in March, and were later joined by

“April was a low point and it appears to us through appointment data, that patients are starting to book appointments again in a positive indication that they want to use member services. This is reinforced by purchases data which indicates a return to ‘normality’, albeit slowly,” he said at the time of writing. “We expect the recovery to pick up some pace now that restrictions have been eased a little. As long as practices follow the appropriate protocols, we are encouraging members to let their patients know that they are open for business again.” continued page 6

TELEHEALTH INACTION FRUSTRATES SECTOR Optometry providers have expressed disappointment over a lack of progress to introduce Medicare coverage for telehealth services during COVID-19, after hoping the measure would have been in place many weeks ago. Since late March, Optometry Australia (OA), Specsavers, Luxottica and Diabetes Australia have lobbied for telehealth-related modifications to item numbers 10916 and 10918. However, at the time of writing this proposal remained under government consideration. “We are disappointed there is not yet Medicare support for telehealth services provided by optometrists and had hoped Medicare coverage

for some optometry consultations provided by telehealth would have been introduced a number of weeks ago,” Ms Lyn Brodie, CEO of OA, told Insight on 5 May. She said tele-optometry enabled access to necessary eyecare, while minimising infection risks associated with travel. It could be undertaken in a manner to support ongoing chronic disease management and provide effective triage of new or acute presentations. “Health officials have indicated in public forums they have concerns that optometric care cannot be effectively provided via teleheath. We have sought to ensure the department understands how

optometrists can provide care via telehealth,” Brodie said. “The Medicare items that Optometry Australia, and the optometry sector, have sought to be permitted to be billed when provided via telehealth, attract relatively low rebates, and we do not expect that total cost associated with billing these items for telehealth consults would be high, particularly in relation to billing of optometry items outside the pandemic crisis.” Specsavers director of communications Mr Charles Hornor said the sector presented a clear battery of tests that could be performed under the proposed continued page 6

TELEHEALTH FORGES NEW PATH FOR PATIENT MANAGEMENT The COVID-19 crisis has spurred a telehealth revolution that’s helping mitigate disruption for practitioners and patients. Leading professionals share their telehealth tips and discuss why the technology might be here to stay.

page 37

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UPFRONT Just as Insight went to print, RANZCO announced this year’s postponed 52nd Annual Scientific Congress will now take place between 19-23 November 2021, at the Brisbane Convention & Exhibition Centre. The college revealed the new event details, alongside an extensive list of local and international speakers. RANZCO postponed this year’s congress due to the COVID-19 pandemic. It explored turning the event into a virtual meeting, however this was ruled out due to a range of factors.

WEIRD

IN OTHER NEWS, ProVision is allowing Optometry Australia-member independent practices access to the country’s largest frames database, ProSupply. The system features 24,000 preferred supplier frames complete with frame imagery, specifications and suggested retail pricing. Practices can also search for frames using key criteria including brand, frame type, construction, material and shape. ProVision CEO Mr Steven Johnston said: “We recognise just about everyone in the independent optometry ecosystem or supply chain is struggling right now, so for three months we will be extending access to ProSupply Guest, for all independent optometrists

who are Optometry Australia members.” FINALLY, national icon and Macular Disease Foundation Australia patron Ms Ita Buttrose issued a passionate plea to macular disease patients during COVID-19. “I’m concerned many people who need urgent, sight-saving eye injections for diseases like wet AMD and diabetic macular edema are not keeping their appointments with their ophthalmologists because of fear and confusion around public health protocols." Her comments coincided with the Macula Month awareness campaign in May, and followed reports from some ophthalmologists that up to a third of patients were cancelling appointments.

WACKY

A US ophthalmologist has done away with telehealth and a limited care model and set up a ‘drive through’ eye clinic amid COVID-19. Dr Parisa Farhi was concerned about the risk of infection, as well as the impact of missed glaucoma check-ups on patients, so she pitched a tent in the clinic’s car park to continue intraocular pressure tests.

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WONDERFUL

An optician came to the rescue of a UK nurse who couldn’t return to work on the COVID-19 frontline due to her broken spectacles. The nurse was also selfisolating as a precaution and couldn’t drop her glasses for repair. Val Hughes Optometrists in Lostock Hall fetched the spectacles from her house and returned them fixed within 45 minutes.

Published by:

Publisher Christine Clancy

STAT

A toxic plant that causes nasty blisters, boils and even blindness has been found growing in parts of Bristol, UK. The city is one of the many hotspots for Giant Hogweed, which grows along riverbanks. Several children have been hospitalised with third-degree burns due to the plant, with warnings its sap can cause permanent damage if it comes into contact with the eye. n

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SPORTS VISION In Australia, 13% of the population has been sidelined from sport due to eyesight issues, according to Optometry Australia’s The 2020 Vision Index. Full report page 27.

Art Director Blake Storey Graphic Design Jo De Bono

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INSIGHT June 2020 5

NEWS

PRACTICES ADOPT STRICT HYGIENE MEASURES continued from page 3

ProVision has advised members to prepare for some unpredictability because "it will be unlikely that we see a linear trend line emerge over the coming months”, Johnston added.

‘PLAYING CATCH UP’ Meanwhile, Specsavers optometry director for Australia and New Zealand Dr Ben Ashby said, since the introduction of Level 3 restrictions in late March, the majority of its 350 Australian optical stores remained open for urgent eyecare, and essential dispensing care and repairs. “Fast forward to now (13 May) and we are in the process of standing up significant numbers of team members under a modified practice environment that strictly follows health department guidelines,” Ashby said. “Having now opened our appointment books to customers we are seeing a very positive response from local communities looking to catch up with their eyecare needs, even before we re-start our own recall routines.” Ashby said it was important to return to business in a way that is sustainable and adaptable should tighter restrictions return, while also accounting for people requiring prioritised care.

“We will be recalling patients with diabetes who have missed their original appointment as a matter of urgency because we do need to make sure they receive their regular diabetes eye check in good time. Similarly, we need to manage those with other eye conditions such as glaucoma while also factoring in bookings for all of the day-to-day cases where unusual or previously unknown conditions often present.” Specsavers has been reviewing historical data as a reminder of typical levels of disease detection and referral. In a typical month, its optometrists make almost 3,500 urgent and more than 13,000 non-urgent referrals. “Clearly, these sorts of numbers indicate the likelihood of serious vision loss due to the lockdown period and we are consequently mindful of the need to play catch-up within a safe and hygienic practice environment,” Ashby said.

“In general, our practices are screening all patients before they are able to confirm an appointment. Ensuring that patients meet the current government health guidelines.

“WE ARE ALSO SEEING MOST OF OUR PRACTICES EXPANDING THEIR OPERATING HOURS AGAIN, SOME BACK TO THE PRECOVID-19 OPENING TIMES” PHILIP ROSE, EYECARE PLUS

“Social distancing protocols and limiting the number of people allowed in the practice as well as disinfecting all equipment and frames between patients are obvious standards that all practices should be adhering to.” Mr Peter Murphy, OPSM director of eyecare and community for Australia and New Zealand, said throughout May OPSM and Laubman & Pank stores would progressively re-open, in line with the easing of restrictions across Australia, and the lifting of lockdown measures in New Zealand. “We are very proud of how well our teams have implemented and adopted a number of enhancements to our customer journey, including more options for our customers to gain access to eyecare needs such as our tele-optometry program, that has proven successful during the pandemic,” he said.

Eyecare Plus national business development manager Mr Philip Rose said some practices within the independent network were seeing more patients, particularly in regional locations.

“As part of these re-openings, we will keep implementing stringent hygiene practices, and will incorporate updated hygiene protocols as part of all our eye consultations.” n

“We are also seeing most of our practices expanding their operating hours again, some back to the pre-COVID-19 opening times,” he said.

HEALTH OFFICIALS STILL CONSIDERING COVERAGE continued from page 3

Medicare item numbers. “We have a fantastic industry-inclusive platform in Oculo that is ready to go for telehealth and there is no real work required to convert the two item numbers for telehealth usage,” he said. Looking ahead, Hornor said it is important to note the patient backlog, including people with diabetes who have fallen behind on their regular checks or patients with other conditions and anxieties that could have been managed via telehealth from the end of March. In April, Luxottica-owned OPSM launched tele-optometry in Australia and decided to offer it free of charge, despite the lack of Medicare coverage.

INSIGHT June 2020

“We have already seen some instances of serious eye health conditions where our optometrists have been able to intervene and saved someone’s sight thanks to a remote video consultation,” OPSM’s director of eyecare and community for Australia and New Zealand Mr Peter Murphy said. “In the long term, even after the current health emergency has subsided, we see tele-optometry and telehealth remaining a crucial solution for those whom maybe homebound, or unable to visit one of our stores for a variety of reasons, and hence we expect the conversations on this topic to continue.”

DEPARTMENT RESPONDS Asked about the lack of progress, a

Department of Health spokesperson said the telehealth items announced to date were implemented quickly because they mirrored the clinical requirements for existing face-to-face items.

Lyn Brodie, OA.

The department is now considering whether to introduce additional telehealth services where mirroring existing item numbers isn’t possible, because the MBS item contains clinical elements requiring face-to-face contact. “The department is engaging with representatives of the relevant professions, including optometry, to discuss what services can be safely and appropriately delivered by telehealth," the spokesperson said. "The department will then provide advice to the government." n

NEWS

RANZCO URGES CAUTION IN ELECTIVE SURGERY RETURN RANZCO has provided guidance for a welcomed return to elective surgery, cautioning that operating lists and through-put will be restricted by social distancing and infective precautions. The college published a new resource titled Return to elective surgery – guidance during COVID-19, which is designed to help ophthalmologists navigate the resumption of elective eye surgery after it was suspended in April. The initial wave of elective surgeries reinstated after Anzac Day weekend were all Category 2 and ‘important’ Category 3 surgeries. They include cataracts and eye procedures, as well as IVF, joint replacement, breast reconstruction and dental procedures.

questionnaire should occur, as well as body temperature testing on arrival. Patients that screen positive for at-risk characteristics must be sent home and referred for COVID-19 testing.

It was estimated the staged reintroduction would see one in four cancelled operating lists reopen.

The guide also says patients should wear surgical masks and maintain a distance of 1.5m from other patients at all stages through the preoperative and post-operative process.

According to RANZCO, recommencement of elective surgery must be performed with care and recognition there is an ongoing risk of community spread of COVID-19.

Additionally, the college advises all staff should consider wearing surgical masks, maintain social distancing and limit total patient contact to no more than 15 minutes.

“This cannot yet be a return to ‘business as usual’ and lists and patient through-put will inevitably be limited by the necessity to maintain social distancing and infective precautions,” the college stated.

Theatre staff are to wear surgical masks and standard person protective equipment (PPE). It says eye protection is recommended but at the surgeon’s discretion due to a compromised view through the operating microscope.

Australian Society of Ophthalmologists president Dr Peter Sumich also welcomed a responsible return to elective surgery.

Patients known to have risk factors or symptoms, as well as those who are COVID-positive, should be referred for testing and surgery deferred – unless it is emergent and cannot wait for medical reasons.

“I think all the private surgeries have played their role in standing down while the emergency was on,” he said. “But we are available to step down again if it’s needed.” RANZCO's return to surgery guide advises how ophthalmologists should handle asymptomatic patients with no known symptoms, as well as confirmed or suspected cases. The college advises surgery centres to telephone screen and brief patients prior to surgery. Patients deemed at-risk must be referred for COVID-19 testing and have their surgery deferred unless it is ‘emergent’. Patients should also be instructed not to present for surgery if they develop any relevant fever or respiratory symptoms. The guide states that screening by

“For at risk and COVID-positive patients undergoing surgery before they are cleared, PPE should be worn according to the Australian Government Department of Health Interim recommendations for the use of PPE during hospital care of people with COVID-19,” RANZCO stated. “At this stage, phacoemulsification, vitrectomy surgery and laser refractive surgery should be considered to have the potential to be aerosol generating procedures and lacrimal surgery is considered high risk. Contact and airborne precautions are recommended with long-sleeved gown, fit-checked P2/ N95 respirator, face shield or goggles and gloves.” n

IN BRIEF n “ALL PRIVATE SURGERIES HAVE PLAYED THEIR ROLE IN STANDING DOWN WHILE THE EMERGENCY WAS ON. BUT WE ARE AVAILABLE TO STEP DOWN AGAIN IF IT’S NEEDED" PETER SUMICH, ASO

RANZCO ELECTION

The RANZCO Council will vote on the appointment of a new president-elect on 13 June. Following the vote, the successful candidate will shadow the current president Associate Professor Heather Mack until October before taking over the lead role. The term is for two years and the president holds the position of chair of the RANZCO Board. The handover of presidents traditionally occurs at annual scientific congress, however that has been postponed until November 2021. There will be a virtual handover with the ceremonial aspects to occur in 2021. Nominations were open to all RANZCO Fellows and closed on 24 May.

FEE RELIEF

The Australasian College of Optical Dispensing (ACOD) is offering fee relief in the wake of the COVID-19 crisis. Mr James Gibbins, director and senior teacher, said it is available to all existing students and special flexible arrangements can be made for employers considering enrolling students. The initiative was announced on 30 March. “ACOD recognises that a period of self-isolation could actually be used very productively by students to make wonderful progress with their online studies, and we want to encourage this without them having the added burden of needing to make their next payment. Therefore, students or their employers are invited to contact the ACOD office to formalise fee relief and time extension.”

LUCENTIS BIOSIMILAR

Bausch + Lomb has agreed to commercialise Lucentis (ranibizumab) biosimilar candidate Xlucane in the US and Canada. The deal is with Stada Arzneimittel, Germany, and its Swedish partner company Xbrane, which are jointly responsible for finalising development. Bausch + Lomb will undertake the sales, marketing and other commercialisation efforts. “Bausch + Lomb has a very strong brand recognition and reputation amongst ophthalmologists and an existing sales infrastructure to leverage. We are excited to finalise the final steps towards marketing approval and bring the product to patients with severe eye diseases in dire need for cost-efficient VEGF-A inhibitors,” Mr Martin Amark, CEO of Xbrane Biopharma, said.

INSIGHT June 2020 7

NEWS

FEARS INDIGENOUS PATIENTS WILL BE AT THE END OF LONG WAITING LISTS AS SURGERY RESUMES "FOLLOWING THIS PANDEMIC THERE WILL BE A PERIOD OF EVEN GREATER BACKLOG OF DEMAND FOR PATIENTS FOR EYECARE, SO WE ARE CONCERNED ABOUT LOSING TRACTION" ANGUS TURNER, OUTBACK VISION Dr Kris Rallah-Baker says timely care is key to maintaining a patient's independence and mobility.

The Fred Hollows Foundation and Australia’s only Indigenous ophthalmologist are calling for governments to prioritise Aboriginal and Torres Strait Islander eye health amid concerns over a cataract backlog caused by a suspension of elective surgeries. The alert comes as Lions Outback Vision warned against losing traction on 'Close the Gep' efforts after COVID-19 curtailed its key services in Western Australia, leaving it to treat only urgent cases through costly chartered flights. Fred Hollows Indigenous Australia program manager Mr Shaun Tatipata and Dr Kris Rallah-Baker say the COVID-19 crisis has highlighted the need to further address the existing eye health disparity between the Indigenous and nonIndigenous populations. While it’s encouraging that some elective procedures, including cataract surgery, can resume, Tatipata said Australia’s First Peoples were at risk of being at the end of already long waiting lists. "We supported the Australian Government’s decision to put non-urgent surgery on hold as COVID-19 escalated. We also welcome their decision to recommence elective surgery now that the curve has flattened,” he said. “This presents an opportunity to all federal, state and territory governments and private hospital providers to partner to prioritise closing the gap in elective surgery needs for Aboriginal and Torres Strait Islander Peoples, particularly cataract surgery.” Tatipata said The Fred Hollows Foundation was calling on the government

INSIGHT June 2020

to ensure equity when it comes to cataract surgery and allow the Indigenous population to be among the first to access the procedure. “This pandemic has been incredibly tough for everyone. It has been particularly hard on people who have life-limiting health conditions but can’t access the surgery to fix it,” he added. “The foundation looks forward to working with partners to restore sight among our nation’s First Peoples and recommencing work to clear the cataract backlog with the government and our partners.” Rallah-Baker, Australia’s first and only Indigenous ophthalmologist and president of the Australian Indigenous Doctors’ Association, supported the message. He said the COVID-19 crisis highlighted the need to address both the health disparities and social determinants of health for Aboriginal and Torres Strait Islander Peoples. “Timely ophthalmic care and in particular cataract surgery is key to maintaining an individual’s independence and mobility," he said. "Australia’s Indigenous Peoples must be appropriately triaged and included in our nation’s return to normal operations."

the spread of the virus to vulnerable communities restricted the organisation’s ‘hub and spoke’ model for dealing with dispersed populations over vast geographic areas in WA. During the elective surgery suspension, Dr Angus Turner, McCusker Director of Lions Outback Vision, part of the Lions Eye Institute, said the biggest challenge was the continuation of vision-restoring intravitreal injections for retinal diseases. He said these were managed with careful triage and prioritisation, and accessed via chartered flights to communities across the Kimberley and Pilbara regions. “We have to make sure these patients don’t experience any significant vision deterioration,” Turner said. “For many country patients, the injections allow them to continue driving and keep a job – they are very well-attended and patients are more compliant with this form of treatment because of the clear benefits.” Overall, Turner said, for a population that has a higher burden of vision loss and blindness, there needed to be a bolstered post-pandemic effort to ensure the sector does not lose ground on its pursuit of eye health parity. Funding to support aviation will be a critical part in enabling the efficient provision of eyecare across a vast geographic area. “We were already on the backfoot in many regions, trying to keep up with the burden of disease, and the maldistribution of ophthalmologists in the regions in Australia, so following this pandemic there will be a period of even greater backlog of demand for patients for eyecare, so we are concerned about losing traction with the efforts to close the gap,” he said. n

SIGHT-SAVING FLIGHTS Meanwhile, Lions Outback Vision was concerned about losing ground on its Indigenous eye health efforts after the COVID-19 emergency curtailed its Vision Van and Visiting Optometrist services, leaving the organisation to treat only urgent cases through costly chartered plane flights. Strict intra-regional barriers to prevent

Shaun Tatipata, The Fred Hollows Foundation.

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NEWS

ELLEX SHAREHOLDERS APPROVE LUMIBIRD SALE; COMPANY TO OPERATE UNDER NEW NAME Adelaide-based Ellex Medical Lasers shareholders have backed the $100 million sale of the lasers and ultrasound business to Lumibird Group. They also agreed to re-name the company Nova Eye Medical, forming a debtfree entity with a long-term focus on glaucoma therapies. At an extraordinary general meeting in April, shareholders voted in favour of three resolutions that included the return of approximately $61 million of sale proceeds back to them. The remaining $39 million will fund the expansion of the company’s two remaining business segments comprising the iTrack glaucoma therapy and 2RT for intermediate age-related macular degeneration (iAMD), as well as tax liabilities arising from the transaction, closing adjustments and costs associated with the sale. The Ellex brand will transfer to Lumibird, a French laser technology giant that will also acquire Ellex’s production site in Adelaide and commercial subsidiaries

to its glaucoma device sales channel.

in Australia, Japan, the US, France and Germany. Subsequently, Ellex shareholders approved a change of name to Nova Eye Medical, which will operate under a new Australian Securities Exchange ticker ‘EYE’. The entity will be debt-free with approximately $21 million in cash, including $2 million held in an escrow account for 12 months. Ellex chairman Mr Victor Previn said the new ticker represented a continued focus on eye disease. “The primary focus of Nova Eye Medical Limited will be on glaucoma disease via the iTrack business, with manufacturing in Fremont, California and a sales network across the US, Europe and Asia Pacific,” he said. “This segment generated first half product sales of $6.6 million and an [earnings before interest, taxes, depreciation, and amortisation (EBITDA)] loss of $1.7 million.” Previn said the company was now assessing potential acquisitions to add

“This activity is expected to result in at least one transaction during the 2020 financial year,” he said.

“LONGER TERM, THE PLAN IS TO BUILD A PORTFOLIO OF PRODUCTS WITHIN THE HIGH GROWTH GLAUCOMA CONSUMABLE DEVICE MARKET" VICTOR PREVIN, ELLEX

“Longer term, the plan is to build a portfolio of products within the high growth glaucoma consumable device market, while carefully investing into the business to drive revenue growth. “Both parties continue to work diligently to finalise the necessary steps for the transaction to complete. There are a number of conditions outstanding and Ellex is working towards achieving the conditions, but there is no guarantee at this time that they will be achieved.” Nova Eye also retains the proprietary 2RT laser technology as a therapy for patients with iAMD. This segment generated first half sales of $800,000 and an EBITDA loss of $200,000. Prior to the sale, the Ellex board engaged an independent expert who provided a report to shareholders stating the transaction with Lumibird was fair and reasonable. n

AUSTRALIA'S MOST TRUSTED EYECARE BRANDS REVEALED Specsavers, OPSM and Bausch + Lomb have featured in the eyecare categories of the 2020 Australian Trusted Brands Survey, while Guide Dogs Australia emerged as the top charity. Research company Catalyst Research conducted the independent survey for the Australian and New Zealand Reader’s Digest magazines. It polled a crosssection of more than 3,000 Australians and 1,601 New Zealanders to establish the most-trusted brands across more than 70 consumer categories. Specsavers topped the optometry category in both Australia and New Zealand, while OPSM received a highlycommended award in each country. The other highly commended recipients were the Optical Superstore in Australia and Visque in New Zealand. The Australian awards included a contact lens eye solutions category, which was won by Bausch + Lomb with its Renu

INSIGHT June 2020

designed to ensure the rating of top brands in each category was without prejudice. Each respondent completed an online questionnaire. Catalyst Research asked each participant to rate the brands they trust for each category, then which is their most trusted and why.

Readers Disgest has named the most trusted Australian brands for 2020.

Fresh solution. Opti-Free and Reclens were highly-commended. In the charities section, Guide Dogs Australia was rated ahead of the Cancer Council and RSPCA. It is the seventh time it’s been awarded the title since being added to the survey in 2013. According to Readers Digest, the list of brands rated in the survey was generated by asking consumers for their most trusted brands. This was an unprompted question

A Specsavers spokesperson said trust has never been more important, especially as the COVID-19 pandemic forces changes to operating models and service delivery. “We are in a climate where optometrists are playing a crucial role in supporting the healthcare sector by triaging customers with concerns, advising and reassuring them, and in many cases referring them on for further assistance either through other primary or even tertiary health providers,” the spokesperson said. “It’s a climate where trust has never been more essential. That’s why we are thrilled to receive this good news." n

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NEWS

POTENTIAL COVID-19 DRUG POSES RETINAL TOXICITY RISK The Australian Therapeutic Goods Administration (TGA) has warned an autoimmune and malaria drug being investigated as a potential treatment for COVID-19 can cause retinal damage. Hydroxychloroquine (HCQ), and the similar compound chloroquine, are under evaluation in more than 300 clinical trials to treat COVID-19. Recent reports of increased off-label prescribing of medicines containing HCQ have concerned health authorities who fear a potential shortage in Australia. Novartis, whose genetics and biosimilars division, Sandoz, only holds a registration for HCQ in the US, has committed to donate up to 130 million 200mg doses to for the global COVID-19 response. It has reached an agreement with US regulators to proceed with a Phase 3 clinical trial of HCQ in hospitalised COVID-19 patients. The Guardian reports mixed results from clinical trials so far, with a US study showing no benefit from the drug, either alone or given in combination with an antibiotic. Patients treated with HCQ alone had a higher mortality rate. It was also revealed COVID-19 patients admitted to intensive care at the Royal Brisbane and Women’s hospital are being given HCQ.

A separate study, known as Ascot, is under way in more than 70 Australian hospitals and will test whether lopinavir/ritonavir and HCQ, alone or in combination, prevents deterioration of COVID-19 patients. A study leader, Professor David Paterson, told The Guardian despite the US findings, the Australian study would proceed. The US study was retrospective and conducted in a relatively small group of patients, whereas the Ascot study is a more robust randomised controlled clinical trial.

"RETINOPATHY IS REPORTEDLY DOSE RELATED, AND EXCEEDING THE RECOMMENDED DAILY DOSE SHARPLY INCREASES THE RISK OF RETINAL TOXICITY" THERAPEUTIC GOODS ADMINISTRATION

On 24 March, the TGA issued an alert noting that HCQ and chloroquine pose many well-known risks. According to the agency, HCQ, which is indicated for rheumatoid arthritis, mild systemic and discoid lupus erythematosus and the suppression and malaria, has caused

blurred vision and irreversible retinal damage in some patients. It affected patients who had received long-term or high-dosage 4-aminoquinolone therapy for discoid and systemic lupus erythematosus, or rheumatoid arthritis. The TGA says retinopathy is reportedly dose related, and exceeding the recommended daily dose sharply increases the risk of retinal toxicity. Chloroquine, indicated for the treatment of malaria, is registered in Australia but is not currently marketed. Its contraindications include retinal damage or impaired visual field. Medscape reported the most significant risk factors for HCQ-related retinal toxicity are a high dose relative to real weight and duration of use. Limited studies assessing higher doses for non–small cell lung cancer and chronic graft-versus-host disease showed an increased incidence of retinopathy within one to two years, and previous data suggest that a lifetime cumulative dose of 1000g increased the risk for macular toxicity. “There is no current consensus on the appropriate dosage of HCQ in the treatment of COVID-19, but early reports suggest that a higher dose (600-800 mg/day) for a short period of time (typically not lasting more than 10 days) may be optimal," Medscape reported. n

OPTOMETRY AUSTRALIA SLASHES MEMBERSHIP FEES DURING PANDEMIC TO EASE ECONOMIC HEADWINDS Optometry Australia (OA) has cut its membership fees in half for optometrists joining or renewing with their state division by 30 June, with payments not due until October this year. The organisation said all members will receive a 50% discount on their fees for the 2020-2021 membership period, equating to six months’ free membership with no reduction in services. The measure is designed to ease the financial burden on optometrists amid the pandemic. National president Mr Darrell Baker said the OA national body and the state and territory divisions have worked together to ensure member services remain strong despite the significant fee reductions. “We remain committed to providing

INSIGHT June 2020

excellent member value. Fee reductions will be funded from reserves and not operational budgets and we have been diligent in managing our investments,” he said. “For our members, if there was ever a rainy day, it is now, and we are fortunate to be in a position to help.” Baker said the national and state boards, who are all optometrists, were aware of the impact COVID-19 was having on the sector with the shutdown, or scaling back, of many practices. “While we are supporting our members through this crisis with a wide range of information and advice, as well as constant advocacy to the key health decision makers at federal and state government levels, we know members are hurting financially,” he said.

According to Baker, the six months free membership will enable members to remain part of a cohesive and united community and ensure they continue to be represented by a strong professional body. Darrell Baker, OA.

The fee reduction is applicable to all membership categories – including full-time, part-time, minimal practice and academic membership – nationwide for 2020-2021 with dues not payable until October. The organisation stipulated the October cut-off point to ensure that each member is covered by OA's professional indemnity insurance policy, which is negotiated annually in November. Non-members wanting to join OA are advised to contact their relevant state division before 30 June. n

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NEWS

OPTHEA PROGRESSES DIABETIC MACULAR EDEMA TRIAL DESPITE CORONAVIRUS DISRUPTION Opthea will soon report results from its latest clinical trial evaluating the safety and efficacy of its lead drug candidate in combination with Eylea in diabetic macular edema (DME) patients. The Melbourne-based biopharmaceutical company is also forging ahead with its Phase 3 program in neovascular age-related macular degeneration (nAMD), including preparing documentation for regulators in the US and Europe, and to progress manufacturing its drug for Phase 3 clinical trials. The ASX-listed company has developed OPT-302, a ‘trap’ molecule that blocks the activity of two proteins that cause blood vessels to grow and leak; processes which contribute to the pathophysiology of retinal diseases. In a statement released on 30 March, Opthea announced it has completed patient dosing and all follow-up week 12 patient visits in its Phase 2a trial evaluating the safety and efficacy of its OPT-302 when administered with Eylea (aflibercept) to treat DME. Opthea CEO and managing director

Dr Megan Baldwin was “extremely grateful” to have reached the clinical milestone, “particularly given the current challenges presented by the COVID-19 pandemic and restricted movements of patients globally”. “With all patients now having completed the treatment phase of the study, Opthea is now focused on data cleaning and preparation for data readout. A large proportion of the data cleaning activities have already been completed for the majority of patients enrolled in the study, and if necessary, the remaining activities may be performed remotely,” she said. Baldwin expected the study report to come out in accordance with Opthea’s timelines, pending any potential impact of government mandated isolation procedures. In addition to advancing the Phase 2a DME trial, planning continues for its Phase 3 program in nAMD, and manufacturing OPT-302 for these clinical trials. “These activities are on-going and not currently impacted by the COVID-19 situation,” Baldwin said. In the nAMD trial, Opthea reported

"A LARGE PROPORTION OF THE DATA CLEANING ACTIVITIES HAVE ALREADY BEEN COMPLETED FOR THE MAJORITY OF PATIENTS ENROLLED IN THE STUDY" MEGAN BALDWIN, OPTHEA

positive outcomes from an international, multi-centre, prospective, shamcontrolled, double-masked, superiority study that enrolled 366 treatment-naïve patients. The study met the primary endpoint demonstrating superior vision gains in participants who received OPT-302 (2.0 mg) in combination with ranibizumab (Lucentis) on a monthly basis over six months. Baldwin said Opthea’s current financial position provides sufficient scope to focus on corporate strategic objectives and clinical development activities as the COVID-19 situation continues to evolve. “The fundamentals of our technology remain unchanged despite the global challenges we are facing with the COVID-19 pandemic,” Baldwin said. “Now, more than ever, we are reminded of the vulnerability of our communities and the need for effective treatments to improve the health and quality of life for all individuals.” She said Opthea will continue to assess the impact of government policies and the recommendations of health authorities on its programs. n

AUSTRALIAN COMPANY TESTING PEPTIDE TO TARGET GLAUCOMA SHOWS 'DISEASE MODIFYING POTENTIAL' new foundation for the development of novel mechanism-based therapy, and preventive intervention for glaucoma,” NSB chairman Mr Brian Leedman said.

Perth pharmaceutical company NeuroScientific Biopharmaceuticals (NSB) has announced its lead drug candidate slowed glaucoma-induced damage to the optic nerve, in findings that highlight its potential as a clinically useful treatment. The pre-clinical efficacy study of its drug, EmtinB, conducted by the Lions Eye Institute (LEI) in Perth, demonstrated the neuroprotective effect of the drug by slowing damage to the optic nerve caused by glaucoma. It produced statistically significant increases in neurofilaments and cytoskeleton proteins. New findings released in a final report recently also showed it did not cause any toxicity in the tissues analysed during the study. The trial simulated high intraocular

INSIGHT June 2020

Brian Leedman, NBS non-executive chairman.

pressure in a pig model, which was the closest experiment to replicate severe human glaucoma pathology. The positive results, the company claims, indicates the disease modifying potential of EmtinB. “We strongly believe that our studies in rabbits, pigs and subsequently humans can lead to the paradigm shift in the glaucoma field and offer a

“These studies may also have a wider impact on discovering the pathogenesis and therapeutics of other neurodegenerative disorders in the eye, brain and spinal cord such as macular degeneration, Alzheimer’s, multiple sclerosis (MS) and spinal injury.” Professor Dao-Yi Yu, who led the LEI research team, added: “The experiments went very well and it is encouraging that EmtinB has shown protective effects in this pig model of intraocular pressure elevation. Taken together with recent results from other groups, there seems to be real potential for EmtinB to be clinically useful in the treatment of glaucoma.” n

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NEWS

STUDY DISPELS MYTHS SURROUNDING CORONAVIRUS AND CONTACT LENS WEAR An Australian professor has co-authored a new study addressing misinformation related to COVID-19 and contact lens wear, stating there is no evidence to suggest an increased risk compared with spectacle wear. Mark Willcox, UNSW. Professor Mark Willcox, from the University of New South Wales, and four other academics from around the world penned the study, which was published in Contact Lens and Anterior Eye on 6 April.

In their work, Willcox, whose expertise includes ocular microbiology and ocular inflammation and infection, and his peers acknowledged the significant amounts of misinformation and speculation being reported and shared via various news outlets and on social media relating to how best to limit the chance of infection. “Among these, recent rumours have circulated stating that contact lens wear is unsafe, that wearers of contact lenses are more at risk of developing COVID-19, that certain contact lens materials are more ‘risky’ than others and that contact lens wearers should immediately revert to spectacle wear,” the authors note. Willcox and his peers asserted there no evidence to suggest that contact lens wearers who are asymptomatic should cease wear due to an increased risk of developing COVID-19. They also noted there was no evidence that wearing prescription spectacles provides protection against the virus or that any one form of contact lens material is more likely to enhance or reduce the risk of future infection. “A focus on fully compliant contact lens wear and especially on the modifiable risk factors associated with contact lens complications are especially important during the height of the pandemic, where access to primary and secondary optometric care may be substantially different to normal,” the authors said. “Practitioners should act to minimise the burden on the wider healthcare system by considering their local clinical pathway options.” n

INSIGHT June 2020

AUSTRALIA’S FIRST VIRTUAL OPTOMETRY PRODUCT SHOWCASE "WE FELT THERE WAS NO BETTER TIME THAN NOW TO HOLD SUCH AN EVENT. VIRTUAL CONFERENCES ARE BECOMING INCREASINGLY POPULAR" DARRELL BAKER, OPTOMETRY AUSTRALIA

Optometry Australia (OA) will be hosting a three-day virtual event this month that will feature an accredited CPD program and the sector’s first online product showcase. The organisation said the event, Optometry Virtually Connected, aligns with its commitment to support members during the COVID-19 crisis by using technology to advance members’ education and continued career development.

also network with colleagues in real time within an online platform during the threeday program. “With technology providing more and more scope to be innovative, we felt it was time that we too stretched ourselves by introducing new ways to do things,” Baker said.

The virtual event, to be held from 26-28 June, will be free to all OA members. Non-members will also be able to register to access a more restricted three-day event for $349.

Due to COVID-19 restrictions, virtual events, conferences and trade shows have increased in popularity within the ophthalmic profession in recent times, providing an opportunity to attend a live program without the added expense of travel and accommodation.

OA national president Mr Darrell Baker said the event will feature Australia’s first virtual optometry product showcase.

Baker said the organisation had been exploring the idea of a virtual conference for a while.

“We believe that it is important to keep abreast of the latest clinical and patient care management technology and products on the market,” he said.

“We felt there was no better time than now to hold such an event,” he said. “Virtual conferences are becoming increasingly popular as already demonstrated by the strong support of those attending AVC 2020 as a virtual event and the WAVE athome series of webcasts.” n

Optometry Virtually Connected will allow delegates to attend a series of accredited live and pre-recorded webcasts. They can

SURGING DEMAND FOR ZEISS SLIT LAMP BREATH SHIELD PROGRAM Ophthalmic equipment manufacturer Zeiss has experienced significant demand for its free slit lamp breath shield offer during COVID-19, with thousands of units ordered across Australia and New Zealand.

Zeiss customers. As of 13 May, Mr Matthew Wensor, the strategic marketing manager within Zeiss’ Australian medical technology business group, told Insight the company had sent 2,880 breath shields, with that number set to climb.

On 17 April, the company had sent just 200 breath shields to existing Zeiss customers, and had received orders for 100 more units.

The free breath shields are a donation by Zeiss. Due to limited supply, the company will provide two shields and one shipment per practice.

That number has ballooned due to increased awareness of the program, which is available to all practitioners who use slit lamps, including non-

Shipments may take up to two weeks and there's no guarantee they will fit every make and model. The program is ongoing. n

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Donâ&#x20AC;&#x2122;t pay until October 2020 Contact your state organisation for details: Optometry NSW/ACT:

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Optometry QLD/NT:

(07) 3839 4411

Optometry TAS:

(03) 6224 3360

Optometry VIC/SA:

(03) 9652 9100

Optometry WA:

(08) 9321 2300

NEWS

OPTOMETRY BOARD CHAIR JOINS CRISIS LEADERSHIP GROUP

OPSM INTRODUCES FREE TELEHEALTH SERVICE OPSM is offering tele-optometry consultations free of charge, despite there being no optometry Medicare item number for the service at the time of announcement. The optical chain, which is owned by Luxottica, is the latest to offer telehealth for its patients as the eyecare sector adapts its service model to align with COVID-19 social distancing and restricted travel measures. While it has kept key stores open for patients requiring urgent or critical care, OPSM’s telehealth service is designed to ensure other essential eyecare needs are met. At the time of writing, optometry wasn’t included in the list of telehealth consultations that can be covered by Medicare during COVID-19. In recent months, Luxottica has joined Specsavers, Optometry Australia and Diabetes Australia to advocate for changes to two existing item numbers (10916 and 10918) to allow optometrists to bill for telehealth under the scheme. “OPSM wants to ensure that Australians continue to have access to eyecare services in the current health crisis,” Mr Peter Murphy, OPSM’s director of eyecare and community for Australia and New Zealand, said. “Our tele-optometry services will help in two main scenarios. The first is where the patient may have an eye health concern. The second is where the patient may have an urgent need to replace their lost or broken glasses.” He added: “If the patient has been to see us previously the optometrist will have access to case histories and electronic records, so that an informed diagnosis can be made, and the patients guided through the next steps,” he said. “In some cases, the optometrist may request that the patient visit an OPSM store for a more comprehensive consultation; alternatively, the optometrist may refer the patient for either general medical care, or direct to a hospital for ophthalmology care if necessary.” n

INSIGHT June 2020

"WE NEED TO LEVERAGE THE DISRUPTION WE ARE FACING TO ENSURE OUR MEMBERS AND THE PROFESSION IS STRONGER IN RECOVERY THAN IT HAS EVER BEEN" LYN BRODIE, OPTOMETRY AUSTRALIA

Optometry Board of Australia chairman Mr Ian Bluntish and his New Zealand counterpart have joined an expanding Crisis Leadership Group established by Optometry Australia (OA) in response to the COVID-19 emergency. OA has formed the group which comprises the organisation’s national board directors, as well as all state division presidents and CEOs. Bluntish has joined the group alongside New Zealand Association of Optometrists (NZAO) president Ms Rochelle van Eysden and New Zealand Optometrists and Dispensing Opticians Board (ODOB) chair Mr Jayesh Chouhan. OA CEO Ms Lyn Brodie said the Crisis Leadership Group would meet every Tuesday night for one hour. It is planning to do so for at least three months before re-evaluating. “We believe it is absolutely critical that we work cohesively and collaboratively to ensure the long-term sustainability of our profession and the association. Our members will look to us to lead and presenting a united group and commitment at this level, is powerful,” she said. “We need to deal with the immediate, short, medium and long-term situation, at the strategic level. We need to leverage

the disruption we are facing to ensure our members and the profession is stronger in recovery than it has ever been. We have the opportunity to truly lead, by not simply surviving but using disruption to the advantage of our members and the profession.” The group is currently focusing on; advice and action regarding clinical practice and protocols in a pandemic; ensuring continuity of CPD; business continuity and transformation - for the benefit of employers, employees, locums and casuals; member mental health and well-being; lobbying and advocacy; and media relations. “Optometry Australia is supporting NZAO with access to clinical and other relevant materials. Optometry Australia is working through the provision of access to CPD/Institute to all NZ optometrists free for six months over the crisis.” n

VISION SCIENTISTS SHINE LIGHT ON HAND WASHING TECHNIQUES Researchers from the Sensory Processes Research Laboratory within the UNSW School of Optometry and Vision Science have developed augmented reality software that shows the effectiveness of differing hand washing techniques. Dr Nayuta Yoshioka, Dr Juno Kim and Mr Jason Feng developed the system, which adopts similar imaging techniques to those used in eyecare, to demonstrate how much gunk remains on the hands at each stage of the World Health Organization’s six-step handwashing method.

a program to overlay a heatmap on their hands to highlight the level of cleanliness. Purple areas were considered clean, while the red and yellow parts had not been sufficiently washed.

As part of the study led by Yoshioka and Kim, participants’ hands were covered in UV florescent lotion before washing. The researchers then used

Kim said the augmented reality demonstration showed the importance of following all six stages of the WHO handwashing guidelines. n

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NEWS

MAJOR FUNDING BOOST FOR CONSUMER AWARENESS CAMPAIGN Optometry Australia (OA) has received a government grant worth more than $400,000 to promote optometry and community eye health under its Good vision for life flagship consumer brand through to mid-2021. The funding will aid distribution of eye health messages via the initiative, which was launched in 2016. It will utilise advertising, public relations and social media to emphasise the importance of prevention and early detection among the public, as well as the role optometrists play as part of a general health regime. OA has also sought to bolster the Good vision for life consumer awareness campaign and unite the sector behind a ‘2020: Year of good vision for life’ theme so that it can deliver a consistent message about eye health management and the need for regular optometry visits through life. OA president Mr Darrell Baker thanked Federal Health Minister Mr Greg Hunt and the Department of Health for allowing the peak body to deliver the promotion. “The allocation of this grant indicates the minister’s commitment to the eye health sector and the government’s support for optometry. It is an endorsement for our ongoing efforts to advocate the importance of regular eye examinations to Australians,” he said. “Earmarked to promote 2020 as the year of good vision for life, the grant will be vital to raising awareness of eye health and optometry this year, particularly in the lead up to, and post-COVID-19 restrictions lifting.” Baker said while OA wants Australia to make this – and every year – the year of good vision for life, the government has allowed until 30 June, 2021 to finalise the grant-funded campaign. This provides added flexibility for OA’s promotional activity delivery. n

OPTOMETRISTS VIE FOR TOP SPOTS AT LOCAL BUSINESS AWARDS "NOMINATED OPTOMETRY PRACTICES RANGE FROM INDEPENDENT OPTOMETRISTS AND GROUPS SUCH AS EYECARE PLUS TO CORPORATE STORES" CHRIS JAMGOTCHIAN, PRECEDENT PRODUCTIONS

As many as 50 optometry practices are in the running to be recognised for exceptional customer service as part of a local business awards program replicated throughout Sydney and surrounding areas. The 2020 Local Business Awards, hosted by Precedent Productions, acknowledge outstanding businesses and their people who go ‘above and beyond’. It is hosted across 28 local government areas, ranging from Blacktown to Hawkesbury, and from Liverpool to the Central Coast. Forestway Optometry, in Glenrose, winner of the Health Improvement Services category last year in Northern Beaches, New South Wales, is again contending for the title. The ProVision practice features among dozens of optometry nominations, including Absolute Eyecare in Penrith City, Hannaford Eyewear in Southern Highlands and Guildford Optometrist in Parramatta. The awards program cover a wide variety of industry categories which vary across each region in order to recognise the industries in the specific business community. Optometry practices are nominated

Mr Chris Jamgotchian, project manager at Precedent Productions, which created the awards 35 years ago, said nominated optometry practices range from independent optometrists and groups such as Eyecare Plus to corporate stores, including Bupa Optical, Specsavers and OPSM. Voting has closed in some areas, with some business already named as finalists, including Eyeview Optometrist in Campbelltown. n

Low vision patients are set to benefit from the world’s first state-of-theart sensory campus at Guide Dogs Victoria with $2.5 million in new Federal Government funding. The investment, which builds on $2 million in funding provided in 2016, will modernise the organisation’s current facilities in the Melbourne suburb of Kew and provide job opportunities.

It will also include a world-class training centre, a new building for client services, refurbished onsite accommodation for clients and a commercial hub with a

INSIGHT June 2020

in the Health Improvement Services category, competing against dental, medical, imaging, chiropractic, audiology, physiotherapy, and osteopathy services, to name a few.

WORLD-FIRST SENSORY HUB TO SUPPORT PEOPLE WITH LOW VISION

The redevelopment will include a new world-first sensory hub which utilises sounds, textures and scent together with human-enabled technology and braille, which is designed to provide an engaging space for people with low vision or blindness.

Forestway Optometry practice co-ordinator and frame stylist, Karen, (from left) practice manager Sean Langton and senior optical dispenser and frame stylist, Akiko at the 2019 awards.

Federal Treasurer and Kooyong MP Josh Frydenberg with Guide Dogs Victoria CEO Karen Hayes.

veterinary hospital, dog day-care centre and on-site café. Deputy Prime Minister and Minister for Infrastructure, Transport and Regional Development Mr Michael McCormack said the new commercial hub and sensory campus would help Guide Dogs Victoria become financially selfsustaining into the future. n

FALL IN DONATIONS TO CONTINUE FOR MANY MONTHS: CHARITIES SEND STARK WARNING Australian charities and not-for-profits are feeling the strain of coronavirus through a combination of dwindling funds, ineligibility for government aid and a suspension on non-emergency fieldwork. The Fred Hollows Foundation and the Queensland Eye Institute (QEI) Foundation, which feature among more than 7,300 health-related charities in Australia, have spoken of the challenges they face as the crisis tightens its grip on the economy. Fred Hollows CEO Mr Ian Wishart said complex funding structures and sources of income meant many international non-government organisations (NGOs) would likely remain ineligible for the Federal Government’s $130 billion JobKeeper program. That’s despite a lowering of the income threshold for charities to access the scheme to 15%. Comparatively,

"WE EXPECT OUR FALL IN DONATIONS TO CONTINUE FOR MANY MONTHS AS THE AFTEREFFECT OF THE COVID-19 DOWNTURN IS FELT"

businesses with an annual turnover of less than $1 billion are eligible if they estimate their turnover to fall by 30% or more.

IAN WISHART, FRED HOLLOWS

Wishart said the foundation, along with others in the sector, requested the JobKeeper program be amended to allow registered charities access to the program if their turnover is reduced by more than 15%, excluding government grants and specific purpose grants and philanthropic funds.

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The foundation also proposed that charities should be eligible if the reduced turnover is expected to occur for the 2020 calendar year relative to that reported in their previous annual information statement or financial report. “Australian charities are being hard-hit by the economic downturn and may struggle to survive without support,” Wishart said. “We expect our fall in donations to continue for many months as the aftereffect of the COVID-19 downturn is felt.” Following the summer bushfires that contributed to ‘donation fatigue’, Professor Mark Radford, QEI Foundation CEO, estimates that the sector is down at least 35% during the past six months. He predicts a greater downturn during the next 12 months. The QEI Foundation has written to Prime Minister Scott Morrison to seek an urgent stimulus package to protect not-for-profits.

COMPANY

SAFILO ACQUIRES CELEBRITYLABEL PRIVÉ REVAUX IN NEW DEAL Italian eyewear company Safilo Group is acquiring a majority stake in highend fashion label Privé Revaux and has announced a new 10-year licensing agreement with French designer brand Isabel Marant. Privé Revaux, which sells sunglasses and reading glasses co-branded through celebrity collaborations, will offload 61% of shares to Safilo.

J&J VISION APPOINTS NEW CHIEF MEDICAL OFFICER

Privé Revaux founding entrepreneur and CEO Mr David Schottenstein retains ownership of approximately 15% of the equity, while the remainder is held by celebrities Mr Jamie Foxx, Ms Hailee Steinfeld and Ms Ashley Benson, plus the company’s senior management and other investors.

Johnson & Johnson (J&J) Vision has appointed accomplished ophthalmologist Dr Rajesh Rajpal as its new chief medical officer and global head of clinical and medical affairs. According to the company, Rajpal has more than 25 years’ experience and joins the company after serving as chief medical officer at Avedro, a company focussing on the field of corneal remodelling that was recently acquired by Glaukos.

According to a Safilo, Privé Revaux was established to disrupt the eyewear with premium, quality eyewear products accessible to everyone.

Rajpal has specialised in cataract surgery, cornea/external diseases, anterior segment surgery, Lasik, and refractive surgery. As a corneal specialist, he has expertise in the diagnosis and treatment of corneal disease, corneal trauma, and surgical complications. He also has a special interest in the diagnosis and treatment of ocular surface conditions.

The company distributes through a broad set of channels and retail partners, both online and offline, and in 2019 it recorded net sales of approximately US$20 million (AU$30 million), a 90% increase compared to the previous year. Safilo’s CEO Mr Angelo Trocchia said the expanding US-origin brand offers affordable, high-quality, well designed eyewear, using celebrities’ endorsements to drive brand awareness and sales.

For J&J Vision, Rajpal will lead new product development to address unmet needs of patients and eyecare professionals. He will oversee clinical trials and the generation of surgical and vision care evidence, and liaise with government agencies and the academic, scientific, and industry communities.

“Privé Revaux has successfully created

Rajpal added: “I am looking forward to guiding and contributing to the continued development of leading-edge products and technology that clinicians, who are my peers, can use to provide the highest level of care to patients globally.” n

INSIGHT June 2020

a repeatable and scalable strategy with celebrity capsule programs that can be introduced into various markets around the world, a consumer-centric marketing model from which we can learn and leverage on, while putting our capabilities at its disposal for its global expansion.” Meanwhile, the new 10-year licensing agreement with Isabel Marant, known as one of the most influential brands among French designers, will see Safilo lead the manufacturing and distribution of the company’s sunglass and optical frames. The first Isabel Marant collection will be launched with the spring/summer 2021 lines. “We are pleased to welcome to our portfolio one of the coolest French designer brands whose unique expression and iconic style ensure it stands out within the advanced luxury design segment,” Trocchia said. n

LUXOTTICA SECURES LICENSE RENEWALS FOR TWO ITALIAN LUXURY BRANDS

“We are very pleased to welcome Raj to Johnson & Johnson Vision and are extremely excited to add his expertise and strategic thinking to the business,” said Mr Shlomi Nachman, group chairman of J&J Vision and the cardiovascular and specialty solutions group. “His experience as both a practicing ophthalmologist and product development leader will be invaluable as we advance our pipeline of new products and services and seek to provide eye health solutions for everyone around the world.”

Angelo Trocchia, Safilo.

Luxottica Group has renewed its exclusive licensing agreements with Italian luxury fashion labels Dolce & Gabbana and Versace until the end of 2029. Leonardo Del Vecchio, Luxottica.

The Italian eyewear giant announced the deals in March and April, which will see it continue with the development, production and distribution of sunglass and prescription frames for both brands for the next 10 years. Mr Leonardo Del Vecchio, executive chairman of Luxottica, said the company had worked with Dolce & Gabbana for 15 years.

“Dolce & Gabbana is a truly global and iconic brand and a true ambassador of ‘made in Italy’. We look forward to continuing to shape the idea of luxury eyewear together in the decade ahead,” he said. Luxottica Group’s worldwide agreement with Versace was an early renewal of an exclusive license agreement. Mr Francesco Milleri, CEO of Luxottica, said the company was pleased to partner with Versace, further extending an agreement which dates back to 2003. n

RESEARCH

NEW STUDY INTO FIRST ITALIAN COVID-19 CASE SUGGESTS VIRUS REPLICATES IN THE EYES A new study into Italy’s first coronavirus patient has found she had traces of the virus in her eyes for several weeks, even after it had become undetectable in nasal swabs. The research, published in Annals of Internal Medicine, is the latest piece of literature to establish a connection between COVID-19 and ocular fluids, suggesting the eye is not only a potential entry point for the virus, but also a source of contagion. At present, researchers say there has been limited data on ocular samples from COVID-19 patients, however unprotected ocular exposure was thought to be responsible for infections in the Wuhan Fever Clinic, in China, in January. Further, SARS-CoV-2 (which causes COVID-19) RNA was detected in conjunctival secretions collected from the only patient with conjunctivitis out of 30 patients from a hospital in China. In this latest study, researchers analysed samples from a 65-year-old woman at the National Institute for

Infectious Diseases in Rome. She was the country's first COVID-19 case after travelling from Wuhan. The third day after she was admitted to hospital, health workers took an ocular swab due persisting conjunctivitis. Viral RNA was detected and subsequent ocular samples collected with almost daily frequency returned positive results up to day 21, with declining virus concentration.

suggesting sustained replication in conjunctiva.” The researchers said the findings demonstrated that ocular mucosa may be not only a site of virus entry but also a source of contagion. The eye may be a source of contagion.

They said it highlighted the importance of appropriate personal protective equipment use among ophthalmologists during clinical examination. “Furthermore, we observed that ocular involvement of SARS-CoV-2 may occur early in the COVID-19 course, suggesting that measures to prevent transmission via this route must be implemented as early as possible,” they concluded.

The researchers said the patient’s conjunctivitis improved significantly at day 15 and seemed to have been resolved at day 20. Five days later it had become undetectable, however SARS-CoV-2 RNA was detected again in an ocular swab sample on day 27.

“Future studies are needed to define the human ocular cell types capable of supporting viral replication and the mechanisms underlying ocular tropism of SARS-CoV-2.”

“[It was also] detected in ocular swabs days after it was undetectable in nasal swabs,” the researchers said.

The authors note the findings help reinforce the importance of control measures, such as avoiding touching the nose, mouth, and eyes and frequent hand washing. n

“In addition, the cycle threshold values detected in the late ocular samples were lower than those observed in the nasal swabs,

THE IMPLICATIONS OF INHIBITING VISUAL PERCEPTION "ONE OF THE MOST IMPORTANT ASPECTS OF VISION IS FAST DETECTION OF IMPORTANT EVENTS, LIKE DETECTING THREATS"

A study examining early visual processing in mice could have implications for conditions that affect perception and visual attention, according to researchers at the National Eye Institute (NEI) in the US. Published online in the Journal of Neuroscience, the study found inhibiting a specific region of the brain in genetically modified mice hindered their event perception, which could aid in better understanding conditions like schizophrenia and attention deficit hyperactivity disorder (ADHD). Researchers defined a specific 100-millisecond window that mice need to process visual events. They found that as the brain processes visual information, a region known as the ‘superior colliculus’ notifies other regions of the brain that an event has occurred. Inhibiting this particular brain region during the crucial window

inhibited event perception in mice. Senior author of the study Dr Richard Krauzlis said: “One of the most important aspects of vision is fast detection of important events, like detecting threats or the opportunity for a reward. Our result shows this depends on visual processing in the midbrain, not only the visual cortex.” The authors noted that although they had to be cautious translating data from mice to humans, because of the difference in visual systems, mice have many of the same basic mechanisms

RICHARD KRAUZLIS, NATIONAL EYE INSTITUTE

for event detection and visual attention as humans. In the study, Krauzlis and colleagues used a technique called optogenetics to tightly control the activity of the superior colliculus over time. They used genetically modified mice so that they could turn neurons in the superior colliculus on or off using a beam of light. This on-off switch could be timed precisely, enabling the researchers to determine exactly when the neurons of the superior colliculus were required for detecting visual events. The researchers trained their mice to lick a spout when they’d seen a visual event, and to avoid licking the spout otherwise. The researchers found that the deficits with superior colliculus inhibition were much more pronounced when the mice were forced to ignore things happening elsewhere in their visual field. n

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RESEARCH

LONG-TERM REPEATED INJECTIONS CAN CAUSE CUMULATIVE DAMAGE New research suggests repeated use of intravitreal injections could have cumulative long-term effects such as an increased likelihood of glaucoma surgery, in findings that may influence the way eye conditions are treated. Published in the April issue of Retina, the study was designed to address a lack of knowledge around the long-term consequences of eye injections, which are a relatively recent development in the treatment of macular diseases. The authors, from the Department of Ophthalmology at the New York Eye and Ear Infirmary of Mount Sinai, wanted to know the immediate impact on blood flow to the eye, given the injections cause eye pressure to temporarily increase three times normal levels. Using optical coherence tomography angiography, senior investigator Dr Richard Rosen and his team analysed 39 patients aged over the age of 18 after they received intravitreal bevacizumab or aflibercept injections for diabetic retinopathy, macular degeneration, choroidal neovascular membrane, retinal vein occlusion, or radiation retinopathy. Minutes after the injections, the researchers measured blood flow in different areas of the macula and optic nerve. According to their results, some areas of the macula and nerve were stressed more than others, which may prompt doctors to use advanced imaging and visual field testing to look for early signs of damage. Lead author Dr Alexander Barash said that if intravitreal injections are inadvertently causing damage to ocular structures, the profession should make sure that all physicians performing the procedure are aware of possible side effects. “This study is important because we know that high eye pressure leads to tissue damage in glaucoma. If patients are receiving monthly injections that repeatedly stress the eye, we may have to start looking for signs of cumulative damage,” he said. n

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MALE-ONLY STUDY LINKS VAPING TO DRY EYE AND POOR TEAR FILM "LITTLE IS KNOWN ABOUT THE EFFECT OF E-CIGARETTES ON THE EYES EXCEPT FOR REPORTED EYE IRRITATION" NATIONAL INSTITUTE OF OPHTHALMIC SCIENCES

Dry eye and poor tear film quality has been linked to e-cigarette smoking in a male-only study conducted by the National Institute of Ophthalmic Sciences in Malaysia. The study, published in Optometry and Vision Science, was designed to fill a knowledge-gap on the correlation between smoking e-cigarettes, or vaping, and eye health. “Little is known about the effect of e-cigarettes on the eyes except for reported eye irritation among individuals who were exposed to e-cigarette vapors and e-liquids. This study aims to investigate the effect of vaping on ocular surface health of long-term vapers,” the authors said. The researchers evaluated 21 male e-cigarette smokers, between the ages of 19 and 30 and with at least one year of continual vaping history. The control group was made up of 21 non-smokers, also male, with no smoking history. All participants underwent measurements of the Ocular Surface Disease Index (OSDI), non-invasive tear

breakup time, fluorescein breakup time, ocular surface staining, tear meniscus height, and the Schirmer test. The effect of voltage used during vaping was also evaluated against the measurements. Results shows that vapers experienced moderate-to-severe eye dryness as indicated by the OSDI. Significant reductions of non-invasive tear breakup time, fluorescein breakup time, and tear meniscus height were noted in vapers, while the Schirmer test showed higher results compared with non-smokers. The study also found that an increase in vaping voltage aggravated the dry eye symptoms and tear instability; a higher Schirmer test result was also noted as voltage increases. n

AB INTERNO TRABECULOTOMY EFFECTIVE IN CHILDHOOD GLAUCOMA Single-incision ab interno trabeculotomy is an effective and safe treatment for paediatric glaucoma patients, according to a new US study. Led by paediatric ophthalmologist Dr Raymond Areaux, from the University of Minnesota Health paediatric in Minneapolis, the multicentre retrospective interventional case series involved 46 eyes with childhood glaucoma. Each underwent trabeculotomy using the Trab360 device, by Sight Sciences, inserted by one of four surgeons at four academic medical centres with at least three months of follow-up. Success of the surgery was defined by postoperative intraocular pressure (IOP) of 24 mm Hg or less, with or without medications, with no additional IOPlowering surgeries. They found 67% of eyes with childhood successfully met this endpoint, according to Healio/OSN.

Mean preoperative IOP was 30.9 mm Hg, and mean follow-up was 16.2 months. “We concluded that single-incision ab interno trabeculotomy is effective and safe for treating pediatric glaucomas, especially primary congenital glaucoma. Good surgical technique and caution in high-risk angles is imperative to avoid cyclodialysis,” study co-author Raymond Areaux said. Additionally, the study found in 40 eyes for which Trab360 was the first glaucoma surgery, success was achieved in 70% of cases. n

INTERNATIONAL

PROFESSION APPEARS ‘STRONGER THAN EVER’ IN NEW DOCUMENTARY The global eyecare community tuned into the virtual screening premiere of Open Your Eyes, a new documentary highlighting the increasing role of optometrists as frontline detectors of systemic diseases. With the key message that ‘the optometrist is the new general practitioner’, the film’s inaugural viewing took place on 29 April. The film aims to inform the public that optometrists do more than prescribe spectacles and contact lenses. It highlights the importance of optometric eye testing to identify and thwart the rise of 300 systemic diseases such as hypertension, diabetes, myopia and Alzheimer’s. Dr Kerry Gelb, the storyteller and host of the film, said optometrists were the only primary care profession that can see blood vessels non-invasively, placing them at the forefront of preventative medicine. “The film will make the profession look stronger than ever and enlighten the public to the far-reaching technology optometrists now have in their hands,” he said. “I’m excited that the optometric community will be the first ones to see it.”

As part of the documentary, Vision Monday reports that Gelb travels to Nicoya, Costa Rica to learn about how centenarians have maintained their eye health over the course of their lives. He also meets with Dr Javier Prada Lopez to examine the prevalence of myopia in Costa Rican children. Gelb also speaks with Ms Carey Gillan, a journalist and the author of Whitewash, and Mr Jeffery Smith, an activist, to understand how the insecticides are impacting the human body. The documentary has been created by Emmy Award winning filmmaker Mr Wayne Chester and the ALLDocs Association. Main sponsors include CooperVision, Bausch + Lomb, Alcon and Johnson & Johnson. Smaller sponsors were ABB Optical, Essilor and Omni Eye Service. n

SCIENTISTS MODIFY COMMERCIAL CL TO CORRECT COLOUR BLINDNESS Researchers from the Faculty of Engineering at Tel Aviv University in Israel have modified an off-the-shelf contact lens to correct a form of red–green colour blindness known as deuteranomaly, the most common type of colour vision deficiency. By embedding artificially engineered thin metallic films that can be finetuned to interact with light – known as metasurfaces – on to the surface of commercially available rigid gas permeable contact lenses, the researchers restored lost colour contrast and improved colour perception by up to a factor of 10. According to their research, published in the journal Optics Letters, the effect of the contact lenses on colour perception was simulated using Commission

Internationale de l’Eclairage (CIE) colour spaces and conventional models of the human colour-sensitive photoreceptors. The researchers found that the modified contact lens could shift incorrectly recognised colours closer to the original pigments and that lost visual contrast in red–green colour blindness could essentially be restored. An Ishihara-based colour-blindness test also confirmed contrast restoration. n

YEAR-LONG SCREENING REVEALS TRIPLE THE NUMBER OF CATARACTS IN ROHINGYA REFUGEES A new study in southeast Bangladesh has shown Rohingya refugees experience threeto-six times as many cases of operable cataract in those aged 18 to 59 years compared with the local population. About 48,000 Rohingya, displaced from neighbouring Myanmar, received vision screening along with 20,000 Bangladeshi locals between February 2018 and March 2019. The screening, conducted by non-government organisation Orbis International and a local hospital with support from the Qatar Fund for Development, showed the vast majority of vision loss was due to refractive error and unoperated cataract. “The numbers of people that were presenting with operable cataract at our vision centres within the camps, were three- to six-fold higher among the working-age Rohingya community than the host population,” the authors noted. Dr Munir Ahmed, country director of Orbis International Bangladesh, said the demand for eyecare services was significantly higher than anticipated. “It is perhaps not surprising that we saw high volumes of patients among these chronically underserved displaced and host communities who had unoperated cataract or who needed glasses but did not have them,” Ahmed said. “But the very high uptake of service in this program – fully 60% of those aged 60 and over in the targeted Rohingya community – is truly extraordinary when you think about the many health priorities they face. It underscores the potential for eye care to build resilience in such refugee populations.” The study, published a special issue of peer-reviewed medical journal PLOS Medicine focusing on refugee and migrant health, claims to be the largest attempt to document the delivery and demand for comprehensive eyecare in a displaced population. Because the data only captured those at clinics, the study’s authors were unable to assess the burden of cataract and other eye diseases across the entire population. n

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TECHNOLOGY

NEW VIRTUAL BRAILLE KEYBOARD FOR ANDROID DEVICES ELIMINATES NEED FOR EXTERNAL HARDWARE Google has launched a new virtual braille keyboard, TalkBack, integrated directly into Android for a convenient way to type on devices. It replaces the need to connect to an external, physical braille keyboard. Google collaborated with braille developers and users to design a keyboard that is familiar to anyone who has typed using braille before. It uses a standard six-key layout; each key represents one of six braille dots which, when tapped, make any letter or symbol. For example, tapping dot 1 types an “A”; tapping dots 1 and 2 together types a “B”. A swipe left deletes a letter, while a twofinger swipe left deletes a word. Swiping right adds a space, while a two-finger swipe right or up inserts a new line or text, respectively. TalkBack keyboard is activated with a three-finger swipe up on the screen and can be turned on and off by switching between international keyboards. Launched on 9 April, TalkBack braille keyboard is rolling out to Android devices operating version 6.0 or later. It works across all apps on Android devices, supports braille grade 1 and grade 2 and is available initially in English. Google’s Android accessibility product manager Mr Brian Kemler said the virtual keyboard would allow users to quickly post on social media, respond to a text, or write a brief email on their phone without needing to connect to an external device. “As part of our mission to make the world’s information universally accessible, we hope this keyboard can broadly expand braille literacy and exposure among blind and low vision people,” he said. n

AI RETINOPATHY SCREENING CHEAPER THAN HUMAN GRADING "THE PROPOSED SEMIAUTOMATED SCREENING MODEL COULD SAVE $15 PER PATIENT AS COMPARED WITH THE CURRENT HUMAN GRADERS MODEL" STUDY AUTHORS

A new study suggests that deep learning systems (DLS) would eliminate two minutes of human labour required to grade diabetic retinopathy images, however a semi-automated model is most cost-effective, saving national health systems up to 20% on screening costs. In a cost-minimisation analysis, recently published in The Lancet Digital Health, researchers assessed data from the national diabetic retinopathy screening program in Singapore. They aimed to evaluate the potential savings of two deep learning approaches; a semi-automated model as a triage filter before secondary human assessment; and a fully automated deep learning model without human assessment. They compared this alongside the current human assessment model. They found the semi-automated screening model was the least expensive of the three models, at US$62 (AU$95) per patient per year. The fully automated model was $66 (AU$101) per patient, while the human assessment model was $77 (AU$118). The findings revealed that switching to the semi-automated model could generate savings of $489,000, roughly 20% of the current annual screening cost.

By 2050, Singapore is projected to have 1 million people with diabetes. At this time, the annual savings were projected to be $15 million. n

SMART CONTACT LENS DEVELOPER SECURES MAJOR FUNDING BREAK Californian start-up Mojo Vision has raised more than US$51 million (AU$77 million) in new funding to accelerate the development of what it calls the world’s ‘first true smart contact lens’. The company is producing the Mojo Lens, a contact lens with a built-in display that is designed to provide wearers with useful information without requiring them to look down at a screen or lose focus.

This latest round of funding takes its total funding to more than US$159 million (AU$242 m).

INSIGHT June 2020

“This study presents one of the first health economic evaluations of competing models for implementing a DLS designed to screen for referable diabetic retinopathy,” the researcher noted. “From the health system perspective, the proposed semi-automated screening model could save $15 per patient as compared with the current human graders model. This saving is mainly attributable to the substantial reduction in human assessment time and workforce without sacrificing screening performance: each human grader takes roughly two minutes to grade each image, whereas the DLS drives this cost nearly to zero.”

Mojo calls this eyes-up experience ‘Invisible Computing’, using microelectronics and the “world’s densest microdisplay” to layer digital images and information seamlessly into the wearer’s field of vision.

Deep learning systems for diabetic retinopathy may save Singapore $15 million in future.

“This new round of funding brings more support and capital from strategic investors and companies to help us continue our breakthrough technology development. It gets us closer to bringing the benefits of Mojo Lens to people with vision impairments, to enterprises and eventually, consumers,” Mojo Vision CEO and co-founder Mr Drew Perkins said. n

SPORTS VISION

OF THEIR OWN THE SCIENCE OF SPORTS VISION

How can optometrists pull an elite batsman out of a form slump? What’s the best type of laser vision correction for a boxer? And how are prescription lenses integrated into ski goggles? RHIANNON BOWMAN explores sports vision from three perspectives.

hether it be height, muscle mass or agility, sports studies have alluded to an ever-increasing emphasis on physiological attributes that enhance athletic performance.

Vision, the primary sense used in almost every sporting arena, fits neatly into that category, but is arguably an understated determinant of sporting success – or failure. Countless studies have sought to identify differences in the visual performances of athletes and non-athletes. Some have shown that dynamic visual acuity and stereoacuity – essential in sports such as cricket, AFL and soccer – were more developed in athletes, while others believe depth perception and dominant eye awareness play an equally important role. Australian history consists of a rich vein of sporting culture, with current statistics indicating that approximately 82% of Australian adults and 58% of children participate in sport at least once a week. Yet, 13% have been sidelined due to eyesight issues, according to Optometry Australia’s The 2020 Vision Index. For three Australian eyecare professionals who specialise in this field, poor eyesight should be no reason to miss out. This month, an optometrist, ophthalmologist and dispenser discuss their work to help sportspeople remain ahead of the pack.

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SPORTS VISION

THE EYE MAN

Optometrist MR PATRICK GERRY says athletes have more trouble with depth perception than visual acuity. They can't judge the exact ball position, despite being able to see it clearly.

With more than 30 years’ sports vision experience, independent optometrist Mr Patrick Gerry, from Eyeman Optometrists in Brisbane, says the simple act of discussing sport with every patient has shaped his career. “That’s the gospel truth of how all this started,” he says. “My big break came with the Australian Football League (AFL) in 1998. I was locuming when the president of the Brisbane Lions came in; he just needed glasses, but I provided a full consultation and detected health issues with his eyes. We talked about sport and I said, ‘If you’ve got $2.5 million worth of cattle running around the field, shouldn’t you be sure they don’t have any problems?’.” Since then, Gerry’s career has taken him Australia-wide as a consultant, conducting vision screenings for sporting organisations, including the Australian Institute of Sport, Cricket Australia, Cricket Umpires Australia, Queensland Cricket, the National Rugby League, the AFL and Fox Sports. Gerry, who has a degree in optometry and completed a Masters in Sports Vision, works with junior through to elite athletes and, as recent as last November, screened 44 Brisbane Lions players. Following his consultancy work he has returned to his bricks-andmortar practice, Eyeman Optometrists. It features onsite sports vision facilities where athletes can perform drills specific to their sport and the optometrists can observe where their vision needs help. He has collaborated with leading scientists to establish that sports players perform dramatically better when they have strong depth perception, an awareness of their dominant eye, and clear peripheral and central vision. “We can combine different therapies to provide athletes with tangibly improved vision. It’s not always just about prescriptions and contact lenses – in our experience, sports players get the best results when they spend time with our dedicated sports optometrists learning how to use their eyes and how to never lose sight of the ball,” Gerry explains.

“We know from our work over the last decade with elite athletes that sportspeople are far more likely to experience difficulties with their depth perception than with their visual acuity. Three times more likely, in fact. This means that the most common problem a player will face with their vision is not being able to judge where the ball is exactly, despite being able to see it clearly.” Gerry’s team has found that those experiencing handling difficulties or form slumps are trying to watch the ball. But in trying hard to do so, their eyes get stuck where the ball ‘was’ and don’t move to where the ball is going. This leads to them trying to catch or hit the ball using their peripheral vision, increasing the chance of error. This principle, he says, can be applied to any sport, and it is this process of knowing where to look that enables experienced and skilled individuals to perform at an elite level. In his experience, about 30% of athletes will fail a vision screening and require a follow-up. “You need to talk the talk, you need to demonstrate your expertise, for example that over-convergence affects play, you need to demonstrate how it impacts their ability on the field, court, pitch, shooting range, et cetera. “For example, when talking faster ball sports such as tennis I talk about aspects of their game where they are most likely to make an error – which elite players don’t want to hear – so it is always prefaced with comments like, ‘You have got this far because you can play. My job is to minimise the errors in the team; to decrease dropped balls or turnovers, or unforced errors’. “I will then chat about errors specific to that game, but not the player. If I have already worked with that sport, I’ll use examples of other players, or comments from coaches. Players are then more relaxed. I then ensure I take it away from the sport and talk about other aspects of their life – night driving; reading; vision problems other family members might have. This is so essential as they are very protective of their sporting performance and fear failure and being dropped from the team. Where possible, I also get the coach to speak to the players about me first – if you have the coach’s endorsement it is easier to have the player’s trust.” Gerry’s practice focuses on sportspeople at the amateur level too. When children under the age of 14 first arrive at his practice he sits them in the chair and throws a ball to them. He says it helps them relax and demonstrates to parents what their child is doing with their hands, such as if they catch on the body or away from the body, turn their head or close their eyes when they catch the ball. For Gerry, it illustrates to him their level of hand-eye co-ordination, depth perception, peripheral and central vision. For eyecare professionals considering incorporating sports-related care into their practice, Gerry also recommends asking specific questions about the sport they play and talking to coaches and clubs to offer services for vision screening, even if it’s after hours. “For a junior athlete, you need to relate their sports vision back to their school performance, their performance outside of sport, to get buy-in from their parents.” Separately, but through his specialisation is sports vision, Gerry has collaborated with world-renowned scientists to create MiSite technology, a micro-camera that’s built into glasses and helmets to produce first-person, high definition video. He has used MiSite technology as a training tool with athletes and umpires in elite sports and says it has been proven to drastically improve their performance on the field. “In one case, we could see that when the referee was running backwards, with his head down, he missed the actions of the player standing directly in front of him,” he says.

Athletes experiencing handling issues may be inadvertently using their peripheral vision.

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“When athletes are anxious or fatigued, their vision is affected. Using MiSite technology on AFL players doing a 5km run, we can track their head movement when they’re fatigued. This helps players and coaches understand how physical activity and fatigue can impact

vision, without a visual problem being the cause.” He says the technology can be used beyond sport too. “I had a young female patient who had suffered a stroke. She couldn’t see on, or use, her left side. But when she put on MiSite glasses, it was apparent that she was looking straight down at the ground, not to her left to compensate for her vision loss, which you might assume would be the case. Her visual problems weren’t so much from her hemianopia, but rather her poor stability, meaning she had to concentrate on the ground, not what was ahead of her.” MATCHING THE PROCEDURE WITH THE ENDEAVOUR

Ophthalmologist DR CHAMEEN SAMARAWICKRAMA says infection, discomfort and cost can motivate sportspeople to opt for laser correction surgery over contact lenses. Flap dislocation following laser surgery can be a risk for people who play contact sports.

“I wish I did this earlier.” Ophthalmologist Dr Chameen Samarawickrama has heard this statement countless times from patients that elect for laser eye surgery to improve their vision for sport.

hundreds of laser procedures during the past five years in Sydney. “Patients who want to correct their vision for sporting pursuits but don’t want to wear glasses have three treatment options; external to the eye, as in contact lenses; the surface of the eye, as in laser correction; or inside the eye, as in an implantable collamer lens, or ICL.”

As a corneal surgeon and associate professor at the Sydney Medical School, at the University of Sydney, Samarawickrama has performed

Samarawickrama says, by far, contact lenses are the most common form of vision correction among sportspeople due to their affordability,

www.goggleman.com.au

YOUR PRESCRIPTION. YOUR SPORT.

SPORTS VISION

The Bollé Performance sunglass range, including Bollé Shifter (pictured), provides optimised sports vision with its wide lens and frame offering.

ease of use and relatively low risk profile. This assertion is reinforced by OA’s The 2020 Vision Index which states 24% of Australians always wear prescription contact lenses while exercising or playing sport, and that 41% would prefer to wear contact lenses while playing sport over spectacles. However, Samarawickrama notes contact lenses aren’t suitable for everyone. “Some patients are keen for laser surgery because they’ve had several infections from wearing contact lenses. Some patients complain that they are ‘sick to death’ of contact lenses, they’ve been doing it for so many years. They might say it’s starting to get expensive, with the cumulative cost of purchasing contact lenses over the years.”

PROTECTION AND COMFORT

TOP SPORTS EYEWEAR WISH LIST Lisa Wymond, national brands manager at Sunglass Collective, says demand for prescription sunglasses is increasing rapidly, particularly among active and outdoors-orientated consumers. “As Australians, we have a very healthy appetite for the outdoors with a strong and increasing focus on fitness,” she says. “In terms of sporting eyewear trends which meet this active lifestyle, lenses with a large field of view are important for precision optics and they also provide the muchneeded protection from all the elements.” Sunglass Collective is a new venture from the Wymond family (Eyes Right Optical). It promises to bring a new level of style and service to the Australian and New Zealand eyewear market, including the Bollé Performance range. Mr Paul Harrison, head of sales at Sunglass Collective, says the range is an ideal choice in the sports prescription sunglass category with its industryleading wide lens and frame offering, designed to suit a vast power range of (+6.00 to -8.00, cylinder to -4.00) combined power. “The products in this category are made to meet the needs of elite athlete performance, using precision optics and ultimate comfort as its highest design priorities,” he says. “Bollé understands the important needs of elite athletes and through that knowledge, they are industry-leading in the design of customisable frames which can adjust to the wearers shape for the ultimate in comfortability.” The Bollé Performance sunglass range is designed specifically for cycling – road and mountain biking – triathlon, and golf.

The average price per eye for laser surgery in Australia, according to consumer comparison site Finder.com, is $2,200-$3,400 for LASIK, $2,400-$3,400 for photorefractive keratectomy (PRK), $3,300-$3,700 for SMILE, and $4,700-$6,200 for ICL. By comparison, hypothetically, a patient who wears soft contact lenses typically buys a box of six disposable lenses for $30 ($258 per year), and changes lenses at least every two weeks. The patient also buys at least $150 worth of contact lens solution and cleaning products per year, as well as consultation fees, valued at $100 per year, for a total annual cost of $508. Multiplied over a decade, a patient could spend $5,080 on contact lenses or have PRK surgery for an average cost of $5,800. Samarawickrama says that, taking into consideration the cost and risk of infection associated with contact lenses, laser surgery is preferable for some athletes. From a surgical perspective, it’s also becoming incrementally faster to perform and increasingly accurate. “It’s a quick procedure. It used to take 90 seconds; now it takes 30-40 seconds, and it’s only going to get faster. Tracking software has also improved. The laser automatically cuts off if it detects movement,” he says. He explains that treating the surface of the eye can be done via three types of laser eye surgery. LASIK (laser assisted in situ keratomileusis), the most common type performed worldwide, involves creating a thin flap in the front of the cornea with a femtosecond laser. The flap is lifted and an excimer laser is then used to reshape the underlying cornea to treat the refractive error. The flap is then repositioned and a bandage

“In these sports, the needs of the athletes can be varied, depending on the environment and potentially changing conditions,” Harrison says. “However, eye protection and comfort are still two of the most important factors.” “In terms of lenses, Bollé Sunglasses are strongly focussed on delivering the ultimate in precision optics, with a wide field of view and importantly, they are superior in delivering ultra-lightweight, durable and customisable frames.” He says for sportspeople who are continually striving to improve their performance, their eyewear must also provide superior vision, ultimate protection and comfort. “Whether the climatic conditions be static or changing, eyewear technology must be able to adapt to these changing light conditions if it’s required. This is extremely important to the athlete who needs to perform at their best, no matter what the conditions provide.” Harrison says nearly all Bollé lens options are available on Bollé’s B-Thin Active Design prescription program, “including the highly regarded photochromic Phantom lens range and importantly in each of the Shield offerings". Swimmers face increased infection risk from contact lens wear.

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contact is placed over the eye to protect the flap. PRK (photorefractive keratectomy) is a surface laser eye surgery technique where the excimer laser is applied directly on to the surface of the eye without initially creating a flap (as in LASIK). A bandage contact lens is placed on the eye afterwards. SMILE (small incision lenticule extraction) uses the femtosecond laser to cut a disc within the cornea that the surgeon removes through a small incision on the surface. In terms of determining the most suitable laser surgery, Samarawickrama says the sporting endeavour often determines the best approach. For example, he had a male patient who was a high-level Muay Thai boxer. He wore contact lenses, but a punch to the face during a bout dislodged the contact lens in his left eye. The fight continued, but he couldn’t see clearly on his left side as the blows continued. He lost the bout, so he sought a permanent vision correction solution. “In this instance PRK was the best solution for him, and his eyes had healed completely a few weeks after surgery and he could get back in the ring,” he explains. “It’s the same if you play rugby, soccer or martial arts. Contact sports carry a risk of trauma to the head, so PRK is usually the preferred treatment option because there is no risk of flap dislocation in the event of trauma.” He continues: “For swimmers, the risk of infection from wearing contact lenses is high, so decreasing that risk through laser eye surgery is ideal. It doesn’t matter which type of laser surgery they choose, and most opt for LASIK as it heals the fastest. “A third less common option is an implantable collamer lens. I had a 20-year-old male patient who was a -15 D myope. I couldn’t perform LASIK or PRK to correct that degree of myopia, but I could implant an ICL.” For the average patient who has a desk-job in an office and works out in a gym, LASIK is typically the preferred treatment option for vision correction. “The evidence shows that the quality of vision at the one-year mark after surgery is the same for all laser surgeries (LASIK, PRK and SMILE),” Samarawickrama says. “But LASIK is less painful and boasts a faster recovery, whereas PRK is more painful and recovery is slower but doesn’t have the risks from the LASIK flap.” THE GO-TO GUY

MR DAVID AULERT says prescription sports eyewear is a specialised field and requires a lot of technical understanding.

Mr David Aulert is an optical mechanic with more than 30 years at the coalface of making, grinding, cutting, coating, and tinting lenses. That experience has helped carve a new career as a specialist in prescription sports eyewear, supplying ‘hard to find’ products for a wide range of sporting and recreational activities not readily available in traditional optical stores. Aulert operates the company Goggleman, which has provided prescription eyewear since 2002, including prescription swimming goggles, ski masks, SCUBA diving masks and motocross goggles. “Optometrists don’t have in-depth knowledge of what’s available, what’s possible, in this niche market. That’s where my business fits in – retailing

Ski masks are just one example of sports eyewear that can incorporate a prescription.

prescription eyewear solutions for people in sport and recreation,” he says. Aulert’s career began as an optical mechanic with Solar Optics. When the dispensing profession was deregulated, he took a break from the local industry and travelled overseas. When he returned, he accepted a position as technical co-ordinator for Carl Zeiss, which had acquired Solar Optics. “From the mid-1990s to 2010, optical mechanics and dispensers were underpaid and under-valued. When the profession was deregulated, the tradesmanship of optical mechanics and dispensers were lost. In the space of six or seven years, all the good people had left the industry. The optical dispensing industry is all about knowledge, but that education was lost with the deregulation.” While working for Zeiss, Aulert often had to turn down requests to fit prescription lenses into sports eyewear, even though he knew it could be done technically, because of Zeiss company protocols. Those lost opportunities planted a seed in his mind to capitalise on a niche market for a dispensary dedicated to sports and recreation, including skiing, swimming, SCUBA diving, triathlon, cycling, and motocross. He left Zeiss and established Goggleman in the Adelaide suburb of Brighton. It also has an online presence, which accounts for 70% of his overall business income. “It’s a specialised field and requires a lot of technical understanding. I have that optical mechanics knowledge, and that knowledge in this industry is like gold,” he says. Aulert distributes his products directly to consumers from under one roof. Through all his years of problem-solving in optical dispensing, he has built a reputation as the go-to guy for sports and recreation prescription eyewear. With an emphasis on quality, not speed, Aulert utilises his connections in the industry to produce bespoke products, with some orders sent to several labs. “I source the lens from this lab, I get a specialised tint from another lab, I go to another lab for fitting. I can go through three or four labs for one pair of specialised prescription eyewear,” he says. “Based on my years in the industry, I know what labs are good at what, and I can put the pieces of the puzzle together for the best outcome for my customer. “I’m a specialist in what I do, with 30 years’ experience."

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FEATURE

The Glaukos iStent inject Trabecular Micro-bypass System is intended to reduce IOP in adult patients diagnosed with mild to moderate open angle glaucoma.

WHERE ARE WE

WITH MIGS? The 2014 arrival of MIGS to Australia introduced a whole new field of interventional glaucoma therapies. Queensland ophthalmologist Dr Frank Howes re-defines the term and explores current surgical interventions, explaining where each fits in the glaucoma treatment algorithm.

espite all the years that minimally invasive glaucoma surgery (MIGS) has been in existence, it’s intriguing that we are still at sea with so many MIGS procedures and often have to return home to the harbour of trabeculectomy. However, some of these surgical modalities are beginning to prove their worth. We have been running MIGS programs in Australia for the past six years, with many surgeons now using the MIGS procedures where appropriate. The procedures started on an open and even platform; all initially equal. Australia is fortunate to have had access to so many procedures on the world stage to use in an attempt to reduce the risks involved in the surgical treatment of glaucoma. Time has allowed these procedures to rank order themselves according to ease of use, efficacy and complication – and not necessarily in that order. To adequately treat and manage this disease, the ophthalmological world has had to utilise the glaucoma management resources carefully. That means the optimal and judicious use of drugs, laser interventions, minor and major surgical interventions, often in that order, to minimise our patients’ rate of disease progression, while assisting them to maintain an acceptable quality of life. The choice profile used by surgeons in the glaucoma management field revolves around the risk-benefit ratio. The use of too many drugs can cause systemic and local side effects, related to the drugs themselves and the preservatives present. At the other end of the scale, too early an intervention with a major surgical procedure, places a patient’s vision and eyes at unnecessary risk of loss. The human compliance issues make the situation that much more complex. Enter, therefore, the ‘middle ground’ procedures. These started in the

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1980s with argon laser trabeculoplasty (ALT) and in the 1990s with selective laser trabeculoplasty (SLT). These procedures were of great assistance to ophthalmologists around the world (as was the subsequent entry of preservative-free topical glaucoma drugs). The surgical procedure of SLT well predated the category of procedures we now call MIGS, but it could certainly fit the definition. The presence of such procedures, and the ever-present need to provide our patients with the ‘less is more’ concept in glaucoma management, pressed entrepreneurial ophthalmologists and scientists both in Australia and around the world to invent procedures and devices to better fill this middle gap. So, what have we had? One of the first ‘middle ground’ procedures, pre-MIGS, was the nonpenetrating glaucoma surgery group of interventions (deep sclerectomy and viscocanalostomy), quick to be supplemented by simultaneously implanted tiny devices to maintain their function. This taught us again that Schlemm and trabecular manipulation, initially done for children many decades ago, was a viable option for managing outflow facility. So, enter canaloplasty - Schlemm intubation and segmental viscoelastic Schlemm dilation, both ab externo and ab interno. Off shoots from this thinking was the removal or bypassing of the inner wall of Schlemm’s canal and the trabecular meshwork (TM) to better expose the collector channel openings to aqueous humour and enhance outflow. The need for a minimally invasive glaucoma procedure grew from these observations. Work had begun in the first decade of the 2000s on the trabecular bypass systems, the iStent and the Hydrus groups. Parallel to this was the development of the TM removal procedures – GAT (Gonioscopically Assisted

Trabeculotomy), Trab 360, Trabectome, KDB (Kahook Double Blade) trabeculotomy. However, these TM removal procedures, although relatively safe and effective in the short term (despite the bleeding), proved to be destructive of normal anatomy with unknown long-term effects. To complicate the view, work was also being done on minimally invasive devices to bypass the full outflow facility, both into the suprachoroidal and subconjunctival spaces (see below). Of the many surgeons and scientists around the world that contributed to the development of these devices and procedures, Iqbal ‘Ike’ K. Ahmed, MD, FRCSC (Toronto, Canada), was the one who coined the term MIGS in 2009. He did so with the following defining terms, in an attempt to place order into these new surgical approaches: • Ab interno approach – conjunctival sparing. • Minimally traumatic – negligible damage to normal anatomy or physiology.

Figure 1 desmonstrates how each procedure fits the MIGS definiton, with those closest to the epicentre containing greatest defining features.

• Micro-incision – clear corneal incision <2.0mm. • Efficacious. • Extremely high safety profile – rapid recovery. As can be seen there are several different procedures that have come to market that come close to fitting the definition, but some perhaps not, so there are some ‘musts’ and some ‘preferables’. ‘Musts’ include an ab interno approach, conjunctiva sparing, and microor minimally-invasive. ‘Preferables’ comprise a blebless outcome, no cyclodialysis cleft, no cautery, and a limited treatment area. Some of these procedures fit the definitions fully (iStent, Glaukos), some in the epicentre (iStent inject, Glaukos), some close (Hydrus, Ivantis and the ab interno canaloplasty (ABiC) from Ellex), and some further away but still relatively minimally invasive, although invading the subconjunctival space (Xen, Allergan and Preserflo, Santen). Some thought to be minimally invasive (suprachoroidal space) have proved with time not to be so (Cypass, Alcon), others being possibly more complex than initially thought (Xen), with competitors out there to potentially challenge their position (Preserflo). The ‘Dart Board’ in Figure 1 demonstrates roughly where the procedures we call MIGS fit. The further from the epicentre, the less the procedures fit the definition of MIGS. As can be seen, the Glaukos Generation one and Generation two (iStent/ iStent inject) within the green bullseye area fit the definition fully, and are beginning to cement their place firmly in the management of glaucoma. The Ivantis Hydrus device is close to the epicentre, as is the ABiC procedure (inner blue area), but due to the length and extent of intervention of these procedures is by definition not quite as minimally invasive as the microscopic iStent inject.

Dr Frank Howes breaks down MIGS terminology and why some no longer fit the group.

group for the time being. The Glaukos iStent devices have fixed their position in the centre of the MIGS group for the safe management of mild to moderate glaucoma and as a safe device for use in the provision of a mild to moderate effect. This knowledge can also be used to reduce the burden of glaucoma drug management in our patients by allowing a reduction in medication load when used in conjunction with trabecular bypass. This concept has given birth to yet another new medical acronym, ‘MIST’, coined by leading US ophthalmologist Dr Tom Samuelson, of the Minnesota Eye Consultants, standing for minimally intrusive sustainable therapy.

The other procedures in the blue area but outside the red circle, loosely fit the definition of MIGS as they still fulfil some of the pre-requisites of the definition, but the bleeding and recovery time blow out.

We started this dissertation with the statement that all MIGS procedures began on a roughly even playing field. But with time it has become apparent that the procedures are in fact not all equal.

The procedures in the greyed area actually fall out of the definition of MIGS due to conjunctival involvement but knock on the door due to increased safety over full thickness penetrating surgery.

Indeed, after rigorous assessment, the Australian Department of Health (MSAC) has recognised this by the introduction of the term ‘trans trabecular drainage device’ for the recently approved MBS code 42705. Sub-categorisation for the differentiation of the devices now appears to have begun. Furthermore, we now welcome the news of the ‘trans trabecular drainage devices’ being usable as standalone devices in phakic or psuedophakic eyes, as from 1 May 2020, on the new MBS item 42504. Australia is the first country in the world to have a standalone device insurance approved. However, this is under strict surveillance circumstances.

The laser and cryo ciliary destructive procedures have never entered the MIGS arena due to the anatomical change and destructive element, while the suprachoroidal devices have fallen from the MIGS grouping as they have demonstrated significant endothelial cell loss, plus there is the risk of the associated choroidal haemorrhage with manipulation. This group of devices are still searching for their correct place in the management of glaucoma. Certainly, we know that opening the suprachoroidal space lowers intraocular pressure, but when and how to do this remains to be established. These have fallen out of the active MIGS

Decision making in this field is all about minimising risk and maximising quality of life. n DR FRANK HOWES – MBChB MMed FCS FRCS FRCOphth FRANZCO

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REPORT

Extended versions of these articles can be found at www.insightnews.com.au

CHILDREN’S VISION – SEEING THE FUTURE Orthoptics Awareness Week is taking place between 1-5 June with the theme ‘Seeing the future’. The campaign will amplify the integral and expanding role of orthoptists in paediactric eye health. To celebrate, Orthoptics Australia has produced five articles by orthoptists at the country’s leading children’s hospitals.

THE CRUCIAL ROLE OF ORTHOPTISTS IN PAEDIATRIC VISION SCREENING The primary goal of paediatric vision screening is to detect disorders of vision that can lead to amblyopia. Orthoptists can play a key role in amblyopia detection and management thanks to university training programs, workplace experience and continuing education opportunities. The orthoptist skillset means they can competently assess vision from birth into adulthood with specialised testing and adaptive techniques. The techniques of play, distraction, adaptability and a ‘never give up’ attitude are key in paediatrics. These allow orthoptists to gain accurate vision assessment, enabling timely diagnosis and appropriate intervention. Universal vision screening involves thorough planning and accessibility through all stages, including implementation, detection and timely treatment. In New South Wales, StEPS (State-wide Eyesight Preschooler Screening) is one such program, which offers all four-year-old children free vision screening. The Children’s Hospital at Westmead (CHW) has now been involved in the program for 12 years. It sees high priority referrals of four year olds that have undergone primary community-based screening with a vision fail of 6/18 or worse. They are managed within the tertiary level clinics by paediatric orthoptists and ophthalmologists. Orthoptists working within the high priority referral clinic at CHW have a great sense of achievement. Families have anecdotally shown their gratitude; firstly to the community-based screeners for detecting their child’s vision problem; and secondly to the paediatric orthoptists and ophthalmologists involved in their care. Orthoptists working in this clinic feel privileged to deliver first-class care to NSW children and gain good visual outcome for the child by the time they are eight years old. The program adopts a holistic approach and is accessible for all. Those with a disability or additional needs can also be assessed via secondary and tertiary screening to ensure no child is missed. The four year old test is crucial because at this age children have the cognitive function to perform gold standard crowded acuity letter matching tests. It’s also an ideal window of opportunity for treatment during the critical period of vision development. The vast majority of children referred to the CHW high priority clinic with a visual acuity of 6/18 or less have a diagnosis of refractive error with amblyopia. A small proportion are children who were unable to be screened at the community-based screening, while another small proportion have other ocular disorders or pathology. The most common refractive errors are hypermetropic astigmatism,

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myopic astigmatism and anisometropia. It’s no surprise, particularly with the high anisometropic cases, that children in this age group do not complain of vision problems; due to having one ‘good’ eye, their poor monocular vision goes unnoticed by parents and care givers too. This demonstrates the importance of a universal vision screening program. The main form of management is to correct the refractive error with glasses that are worn fulltime for all activities.

Sebastian, who was eight at the time, has

A glasses adaptation period of benefited from the StEPs program in NSW. 12 weeks is allowed and, if sub normal vision persists in one eye, then amblyopia is diagnosed and parttime occlusion therapy of the better eye is commenced. In some cases of high anisometropic amblyopia with poor visual acuity and assumed dense amblyopia, part-time occlusion therapy is commenced immediately at the same time as the glasses are commenced. With close monitoring and support from orthoptists in regard to occlusion therapy, outcomes in this age group are excellent. The majority achieve a final best corrected visual outcome in their worse eye of 6/7.6 or better. Between the ages of eight to 10, children who can demonstrate their vision has stabilised after active occlusion therapy, and can competently perform a subjective refraction, are discharged to their local eyecare provider. Paediatric orthoptists possess great communication and counselling skills, allowing rapport to be built with children and families. This facilitates the provision of accurate information to reassure to families, while ultimately contributing to the best outcome for the child. ABOUT THE AUTHOR: LOUISE BRENNAN is a senior paediatric orthoptist who has worked at The Children’s Hospital at Westmead for the past 25 years.

PAEDIATRICS AND THE PUZZLING PICTURE OF GENETIC EYE PROBLEMS A referral lands with the orthoptist stating the child has trouble seeing the board. Sometimes they have ongoing light sensitivity or trouble identifying colours. Maybe they’re scared of the dark or hold objects close to their face. These are common complaints that don’t usually warrant much further investigation. However, a genetic eye disease can present the same way and orthoptists can determine the likelihood of this. Each inherited eye disease generally comes with its own set of clinical signs and symptoms. Even then, the same mutation may present at different ages with varying degrees of severity/progression. The orthoptist approaches their investigation as a puzzle. The first puzzle piece relates to the history of the complaint. This involves thinking outside the box and digging deeper. For more common genetic diseases, such as a cone/rod dystrophy, albinism or retinitis pigmentosa, age at onset, gradual or sudden changes in behaviour and light or dark adaptation are important, as well as outdoor and indoor behaviours. Maybe children can’t explain what they see or notice visual changes. Asking what they like to do guides the orthoptist in determining signs and symptoms. The parent may also be the best information source. The second puzzle piece pertains to family history. If existent, the task is easy. However, if the ocular symptomology is an unfamiliar phenomenon within the family, a family tree becomes critical. An orthoptist investigates immediate and distant ancestry to determine a likely inheritance pattern. The key may lie in a colour-blind distant relative, or an older sibling who is strikingly blonde with no apparent ocular problems. For orthoptists, no clue is insignificant. The third puzzle piece involves observing the child and their visual

behaviours, particularly when they struggle to sit still and can’t perform other clinical testing. The way they hold their digital device or lose attention at certain distances may provide key information. Clinical examinations – guided by the history and observations – provide the fourth component. An orthoptist may choose cone function tests such as near visual acuity and colour vision. If rod dysfunction is suspected, then visual fields are crucial. Some orthoptists Retinitis pigmentosa – Ophthalmic Imaging, Flinders Medical. specialise in electrophysiology testing for rod and cone disorders. If albinism is suspected, a child will undergo cover testing, nystagmus assessment and cycloplegic refraction. Orthoptists know not to dilate suspected albinism cases before checking iris transillumination defects. The orthoptist meticulously chooses each test, knowing how to extract maximal information. Paired with the ophthalmologist’s findings, they guide the clinical geneticist in determining which genes to test for and, consequently, provide genetic counselling. This completes the puzzle. ABOUT THE AUTHOR: LACHLAN KNIGHT is an orthoptist specialising in paediatrics and genetic eye disease at Flinders Medical Centre and the Women’s and Children’s Hospital, Adelaide. He is undertaking his PhD in the genetics of childhood glaucoma at Flinders University.

PLEASE KEEP CALM AND CARRY ON PATCHING March 2020 saw many changes across Australia due to the COVID-19 crisis. How people conducted shopping, interacted with others and accessed school and work underwent transformative change. The outpatient ophthalmology clinic at the Perth Children’s Hospital (PCH) was no exception after it was required to reduce face-to-face appointments for the upcoming months and re-appoint patients to phone or video consultations via telehealth. Emergency face-to-face appointments could continue. For many orthoptists, the alarm bell would have sounded when considering their patients who were patching. Will they remember? Will they stop because they won’t be seen in clinic for possibly the next six months? If parents have run out of patches or lost their patch, how will they obtain more? And what if all the hard work is undone? It was obvious that during this crisis patching therapy could be neglected. Many parents will face hardship and stress, but it’s important to encourage families to continue patching. The approach at PCH was to send letters to these patients. During telehealth consultations those currently patching were advised to continue and reminded of their patching regime. Other patients who did not have a telehealth consultation but were identified as patching were also sent a letter. The ‘Keep Calm and Carry on Patching’ letter not only served as a reminder, but included key pieces of information such as the importance of patching, as well as key information supported by the Newsham (2002) study. PCH also included tips on the best time for patching, what activities were not suitable and where patches could be purchased online. The letter was a simple tool that was inexpensive, easy to implement

and an effective method to remind and encourage. The Newsham study helped motivate this approach. It investigated the ability of educational material to improve parental understanding of amblyopia and occlusion. Newsham found that parents who received a leaflet about occlusion therapy demonstrated significantly greater knowledge (88%), compared with a control group (49%). Compliance was also found to be higher in the leaflet group.

Parents should be encouraged to continue patching amid COVID-19.

While the PCH’s primary aim was not to improve parental knowledge, but to remind families to continue patching therapy, the Newsham findings are encouraging nonetheless. The letter will continue to be sent, while PCH considers other methods to bolster its efforts. The hospital will also consider other patient groups that might benefit from additional information or treatment reminders. PCH is looking forward to seeing its patients in clinic again and hopeful this modest intervention has proved beneficial. ABOUT THE AUTHOR: HOLLY BROWN is an orthoptist at Perth Children’s Hospital and a private ophthalmology clinic in Joondalup. She has been working in Perth as an orthoptist since graduating from La Trobe University in 2015.

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TIPS AND TRICKS FOR TESTING CHILDREN’S VISION The difficulty in paediatrics lies in that no two cases are the same. Attention to detail, adaptability and patience help overcome this. Imagination is another factor, hence why it’s one of four core values at the Queensland Children’s Hospital. Children learn through play, and now we’re testing through play. The first step is creating the vibe. Children’s eye clinics are abundant with bright colours, stickers, toys and art. Once they’re in the door, interaction is imperative and this is where adaptability becomes essential. Children develop their own personality early on and it’s important to note what interests them. It quickly becomes clear which children there will be limited time to assess, and those needing time before letting down their guard. An orthoptist’s experience and attention to detail are crucial because, with the smallest mistake, one can lose the child’s cooperation. However, the smallest eye movement can provide the necessary information. It’s a balance between speed to maintain interest and rechecking to ensure accuracy. There are a variety of testing methods depending on what the orthoptist wants to know and the level of the child. Does a baby react to light, or is it focusing on mum’s face? Is it following large or small toys? As the age increases, it’s important to reduce the stimulus size, keeping in mind children’s vision develops until age seven.

Occlusion tells a lot about vision but it’s also important when documenting more exact vision in older kids. There are many ways of occluding an eye; perhaps mum has spectacles so Sophie will wear the occlusion glasses too. Johnny tries to peek, but loves pirates so let’s use a pirate patch. Matching games are next. By displaying a picture at a distance and having the child verbalise or match, you’ll know whether they can see it. Testing through play is vital to examine children like Freya, 4. Many granddads also show the pinhole trick. By making a fist with their hand and peaking through the hole, their vision improves. This is science, not magic – and something we utilise frequently because of the insight it gives into the visual potential. There is more than meets the eye when testing children’s vision. And we haven’t entertained other modalities in a routine paediatric exam, how well the eyes work together, depth and colour perception, eye movements, the need for glasses and back of the eye check.

Eye preference and preferential looking is next and orthoptists have a heavy artillery here. Patients should be happy to use each eye equally and instinctively look towards a picture that’s more interesting.

ABOUT THE AUTHOR: FAREN WILLETT, BSc, MOrthop, is a paediatric orthoptist at the Queensland Children’s Hospital.

The professional can tell if the eyes aren’t seeing equally. If a good eye is covered, leaving the poorly seeing eye, a child will understandably become upset.

SCREEN TIME AND VISUAL DEVELOPMENT ADVICE FOR PARENTS As society becomes increasingly reliant on technology, and more children spend time indoors on their screens, concerned parents are often asking orthoptists: Does screen time affect my child’s vision? Screen use has been associated with a number of health concerns in children, including developmental outcomes, obesity, poor sleep quality, ADHD and eye development. This has led to the development of Screen Time Guidelines by respected bodies such as The World Health Organization (WHO). The table (opposite) highlights how, even in 2017, Australian children were using mobile devices and screens much more than the recommended guidelines. The effects of too much screen use on children’s eyes are well documented. The WHO predicts myopia will impact 52% of the world’s population by 2050. It’s well-established this is partly due to excessive near work activities combined with increased time spent indoors, and partly due to a lack of outdoor exposure. As we know, myopia is important to manage because if it progresses into ‘high myopia’ – five diopters or more – it’s associated with sight-threatening complications like glaucoma, retinal detachment and myopic macular degeneration. Research shows spending as little as 40 minutes more a day outdoors may slow myopia progression in children. The orthoptist can detect myopia by assessing the focusing ability of the child’s eyes in a detailed eye examination and advise treatment options. With excessive screen use, children may develop digital eye strain, associated with symptoms like headaches, blurry vision, itchy or dry eyes. In this case, it’s the orthoptists role to educate the child on the importance of resting their eyes during extended periods of near work. They may prescribe activities such as more frequent blinking during near work, or looking into the 36

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Age of Child

Australian Department of Health: Recommended Screen Time Guidelines

Screen time use by children in Australian households in 2017 (3)

Infants / toddlers

Zero hours No screen time

2hrs/day 14hrs / week

2-5 years old

1 hr / day 7hrs / week

3.5hrs / day 26 hrs / week

6-12 years old

2 hrs / day 14 hrs / week

4.5hrs / day 32hrs / week

distance for 20 seconds every 20 minutes. Convergence insufficiency (CI), a condition making it difficult for the eyes to work together on near tasks, can result in symptoms like headaches, double vision for near work, floating letters on the page and blurry near vision. Although not caused by screen use, if a child has CI, they may notice the onset of symptoms after near work. The orthoptist can detect CI during a routine exam and manage the condition to relieve symptoms. The most common form of treatment is orthoptic eye exercises, which the child can perform at home to train the eye muscles. For parents, the take home message should be to balance indoor screen time with daily outdoor activities, and allow time for the eyes to rest when spending extended periods on near work and screen use. n

ABOUT THE AUTHOR: CATHY LEWIS is the chief orthoptist at the Royal Children’s Hospital Melbourne and a casual lecturer in orthoptics at La Trobe University.

TELEHEALTH

FOR PATIENT MANAGEMENT The COVID-19 crisis has spurred a telehealth revolution that’s helping mitigate disruption for practitioners and patients. Leading professionals share their telehealth tips and discuss why the technology might be here to stay.

s the COVID-19 curve continues to flatten, parts of Australia are easing restrictions. There are also promising signs of a partial return to normality for the ophthalmic sector.

While it is impossible to rule out another outbreak, eyecare practitioners are pondering how they will manoeuvre away from an ‘urgent care’ model and cater for pent-up demand. Many are also considering how they will deliver services in the event of further business disruption or if vulnerable patients are apprehensive to visit the practice. Telehealth is one such solution and, in the previous issue of Insight, it was identified as a promising opportunity for the sector beyond the crisis. As it becomes increasingly mainstream, industry figures also believe the use of virtual consultations could drive new innovation and irrevocably alter current care models. This month, the conversation continues as members of the ophthalmic sector offer practical tips on telehealth use and discuss its place in the future of Australian eyecare. THE CURRENT LANDSCAPE Before considering the potential of telehealth, it is important to note both sides of the telehealth coin. Teleophthalmology describes collaboration between optometrist and ophthalmologist and patient. Tele-optometry defines optometrist to patient consultations. Adelaide-based optometrist Mr Ben Hamlyn works in member support

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TELEHEALTH

and is a policy advisor with Optometry Australia (OA). He says the current MBS reimbursement, introduced in 2015, for a telehealth consultation requires the optometrist and patient to be present together while an ophthalmologist participates via online video technology.

According to Hamlyn, optometrists are typically choosing to deliver telehealth from their practice, but it is important that the location is secure and private. For example, ensuring the door is closed so others cannot overhear patient disclosures.

“These MBS items are restricted to patients who are in ‘telehealth eligible’ areas which is non-metropolitan and outside a 15km radius from the treating ophthalmologist. This restricts use to those outside metropolitan areas, unless they are providing care in an aged care facility.”

“Requirements on record-keeping are also the same as for a normal face-to-face consultation but optometrists need to be able to remote access patient records for history and note-taking if they are not in the practice physically,” Hamlyn says.

Although Medicare Benefits Schedule (MBS) data over the past five years has indicated telehealth, or teleophthalmology, consultations are under-utilised in optometry, Hamlyn anticipates it has been adopted more frequently during the COVID-19 pandemic.

Optometrists have also faced the challenge of defining what constitutes ‘urgent care’ under the COVID-19 restrictions. This includes diseases that have a risk of progression, or a patient who has had their visual function impaired.

Subsequently, OA, Specsavers, Luxottica and Diabetes Australia have lodged submissions with the Department of Health to modify optometry MBS item numbers 10916 (brief initial consultation) and 10918 (subsequent consultation) for telehealth purposes.

For example, Hamlyn says a patient may have damaged spectacles, which means they are unable to drive to the supermarket. By definition, they need ‘urgent care’.

At the time of writing, the government still had not approved this proposal, with the lack of progress frustrating the sector. In the meantime, OA has released a Clinical Practice Guide on Telehealth in Optometry in March, and more than 470 members watched a webcast it hosted in early April to share advice on the topic. Hamlyn fielded questions from members during the webcast on appropriate billing, record keeping and workflow requirements. “We are emphasising that it is important for practices to decide under what circumstances, and when, is appropriate to use telehealth,” Hamlyn says. “Telehealth should be considered as an adjunct to regular care and not a replacement for face-to-face care.” Without an MBS rebate, some optometrists are privately billing for telehealth services. Hamlyn says OA recommends charging a fee similar to a regular face-to-face consultation, commensurate with the duration of the consultation. “Professional indemnity insurance is also a matter to consider. Members want to know whether they are covered. We can confirm OA’s professional indemnity insurance provider covers telehealth,” he says, adding that non-OA members should check their coverage before providing telehealth services.

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Telehealth also raises a host of questions for therapeutically-endorsed optometrists, which now account for 65% of the profession. “Members want to know if they can issue a prescription or repeat a prescription, such as an expired contact lens or spectacle lens prescription, without looking at the patient’s eyes face-to-face,” Hamlyn says. “There is no regulatory reason why an optometrist couldn’t repeat a prescription, provided they’ve considered the health of the eyes and the patient, and can potentially shorten the length of the prescription if it is reasonable to do so. We urge optometrists to consider all circumstances available and treat on a case-by-case basis.” Despite the absence of an MBS reimbursement for now, OA has partnered with Oculo to provide its members’ practices access to the telehealth platform – including its real-time videoconference feature – for an initial six months at no cost. The platform is also used by Specsavers and Luxottica optometrists, among others. “It’s designed for eyecare, offers a private and secure environment to transfer clinical data, and can work alongside practice management software to facilitate access to patient records.” As of mid-April, OA reports more than 600 members had updated their online member profile to indicate their practice is offering telehealth, which

TELEHEALTH IS AN EXCITING PROSPECT – IT CAN ELICIT EARLIER, MORE TIMELY ACCESS TO EYECARE, AND CERTAIN CONDITIONS CAN BE DETECTED EARLIER.

THEORETICALLY, AN OPTOMETRIST COULD CONSULT WITH ANOTHER OPTOMETRIST WITH EXPERTISE IN A CERTAIN AREA OF PRIMARY CARE, SUCH AS GLAUCOMA, ORTHO-K, OR BEHAVIOURAL OPTOMETRY.

WE SEE TELEHEALTH BECOMING AN IMPORTANT ADJUNCT TO CONVENTIONAL OPTOMETRY IN THE FUTURE, ONE THAT OVERCOMES SOME BARRIERS TO CARE FOR THE COMMUNITY.

ANGUS TURNER

ALEX CRAIG

BEN HAMLYN

is then displayed in the organisation’s ‘Find an Optometrist’ search function. It’s estimated some 200 practices would ultimately take-up the offer.

Professor Robyn Guymer, CERA.

Alongside telehealth, OA is considering innovative ways to measure visual fields, such as the Melbourne Rapid Field (MRF) software that can be accessed on multiple platforms, including iPad. According to the designers behind MRF software – which is registered with the Therapeutic Goods Administration as a perimetry device – it provides a portable, rapid and accurate threshold testing for patients with eye and neurological conditions. It can be used in clinical settings during COVID-19 instead of viewing-dome or goggle-type visual field devices that make direct contact with a patient’s face. “Telehealth has proven it is useful to patients who live near services, not just those in rural areas. It has shown us all that maybe this is something that will become more part of our profession over time. Some changes are here to stay,” Hamlyn says. “We see telehealth becoming an important adjunct to conventional optometry in the future, one that overcomes some barriers to care for the community enabling high quality care to be provided in an efficient manner that benefits both the patient and the practitioner. It is not a replacement for conventional clinical care, however it opens new ways to care for our patients.” Hamlyn says the most challenging part of changing practice is the transition, and COVID-19 has accelerated this change. OA is also encouraging optometrists and ophthalmologists to work together and look at innovative models in how the eyecare system manages the backlog of patients that will result from temporary reduction in care. “It has opened the eyes of practitioners and staff to other ways of practicing and given them experiences of working in a different way. The innovative approaches that provide benefit to the community are likely to stay. This may be as simple as incorporating regular telehealth for vulnerable groups, or upskilling staff to enable better triaging of urgent appointments.

TELEHEALTH TO CONTINUE GATHERING PACE POST-PANDEMIC Rapid uptake of telehealth amid COVID-19 is energising research focused on new ways to remotely diagnose and monitor eye disease, according to the Centre for Eye Research Australia (CERA). “Video communication has moved into the mainstream and this is an irrevocable change that will also translate into the health system,” CERA deputy director Associate Professor Peter van Wijngaarden says. “New technologies have the potential to detect the early signs of disease – without the need to attend an eye clinic – and determine who needs to be referred for a more detailed clinical assessment. Research is now revealing the potential to test patients at locations that suit them – in their own home, a photobooth in a shopping centre or during a visit to another healthcare provider like a GP.’’ Van Wijngaarden is developing a simple eye test to detect the early signs Alzheimer’s disease. He is also clinical director of KeepSight, a national eye check reminder system for people with diabetes. He says new screening technologies needed to be accessible and convenient, and people need to be motivated to use them. For example, Professor Robyn Guymer, deputy director and head of macular research at CERA, is helping develop a digital application for neovascular agerelated macular degeneration (AMD) patients.

“Technology in this area will continue to evolve and enable optometrists to capture more information remotely, and we should be open to these changes and utilise them to improve our profession and our care to patients. There is still a way to go, but COVID-19 has certainly kick-started telehealth.”

It is hoped new tests will replace the Amsler grid, and involves patients taking a weekly test on an electronic tablet at home to monitor for early signs of disease.

SPEAKING FROM EXPERIENCE

Guymer hopes it will reduce the number of review appointments, minimising pressure on the health system. The next challenge is to ‘gamify’ the digital tests to ensure they’re engaging so patients continue to use them.

Dr Angus Turner is a name synonymous with teleophthalmology in Western Australia. He is the McCusker Director of Lions Outback Vision, part of the Lions Eye Institute in WA, which has run a state-wide teleophthalmology service to rural and remote communities in WA since 2011. “Telehealth is an exciting area and the real-life restrictions put in place due to COVID-19 have placed it on the agenda. It is an opportunity to provide patient access to eyecare, to be as useful in urban areas as it has been in remote and rural Western Australia.” Speaking from nearly a decade of experience in teleophthalmology, Turner believes collaboration between optometry and ophthalmology is a necessity; both professions are maldistributed and cannot afford to duplicate their efforts. “There must be opportunities to work together better in the community. To that end, telehealth is an exciting prospect

She hopes it will incorporate an electronic test that could be accessed remotely by specialists. Patients with noticeable deterioration would be alerted to take action.

Professor Mingguang He is trialling the use of an artificial intelligence (AI) tool to identify people at early risk of blinding eye diseases, including diabetic retinopathy, glaucoma, AMD and cataract. It’s being trialled in real-world setting, including remote Indigenous communities in the APY Lands in Central Australia with the Nganampa Health Council and The Fred Hollows Foundation. The next step will be to compare the AI tool against current telehealth models and measure accuracy, cost-effectiveness, ease of use and patient and clinician acceptance. “After COVID-19, face-to-face consultation will become increasingly challenging. AI integrated with automation and robotic technology will enable us to develop a virtual clinic as a new model of care,” He said. Seperately, He has led the development of an app which enables people to measure their visual acuity at home.

INSIGHT June 2020 39

XX TELEHEALTH

– it can elicit earlier, more timely access to eyecare, and certain conditions can be detected earlier.” In 2014, Lions Outback Vision demonstrated that providing a reimbursement to optometrists for providing a teleophthalmology consultation led to significantly more consultations being performed. This research evidence was used to successfully lobby the Australian Government to provide funding for a reimbursement through the MBS. A year later, the Federal Government introduced an MBS reimbursement for optometry-facilitated teleophthalmology consultations under specific circumstances. It was made available to optometrists to provide realtime teleophthalmology consultations with ophthalmologists for patients that comply with the 15km rule, and are based at an Aboriginal Medical Service, or in an aged care facility. “Real-time teleophthalmology consultations, as per the MBS descriptor, has an inherent problem with lining up three people – optometrist, ophthalmologist and patient – for a video conference,” he explains. “It depends on availability, and we’re still facing that roadblock because, in my experience, optometrists and ophthalmologists work on a different rhythm, although it does have real-time benefits for the patient, because they are in the conversation, and can give their consent to surgical procedures.” Turner says teleophthalmology in WA has adapted and evolved with time. The eventual introduction of on-call services provided immediate access to the specialist ophthalmologist for telehealth at the time of the initial optometry visit, instead of the need to schedule for a future date. “This availability has led to a ten-fold increase in uptake for Indigenous communities in remote areas where optometrists are only visiting for a couple of days at a time,” Turner says. The Lions Outback Vision telehealth model has been audited regularly since its inception in 2011. According to research published in Clinical and Experimental Optometry, during 2018 there were 953 patients referred to the Lions Outback Vision teleophthalmology service. This resulted in a total of 1,028 teleophthalmology consultations, an increase of 50.5% compared to the previous biannual audit. Additionally, a systematic review of real-time teleophthalmology versus face-to-face consultation, also published in the journal, determined that in terms of diagnostic accuracy, real-time teleophthalmology was considered superior to face-to-face consultation in one study and comparable in six studies. OPTOMETRY-TO-OPTOMETRY TELEHEALTH? Independent optometrist Dr Alex Craig graduated from the University of Melbourne in 2015 and accepted a position with OPSM in Karratha, in the Pilbara region of WA. “I grew up in Zambia in Africa and I wanted to work in a rural environment where I’d be exposed to a plethora of eye health conditions and could use my full scope of diagnostic skills.” With no resident ophthalmologist in Karratha, Craig soon became acquainted with the visiting ophthalmologists with the Lions Eye Institute mobile van and, by extension, Dr Angus Turner. “Working with Angus Turner, we were able to set up telehealth through the OPSM practice in Karratha. That was a great start. It allowed us to ensure that patients that required chronic care who needed to be seen, were seen.” Through managing patients that required acute care, Craig forged a stronger co-management relationship with Turner. The pair have used Facetime to connect with patients to plan for their care in real-time. “It was more efficient, there was less lag time. Things were as ‘live’ as they possibly could be. I could take current OCT scans in the practice with the patient and send them immediately to Angus,” Craig says. After four years with OPSM, Craig resigned and locumed interstate for six months, including in Swan Hill and Cairns before returning to the Pilbara and opening his own practice – Karratha Eyecare – in November 2019.

INSIGHT June 2020

Dr Angus Turner, pictured here speaking with optometrist Dr Alex Craig, says restrictions due to COVID-19 have placed telehealth on the agenda across the broader sector.

Due to travel challenges associated with the region, telehealth is an integral part of his practice. “Recently I had a patient email me in the evening; the very next morning I saw them in clinic and diagnosed a retinal tear. With same day telehealth accessibility, I Skyped with Angus, and we created a targeted management plan, taking into consideration whether the patient needed to travel to receive immediate tertiary care. “Telehealth can provide simple assurity. It can ensure I’m covered and the patient knows they are receiving top quality care.” Craig also runs monthly telehealth clinics from Karratha and Port Headland hospitals. “Patients are streamlined, their eyecare needs addressed, they have access to tertiary care, for cataract, for AMD, for diabetic retinopathy. Telehealth offers better intervention, treatment, and follow-up. Compliance and intervention rate is better, it’s a lot more targeted,” he says. From his post in the Pilbara, Craig is well-acquainted with the use of telehealth between the ophthalmologist, optometrist and patient, but he see’s potential for a third side, from optometrist to optometrist. “In teleophthalmology, between optometrist and ophthalmologist, the Medicare rebate has restricted the service to rural areas. Here in Karratha, immediate ophthalmology care accessible to patients and practices gives massive peace of mind. We have on-call a tertiary care provider who can give some form of interactive care and intervention,” he says. “In tele-optometry, between optometry and patient, there are some limitations. You cannot always tell through a telehealth consultation if red eye is conjunctivitis or uveitis. In these cases, you would need some form of minimal investigation of the eye face-to-face to make a clinical decision. However, even though there are some cases where tele-optometry would be suitable this does not apply globally to most patient consultations.” Interestingly, Craig believes there is potential for an optometry-to-optometry telehealth service. “Theoretically, an optometrist could consult with another optometrist who has expertise in a certain area of primary care, such as glaucoma, ortho-k, or behavioural optometry. This peer-to-peer telehealth consultation would contain diagnosis and treatment within the primary care sphere, and not unnecessarily elevate it to tertiary care, a system already over-burdened.” He added: “It’s a way to create a telehealth ‘Rolodex’ of optometry leaders in their sub-speciality fields, and ensure the profession is growing. It could help bring awareness to the need for appropriate referral, such that cases are elevated to tertiary care only when needed.” n

OPERATING THE CORNEAL EYE BANK THE LIONS EYE DONATION SERVICE PLAYS AN ESSENTIAL ROLE ENSURING THE TIMELY RETRIEVAL AND ALLOCATION OF CORNEAL TRANSPLANT TISSUE. TERRY COUPER DISCUSSES ITS INNER WORKINGS.

T TERRY COUPER

ANY CORNEA DEEMED SUITABLE FOR TRANSPLANTATION CAN BE GRAFTED INTO ANY RECIPIENT, REGARDLESS OF THEIR AGE, RACE AND BLOOD TYPE

he eye bank transplant coordinator is responsible for hospital documentation and legal requirements for donation, consent processes with the family and the surgical retrieval, evaluation, preparation, distribution of donated corneas. I am constantly humbled by the selflessness and generosity of the donors and their families by which this service is totally dependent. The Lions Eye Donation Service (LEDS) comes under the Centre for Eye Research Australia (CERA) and works out of the Royal Victorian Eye and Ear Hospital Melbourne. Along with other Australian states, LEDS is regulated by the Therapeutic Goods Administration (TGA) and complies with the Eye Bank Association of Australia and New Zealand (EBAANZ) standards and guidance for eye donors. The retrieval and allocation of eye tissue needs to be performed within a framework of logistical, ethical and time constraints. There is a balancing of the demand for corneas against the process of obtaining donated tissue. Since I became involved with LEDS more than 25 years ago, there have been many changes that have increased donor numbers. Some through public and internal hospital education, others technological and research innovations. An example of this was the storage medium for the retrieved tissue going from a 14-day to 30-day storage limit. This is called organ culture storage where corneas are suspended by a suture in a nutrient tissue culture medium at 34Â°C (close to physiological temperature for cornea) allowing for longer storage. This can help alleviate the natural fluctuations in donor numbers relative to requests for tissue. While the sooner the tissue can be retrieved, the better tissue suitability for transplant, we do have a 24-hour window. There are 300-plus donors a year, of which approximately 500 are transplanted. Any cornea deemed suitable for transplantation can be grafted into any recipient, regardless

A sutured transplant in a recipient eye.

Cornea transfer pot ready for the surgeon.

of their age, race and blood type.

follow up with donor families.

Traditionally, most transplants were full thickness penetrating grafts (PK), however surgical technique advances and expanded patient selection during the past 15 years have seen increases in the number of endothelial keratoplasties (DSAEK & DMEK) being performed.

My main work with the Melbourne Excimer Laser Group (MELG) complements my involvement with the eyebank. A large percentage of MELGs work is for corneal therapeutic lasers and corneal cross linking, which reduces the need for some corneal transplants. With 13 different surgeons working here as mainly corneal specialists, a large proportion are also users of the Lions Eye donation service.

Of all transplant surgeries done today, corneal transplants are by far the most common and successful. Overall success rates are better than 90% after one year, and 74% at five years. Some conditions, such as keratoconus, have even higher success rates (98%). While some corneas unfortunately fail the strict microbiological and quality assessment guidelines, these are sometimes consented for essential research within CERA and LEDS Three permanent staff rotate as the 24-hour on call coordinator for this seven-day-a-week service. Retrieval can take place at a mortuary, hospital ward, funeral home or theatre as part of a multiorgan donation. This can mean travelling to local or country hospitals such as Bendigo Base or the Tissue Bank located at the Coroners Court complex in Southbank, Melbourne. Those not on call continue the preparation, testing and processing of the donated tissue along with the associated reporting and quality documentations requirements. There is also the contact

It has been a varied and fascinating journey so far for me personally and professionally working with the many dedicated people involved in organ and tissue transplant. Something that when I graduated as an orthoptist, I could not have foreseen. n

ABOUT THE AUTHOR: TERRY COUPER graduated as an orthoptist in Melbourne working several years at public hospitals. He also spent 10 years as the southern regional manager for Australia and New Zealand in the Ciba Vision Contact Lens division. He returned to clinical work 25 years ago as the unit manager for MELG and casual eyebank transplant co-ordinator Lions Eye Donation Service with CERA and honorary associate UniMelb Department of Ophthalmology. ORTHOPTICS AUSTRALIA strives for excellence in eye health care by promoting and advancing the discipline of orthoptics and by improving eye health care for patients in public hospitals, ophthalmology practices, and the wider community. Visit: orthoptics.org.au

INSIGHT June 2020 41

DISPENSING

THE LONG AND SHORT OF CORRIDOR LENGTH CORRIDOR LENGTH IS CRUCIAL TO SUCCESSFUL PROGRESSIVE LENS DISPENSING. NICOLA PEAPER CLEARS UP THE CONFUSION AROUND THIS CONCEPT AND WHETHER TRIGONOMETRY HAS A ROLE TO PLAY.

hen is the long corridor short? Or maybe the question should be how short is a short corridor? And where do we measure it from? The answer is not the same for all lens manufacturers. One’s 14mm corridor is another’s 11mm. How can this be? NICOLA PEAPER

I’M CONSTANTLY TOLD MODERN PROGRESSIVES ARE TOO COMPLEX AND SLIGHTLY INCORRECT MEASUREMENTS WILL CAUSE FAILURE. THIS ISN'T TRUE

Some manufacturers measure corridor length to the middle of the near reference circle and some to the top. Because the circle is 6mm in diameter, such discrepancies can arise. If we look at a graph showing the corridor width of a standard progressive, it is affected by length and add power. The graph (opposite), reproduced with Mr Grant Hannaford's permission (Academy of Advanced Ophthalmic Optics), demonstrates when the add reaches +2.50, the width of a 14mm corridor is 1.4mm. We should therefore be thankful corridors rarely come shorter than 14mm. A short corridor may be suitable for reading a phone at 25cm to 30cm away but does not have the width and depth to cope with the intermediate demands of today. Our love affair with short corridor progressives started in the 1990s with the small frames that were fashionable then. However, the affair continues even with the deeper frames available today. This is often explained by patients being accustomed to having a short corridor and, with a deeper frame, finding it difficult to locate the full near add if the corridor was lengthened. The problem is, how to calculate the length of corridor necessary to give the patient the same head and eye position experience when changing both script and frame? Should corridor length be measured as a distance along the lens between the fitting cross and an arbitrary position associated with the near reference circle, or should trigonometry come into it? Diagram 1 demonstrates how pantoscopic tilt (PT) and back vertex distance (BVD) dictate the head and eye position when reading through progressives. When considering the BVD, it shows the further away the lens from the eye, the longer the corridor needs to be to give the same head and eye position for reading clearly.

INSIGHT June 2020

Short Corridor Small CVD

Large CVD

Large pantoscopic tilt

Small pantoscopic tilt

Diagram 1: The effect of pantoscopic tilt and back vertex distance when reading with progressives.

Likewise, as the PT increases, the corridor length should reduce. Practitioners may have dispensed two pairs of spectacles to the same patient only to have them prefer the visual comfort of one over another. Surely this diagram explains why they ‘felt different’ when, in theory, they were measured and dispensed to be identical. Is it even necessary to choose a corridor length? Having seen how the intermediate portion of the corridor diminishes as the add increases, modern progressive designs move aberration around to provide more priority to the intermediate area. Research into modern-day lifestyles, working distances and, most importantly, posture during specific tasks has resulted in suites of lenses, giving priority to different visual tasks, with corridor length being part of the design. The temptation to shorten the corridor, rather than trust the research, simply interferes with the lens design, reducing patient comfort. If patients say the reading seems too far down the lens, look to the BVD and PT. Is the lens sitting

too close or is the PT too high? While these factors affect apparent corridor length, they will also increase the amount of oblique astigmatism and other aberrations, causing swim and reduced width of vision. If in doubt, order designs tailored to the frame being dispensed. That will minimise unwanted aberrations caused by the angle that light is incident on a lens and, if two pairs are dispensed, will allow the same visual and postural experience. I’m constantly told modern progressives are too complex and slightly incorrect measurements will cause failure. This isn't true; it's always taken training and skill to dispense progressives. Today's patients expect more from their spectacles and understanding the implications of our choices enables us to fulfil their needs. n

NICOLA PEAPER spent 20 years working as an optometrist in the UK. For the past 15 years she has worked within the lens manufacturing industry and is currently professional services manager for Rodenstock Australia.

MANAGEMENT

FORMULATING THE PRACTICE ‘BIBLE’ A POLICIES AND PROCEDURES MANUAL DRIVES CONSISTENCY OF STANDARDS ACROSS A PRACTICE. KAREN CROUCH EXPLAINS WHY IT CAN BE AN EFFECTIVE REFERENCE POINT, PARTICULARLY FOR NEW PRACTICE START-UPS.

F KAREN CROUCH

THEY ARE A REFLECTION OF THE PRACTICE’S NORMAL OPERATING PROCESSES AND PROCEDURES WHICH MAY BE FAVOURABLY VIEWED BY A COURT OR INSURER

or the time being, most peoples’ lives have been taken over in responding to the recent COVID-19 crisis. I’m not about to issue yet another update or to offer professional advice other than to say that the country is fortunate to be ‘flattening the curve’ as a result of careful, thoughtful compliance with the crisis management policies and regulations. In effect, the nationwide exercise has aptly demonstrated the value of documented, outcome driven objectives and the necessary behavioral actions to achieve success. In the context of a health practice, it’s akin to a well documented Policy and Procedures (P&P) manual, detailing various policies of the practice and the manner in which they are carried out. It’s not only a vital reference guide but an invaluable set of guidelines that may be viewed as the ‘practice bible’. Albeit, specific COVID-19 amendments could be inserted for temporary measures, such as social/physical distancing in waiting rooms. These could also be annexed as a permanent procedure as part of a Pandemic Plan, or if specific measures apply beyond COVID-19. The P&P manual could also provide certain legal protection for owners. For example, if litigation claims and complaints arise from patients, staff or external parties, P&P manuals are a reflection of the practice’s normal operating processes and procedures which may be favourably viewed by a court, insurer, or Workers Compensation authority. The contents are also a valuable reflection of the owner’s views and preferred practice culture in respect of patient healthcare and treatment generally. It is also important to ensure practice success by regulating levels of personnel performance so that procedures are performed accurately, consistently and efficiently, in accordance with the P&P manual. Apart from its usefulness as a training tool for recently recruited staff and ‘refresher’ training courses, it

also serves as an authoritative point of arbitration in situations where staff have differing opinions on operational matters. An excellent starting point, which is often ignored by most practices, is a Policy on Policies, which describes the various parties that may be empowered to initiate policies, any related parameters – such as financial or requiring owner, clinician or craft group approval – and how the new edict should be implemented. A descriptive flow chart could assist understanding and simplify training activities. Assuming a particular policy has been approved, implementation should include meaningful communication and feedback from craft groups who may be directly affected by a new procedure to ensure their acceptance and understanding. Following this form of cooperative buy-in, the likelihood of successful implementation should be much higher. And, of course, a normal postimplementation review will always identify successful achievement of objectives or the need for amendments. In summary, a comprehensively documented, and regularly updated, P&P manual will serve the following purposes: Reference Point: New/existing staff may verify or clarify correct procedures from time to time, particularly if opinions differ on a moot point. Induction: A training tool for new staff to absorb the policies and procedures of the practice and to appreciate the behavioral/cultural preferences of the owner. Risk Management: Provides evidence of documented instructions and training that staff are given, a defence against claims that the employer may be liable for acts and/or omissions. Practice Performance: Will help determine whether the most efficient systems are being employed and adhered to by all employees. Staff Appraisals: Provides benchmarks and service standards by which to

A Policy and Procedures manual is a vital reference guide during crises like COVID-19.

assess employee performance when conducting appraisals and/or salary reviews. Professional Standards: Regular reviews and updates will ensure the highest professional standards within the practice and compliance with any recent regulatory requirements. Practice Accreditation: A well documented P&P manual will impress an assessor and lay the ground for a favourable practice performance report. Responsibility for compiling the P&P manual, and regularly updating it, usually rests with practice managers who should be familiar with it and capable of documenting one, particularly as one of the most critical actions in a new practice start up. Other medical staff will need to be involved in preparation of policies and procedures such as clinicians and clinical assistants. Needless to say, the ‘bible’ should be readily accessible and not one that accumulates dust on a backroom shelf. From time to time, amendments may be necessary to comply with changes in regulations or practice habits derived from daily operational experiences. n

KAREN CROUCH is the Managing Director of Health Practice Creations Group, a company that assists with practice set ups and the administrative, legal and financial management of the practice. Contact Karen on email kcrouch@ hpcnsw.com.au or visit www.hpcgroup.com.au.

INSIGHT June 2020 43

Careers at EyecarePlus Optometrists ®

EYECARE PLUS OPTOMETRISTS

OPTOMETRIST – TAREE AND GLOUCESTER

Eyecare Plus provides business support and marketing services to over 155 clinically focused independent full scope optometry practices throughout Australia. Our practices are owned and operated independently by our member Optometrist and Dispenser owners. All of our practices have complete clinical independence and are equipped with the latest diagnostic equipment, including an OCT in the majority of our practices. Eyecare Plus offers three membership options; branded, co-branded and unbranded. Further benefits include marketing support, business tools and advice, exclusive territories, conferences, workshops and staff training. We also actively assist Optometrists and Dispensers who are looking to establish their own practice. If you are looking to buy, or sell, an optometry practice, please contact us.

We are seeking a full time Optometrist to join our established and growing practice. The Mid North Coast of NSW offers a relaxed lifestyle with a low cost of living, fantastic sporting facilities and schools all within 3 hours of Sydney. We need an Optometrist with good clinical skills, a caring nature and an ability to clearly explain concepts to our patients. We have an IPL, OCT, Topography, Anterior Segment Photography and Automated Perimetry. Plus, we have a highly skilled and experienced team of dispensers and assistants.

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

Those seeking a part time position are welcome to apply. New or recent graduates are welcome. To Apply: Please apply with your CV and cover letter to p.mckay@eyecareplus.com.au

OPTICAL DISPENSER - SYDNEY

OPTICAL DISPENSER - GORDON Permanent Part Time Position including Saturday 8.30am-4.00pm and other days during the week negotiable. We are seeking a reliable, motivated and enthusiastic qualified or trainee Optical Dispenser. Ideally you will be happy to learn new skills assisting our optometrists and enjoy working in a small supportive environment with experienced staff. There is plenty of parking and only 1 minute from the station. If you believe in providing friendly and exceptional service, have particular attention to detail and high accuracy contact Sally sallyatkins@bigpond.com

The practice in Kingsgrove, is looking for a part-time/casual dispenser. It is equipped with state-of-the-art equipment and the latest fashion eyewear. Essential requirements include a positive and professional attitude, a great work ethic, exceptional customer service skills, confidence in sales, attention to detail, effective problem solving skills, and the ability to learn quickly. At least two years’ experience is preferred but not essential. Flexibility to cover staff holidays and sick leave is highly regarded. This is a unique opportunity to work in a small team environment, where ongoing skill development is encouraged, and where remuneration is competitive.

RECEPTIONIST/ OPTICAL DISPENSER - BRISBANE

If you believe you would be an asset to the practice, please apply by forwarding your resume in confidence to kingsgrove@eyecareplus.com.au. Only potential candidates will be contacted.

Eyecare Plus Alexandra Hills is an independent Optometry practice that has been established since 1989. We have a special interest in paediatrics, contact lenses, sports vision and we are Brisbane’s only Colour Blind Sight Centre.

CURRENT POSITIONS VACANT for more: www.eyecareplus.com.au/careers/

We are looking for a motivated person for a Full Time / Casual position. There will be on the job training and training courses that we will send you to. Previous optical experience necessary. Reception duties are also part of the position.

OPTICAL DISPENSER / SALES ASSISTANT: Melbourne, Sydney, Brisbane. Wollongong. OPTOMETRIST: Taree & Gloucester, Gosford, Wagga.

Please email your CV to Aphrodite Livanes: apli2@bigpond.com Ph: 07 3824 1878 or 0407 585 952

OPTOMETRIST – KATHERINE, NT An idyllic location for you and your family! Ancient rock art, bush walks and canoeing, there is plenty of fun to be had. The hot and thermal springs to wind down and relax. A perfect mixture for one and all. OPSM has a fantastic opportunity for an optometrist to join our team in picturesque Katherine.

OPTOMETRIST – CAIRNS, QLD Cairns boasts a relaxed lifestyle and magnificent sunrises and is void of the ‘hustle and bustle’ of many southern cities. With access to the Great Barrier Reef, Daintree National Park, and numerous tropical islands this is an adventurer’s paradise. We have an opportunity available for an optometrist to join our experienced team!

OPTOMETRIST – SOUTH HEDLAND, WA JOIN OUR TEAM IN THESE ROLES YOU WILL WORK CLOSELY WITH VIBRANT AND SUPPORTIVE STORE TEAMS AND HAVE MANY OPPORTUNITIES TO MAKE A DIFFERENCE THROUGH OUR ONESIGHT OUTREACH PROGRAM. WE OFFER WORLD CLASS TECHNOLOGY INCLUDING LEADING EDGE TECHNOLOGY OPTOS UWDRS. WE PROVIDE OPPORTUNITIES FOR CONTINUING PROFESSIONAL DEVELOPMENT THROUGH FINANCIALLY SUPPORTED INDUSTRY TRAINING, PEER LEARNING COMMUNITIES AND PRODUCT TRAINING, AND REWARD WITH A COMPETITIVE SALARY AND BONUS SCHEME TO RECOGNISE YOUR CONTRIBUTION. WE HAVE FULL-TIME, PART-TIME, CASUAL AND FIXED-TERM OPPORTUNITIES AVAILABLE. ATTRACTIVE RELOCATION PACKAGES ARE AVAILABLE FOR THE RIGHT CANDIDATE.

OPTOMETRIST – MT ISA, QLD Soak up the outback by venturing deep into the mines or escalate to the hilltops to see the most stunning sunsets and lakes. The city life is never too far at the outlook! Our Mount Isa practice is looking for a motivated and caring Optometrist to join the team.

Explore the second largest town in the Pilbara region of WA, in South Hedland. With nature at your fingertips, beautiful reserves, and various tours around Port Hedland, this is the perfect place for you! Making your mark in a remote location is guaranteed to be one of the most rewarding experiences in your professional career.

OPTOMETRIST – ARMADALE, WA With an abundance of new activities to try, copious bush walks and irresistible wildlife, this suburb of Perth was made for you! You will work closely with an experienced store manager and dispensing team to further advance store performance whilst enjoying an unbeatable work life balance.

OPTOMETRIST – MANDURAH, WA Experience the beautiful, southwest coast city of Mandurah. It offers both white sands, and blue waters to the rugged terrain of the Darling Scarp. There is the perfect mix between national parks, bush walks and wineries, and an array of water sports and cruises with the potential to see dolphins! The perfect place to continue your professional development.

OPTOMETRIST – MASTERTON, NZ Positioned perfectly in the centre of the Wairarapa. Masterton is only 1 hour from Palmerston North, and a little over 1 hour from Wellington CBD. More importantly Masterton is only 30 minutes for the vineyards of Martinborough. Our community-based store is looking for a relaxed optometrist to join the well-established team.

OPTOMETRIST – ROTORUA, NZ On New Zealand’s North Island, picturesque Rotorua is the perfect location to become part of our OPSM family. Visit the namesake lake, mountain bike through Whakarewarewa Forest, learn about the Maori culture or visit the bubbling mud pools! An endless adventure awaits you and we are ready for you to join our team.

OPTOMETRIST – INVERCARGILL, NZ In the southernmost city in the South Island, there is an array of must-dos. Get lost in the vast collection of vintage automobiles, stroll through the 80 acres of Queens Park and visit the infamous water tower. Be part of our OPSM team, continue your professional development and explore in your spare time.

Contact the relevant Professional Services Manager for the region to discuss these opportunities and more: QLD/NT: Brendan Philp brendan.philp@luxottica.com.au WA: Mario Basso mario.basso@luxottica.com.au NZ: Jonathan Payne jonathan.payne@opsm.co.nz

OPSM.COM.AU/CAREERS

2020/21 CALENDAR JUNE 2020 WORLD ORTHOPTIC DAY International 1 June internationalorthoptics.org

ORTHOPTICS AWARENESS WEEK Australia 1 – 5 June orthoptics.org.au

RANZCO WEBINAR SERIES Australia 5, 12, 19 June ranzco.edu

ZEISS ADVANCED BIOMETRY WEBINAR SERIES Australia 3, 10, 17 June kapara.rdbk.com.au

WORLD OPHTHALMOLOGY CONGRESS 2020 VIRTUAL International 26 – 29 June icowoc.org

OPTOMETRY VIRTUALLY CONNECTED Australia 26 – 28 June optometry.org.au

JULY 2020 WENZHOU INTERNATIONAL OPTICS FAIR Wenzhou, China 24 – 26 July

ASIA-PACIFIC ACADEMY OF OPHTHALMOLOGY Xiamen, China 5 – 9 August apaophth.org

WORLD CONGRESS ON OPHTHALMOLOGY & OPTOMETRY International (Webinar) 24 – 25 August ophthalmologyconferences.com

SEPTEMBER 2020 TFOS 2020 CONFERENCE Cernobbio, Italy 9 – 12 September tfos2020.tearfilm.org

SPECSAVERS CLINICAL CONFERENCE SCC9 Brisbane, Australia 12 – 13 September spectrum-anz.com

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

Bangkok, Thailand 25 – 27 November silmobangkok.com

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

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

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

INTERNATIONAL OPTICAL FAIR Tokyo, Japan 27 – 29 October ioft.jp

NOVEMBER 2020

Las Vegas, USA 23 – 26 September east.visionexpo.com

WA, Australia *Date to be confirmed ranzco.edu

Nice, France 24 – 26 September ever2020.org

OCTOBER 2020

Kuala Lumpur, Malaysia 14 – 16 August apgc2020.org

SILMO BANGKOK

Amsterdam, Netherlands 2 – 4 October wspos.org

RANZCO WA BRANCH MEETING

AUGUST 2020 5TH ASIA-PACIFIC GLAUCOMA CONGRESS

5TH WCPOS

VISION EXPO – EAST & WEST

EUROPEAN ASSOCIATION FOR VISION AND EYE RESEARCH CONGRESS

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

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

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

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

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

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

GLOBAL SPECIALTY LENS SYMPOSIUM Las Vegas, USA 20 – 23 January na.eventscloud.com/

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

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

FEBRUARY 2021 MIDO EYEWEAR SHOW Milan, Italy 6 – 8 February mido.com silmobangkok.com

MARCH 2021

AAO ANNUAL MEETING

SKI CONFERENCES FOR EYECARE PROFESSIONALS

Las Vegas, USA 14 – 17 November aao.org

Furano, Japan 6 March skiconf.com

INSIGHT June 2020 45

SOAPBOX

UTILITARIAN STRATEGISTS NEEDED FOR RECOVERY battle between zero virus zealots and recovery hawks. The media are not always responsible in this regard and have their own motivations and perverse incentives to entertain and create click traffic. We will need to learn to live with COVID for some time and be discerning analysts of everything we read. Continued success in managing COVID now requires recognition that the exponential growth curve is the inverse curve of the exponential destruction of businesses and livelihoods. The longer we take to restore the economy, the harder it becomes to avoid permanent societal damage. Superimpose the possibility of a second wave and the calculus gets even more challenging.

he great escape for Australia in the COVID-19 battle may have been achieved. At time of writing there were good signs; but only if the next phase is not squandered by political and media discordance. There is a danger that we are so mesmerised; obsessed; indeed hypnotised by the spikey COVID virus that we may not see the wider picture of cost versus benefit. Risk management both economically and medically is the key to continued success. Despite the speed and urgency of government actions in March, there was a concerted effort to consult with medical advisory groups such as the Australian Society of Ophthalmologists (ASO) to calibrate clinical responses for minimal net health damage. I was genuinely impressed with the responsiveness of the government to take guidance on a ‘trust basis’ without all the red tape. I think this will be one of the legacies of Health Minister Greg Hunt which won’t necessarily be reported; that he had good trusted relations and a deep understanding and familiarity with the medical profession and the broader industry which facilitated honest frank communication in the crisis. From the earliest stages, I had written and spoken to my contacts in government about avoiding a COVID secondary health impact in which

INSIGHT June 2020

deferred medical care might create health impacts greater than COVID itself. These outcomes include delays in diagnostic investigations; delayed cancer treatments; resource diversions from critical care in cardiac intervention; cataract falls and fractures and the societal cost of drug abuse, depression, suicide and domestic violence due to prolonged social disruption. After a suspension of elective surgery, we appear to be at a restart. Although these restrictions have now been lifted and we can return to performing eye procedures, we must be mindful that we are not out of the woods just yet, and another wavepeak in cases could lead to another shut down. Having shut down once, we have the experience to do it again. However, the first shutdown will have increased the waiting time for public hospital cataracts and compromised the care of glaucoma patients, diabetics and macular degeneration sufferers compared to optimal management. A second shutdown would certainly create a disproportionately larger decrement to best care. The first stage of virus control has provided an excellent foundation. However, the first stage is only a foundation - a start for the next phase of national recovery. We must use reason and facts and must not devolve into a

It pains me to say that doctors are not the best people to decide on the recovery stage because they are naturally conservative and sometimes too close to the human suffering to be independent observers. Their 15 minutes of fame are over. Their skill is to treat the sick and expertly model the outcome projections. We still need cold hard utilitarian strategists who can overview the entire societal need and make difficult but calculated decisions. This role will fall to politicians and governments who will follow their sometimes-perverse incentives to a conclusion that we hope will optimise the outcome. There are many more chapters to the COVID-19 story. We may look back on this time and regard it as a creation of over-hyped media. We may look back and be very grateful that urgent action was taken. We may look back at death rates and realise that the patients who died were already close to their end of life. The trouble is that we just don’t know yet and must continue to manage the risks appropriately. The 20/20 Retrospectoscope is a device not yet invented by Zeiss. n Name: Dr Peter Sumich Qualifications: MBBS RANZCO Workplace: Hunter Street Eye Specialists, Parramatta Position: Cataract and Refractive Surgeon; President, Australian Society of Ophthalmologists. Location: Parramatta Years in profession: 23

I WAS GENUINELY IMPRESSED WITH THE RESPONSIVENESS OF THE GOVERNMENT TO TAKE GUIDANCE ON A ‘TRUST BASIS’ WITHOUT ALL THE RED TAPE

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