INSIGHT June 2022

JUN

2022 INSIGHT AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975 JUNE 2022

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New HOYA Occupational Lenses

Optometrists wanting to rebuild in the flood-stricken town run the risk of future disasters.

PUTTING A PRICE ON YOUR PROFESSIONAL SERVICE Find out what happened when four independent practice owners introduced private billing.

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LISMORE PRACTICES FACE IMPOSSIBLE CHOICE

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SETTING THE AUSTRALIAN OPHTHALMOLOGY AGENDA CRISPR gene editing, surgery simulation and other innovations shaping the ophthalmic sector.

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JUN

2022

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

FLOOD-STRICKEN LISMORE OPTOMETRISTS FACING TOUGHEST CHALLENGE YET A principal optometrist in Lismore is unsure if his business will return to the centre of the disaster-stricken NSW town, stating it would be difficult to relive the devastating impact of recent floods, one of which destroyed his practice that was designed to withstand such events.

Lamas + Brown Optometrist owner Mr Fernando Lamas has described the sense of shock, overwhelm and community spirit since the record-breaking February-March floods wiped out his Lismore business along with four other optometry practices, including a Specsavers store which will be rebuilt at a new location in the town. He has also detailed the impossible insurance situation

builder to make it flood-proof. For example, downstairs, all walls are Besser Block, all fixtures are either on wheels or split hinges, and we even devised a written, laminated flood plan,” he said.

facing Lismore businesses.

Lamas, a therapeutically-endorsed optometrist, established his business in 2005. He expanded to acquire another practice 30km away in Casino, which also closed, but for a short period, due to the floods.

Overall, the business employs 15 staff, including four optometrists.

He was always aware of the flood risk in Lismore, but figured it could be mitigated with floodproofing measures.

In 2013 he purchased a twostorey building located at one of the highest points of the Lismore CBD, with its front door 10.4m above the river height. With the Wilsons River levee breaching at 10.65m and the previous peak being 12.4m, he had the practice specially designed

The rubbish pile outside Lamas + Brown Optometrist in Lismore after the shop was gutted.

to cope with floods entering the ground floor.

Additionally, it was unviable to insure the building. When his broker sought a flood policy, only one insurer would agree to it – with a $107,000 annual premium.

“We spent a long time with the

“Upstairs was well and truly out of any previous flood by a good 1.7m, and we installed a hydraulic lift for patients which was also flood-proof.”

This plan was tested in a major 2017 flood that reached 11.59m.

Within two and a half hours, the practice had moved all its equipment and stock upstairs rolled up the carpets and underlay and packed up the cabinets and desks.

The business was back operational within a week. continued page 8

ANTI-VEGF REMAINS MOST EXPENSIVE PBS DRUG The Australian government spent $55 million more on anti-VEGF macular disease therapies in 202021 compared to the previous year, with aflibercept (Eylea) maintaining its title as the costliest subsided medicine in the country.

The government spent $665 million on aflibercept (brand name: Eylea) and ranibizumab (brand name: Lucentis) combined last year, according to Australian Prescriber’s top 10 drugs based on Pharmaceutical Benefits Scheme (PBS)/Repatriation Pharmaceutical Benefits Scheme (RPBS) prescriptions from July 2020 – June 2021.

They were the only two eye therapies to appear on the list.

In total, the government spent $444 million (not including rebates)

on aflibercept to cover 364,800 prescriptions, making it the most expensive PBS treatment for a second consecutive year. That’s a 13% increase on last year’s $392 million (315,200 scripts).

For ranibizumab, which ranked eighth by cost, it paid $222 million for 190,300 prescriptions, up from $218 million for 190,126 injections in 2019-20.

Although the anti-VEGF therapies featured prominently in the top 10 drugs by cost, they did not feature in the top drugs by volume. That list was topped by the cholesterol-lowering rosuvastatin (14 million scripts) and atorvastatin (11 million scripts), as well as pantoprazole for stomach ulcers and gastroesophageal reflux disease (9 million scripts).

Asked why anti-VEGF therapies

remained among the most heavily PBS-subsidised therapies, Macular Disease Foundation Australia (MDFA) told Insight it estimates there are 156,000 neovascular (wet) agerelated macular degeneration patients (nAMD), 72,000 with diabetic macular oedema (DMO) and up to 135,000 with other vision-threatening macular diseases who could benefit from antiVEGF therapies.

“Patients with wet AMD require regular and frequent treatment to reduce the risk of permanent vision loss and blindness. Treatment is not a cure, and while the current drugs are highly effective, patients typically receive between five to seven injections per year on an ongoing basis and will need to continue for the continued page 8

LENS SHOWS LONGTERM EFFICACY New six-year data for Hoya’s defocus lens unveiled at ARVO 2022 marks the longest study of a myopia control spectacle lens – and answers some burning questions for optometrists.

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IN THIS ISSUE JUNE 2022

EDITORIAL

FEATURES

A WIN FOR MACULAR PATIENTS The ophthalmic sector, and the Macular Disease Foundation Australia (MDFA) in particular, should be commended after a decisive win for macular disease patients and access to anti-VEGF injections.

For almost three years, the sector has advocated for the government to reject the MBS Review Taskforce’s recommendation to slash the rebate for intravitreal injections from around $250 to $75 (69% reduction), fearing pensioners would have to make impossible choices between things like groceries or their eye health.

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DISTINCTIVE DESIGN Aussie eyewear company Modstyle goes to a new level with a purpose-built creative space.

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ACANTHAMOEBA KERATITIS A CPD article (0.5T hours) on this rare but debilitating infection found mostly in contact lens wearers.

MDFA made this a central issue in its annual Macula Month campaign last month, with patients like Michael Wolf, 77, sharing personal stories in mainstream media about the miraculous impact of anti-VEGF injections, and his dire future if the rebate was cut.

A few days later, Federal Health Minister Greg Hunt confirmed to MDFA the Coalition would not consider the rebate cut if re-elected. This commitment was then matched by the Labor party.

Suddenly, years of uncertainty were alleviated.

Many didn’t expect a decision on this thorny issue prior to the election, but Macula Month coinciding with the federal election – and the need to secure votes amid a cost of living squeeze – provided the perfect storm, perhaps.

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KNOWING YOUR WORTH Many optometrists worry private billing will turn patients away, but is this a myth?

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ORTHOPTIC OPPORTUNITIES Orthoptics Awareness Week 2022 spotlights Australian-trained orthoptists across the world.

EVERY ISSUE 07 UPFRONT

55 MANAGEMENT

09 NEWS THIS MONTH

56 PEOPLE ON THE MOVE

52 OPTICAL DISPENSING

57 CLASSIFIEDS/CALENDAR

54 ORTHOPTICS AUSTRALIA

58 SOAPBOX

The MDFA should be applauded for the legwork, especially its commissioned PwC modelling showing an additional 47,000 Australians would experience severe vision loss and blindness within five years, if the rebate was cut, with average annual out-of-pocket costs increasing from $1,900 to $3,900.

Importantly, it demonstrated the $168 million direct ‘cost-shifting’ problem for the government in primary health, mental healthcare and early admissions to residential aged care, and $2.6 billion in indirect costs through loss of patient and family carer productivity.

Ultimately, it would have taken a brave politician to follow the taskforce’s lead. But the protection of the intravitreal injection rebate is an important win for the sector, and shows the power of robust and spirited campaigning.

MYLES HUME Editor

INSIGHT June 2022 5

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UPFRONT Just as Insight went to print, THE SPECTACLE SITE was acquired by EyeQ OptometristsNational Optical Care (NOC). The purchase now sees EyeQ-NOC expand its practice network to 46 locations, with another expected to join in May. The Spectacle Site acquisition comprises five practices in Victoria: Croydon North, Croydon Central, Rowville, Healesville, and Seymour, as well as Specialeyes in Canberra. The Spectacle Site’s Boronia location was not included in the deal due to a different ownership structure and will continue to operate as an independent site.

IN OTHER NEWS, the Australian College of Optometry (ACO) is joining Optometry Australia’s call for a $1 million investment into a collaborative eyecare pilot to reduce ‘drop out’ from routine intravitreal injections.

The ACO believes a joint approach between optometrists and ophthalmologists will improve eyecare equity. The ACO said international evidence shows optometrists can administer intravitreal injections safely.

But the current regulatory environment doesn't allow this locally. The proposed pilot would look at making best possible use of optometry in the care pathway, but would involve ophthalmology oversight and, most likely, a medical doctor injecting.

FINALLY, Adelaide's Nova Eye Medical says it has navigated time-consuming and complex dialogue with the US FDA to pave a clear approval pathway for its pioneering 2RT laser system for selected intermediate age-related macular degeneration patients.

Melbourne’s Professor Robyn Guymer will now run a study to build on findings in the seminal LEAD trial. “2RT addresses the disease in its earlier stages. No other device or pharmaceutical does this. The LEAD study was very encouraging but was not conclusive. I look forward to starting this work, providing additional information to the FDA and then a successful study outcome," Guymer said.

insightnews.com.au Published by:

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

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WEIRD

A 53-year-old French man who went to hospital with an itchy eye was shocked to discover the source of irritation was “more than a dozen mobile, translucent larvae” around the cornea and conjunctiva. The man told doctors he had been gardening near a farm the same day when he felt something entering his eye, according to a report in New England Journal of Medicine. n

Editor Myles Hume myles.hume@primecreative.com.au Journalist Rhiannon Bowman rhiannon.bowman@primecreative.com.au

Commissioning Editor, Healthcare Education Jeff Megahan Business Development Manager Alex Mackelden alex.mackelden@primecreative.com.au

WONDERFUL

The colour blind are being helped to see exhibits in a new light thanks to an Australian-first technology partnership. Visitors to the University of Sydney's Chau Chak Wing who have deuteranopia are being loaned visionaltering glasses that block specific light wavelengths to create signals that are better calculated by the brain and allow wearers to perceive colour better. n

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QUOTE

WACKY

A new study has revealed people who live with blindness can remember speech and language better than sighted people. “It’s interesting that people who are blind only showed an advantage with verbal memory,” author A/Prof Marina Bedny, of Johns Hopkins University, said. “Blind people may use language like a mental tool to remember information.”

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– Andrew Greer, Eyecare Plus Tamworth. Page 35.

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INSIGHT June 2022 7

NEWS

CORPORATE STORE TO REBUILD AT NEW SITE continued from page 3

good plan, but we now know 12.4m isn’t the maximum – it is 14.4m.”

OCT, topographer, visual fields system, $30,000 server, and equipment from its two consulting rooms were stored on tables above the water height.

Consistent with other business owners, Lamas was disappointed with the lack of support from governments, but has been heartened with the community response.

“Another one foot of water would have caused another $350,000 damage,” Lamas estimated.

Lamas + Brown shop interior before the floods.

Flood waters collapsed the suspended ceiling along with the wiring and air-conditioning ducts.

On Sunday 27 February 2022, the practice performed the same protocol and Lamas thought it would pull through again.

“And then it just started bucketing. Over the next 30 hours we got something like 700mm,” Lamas said.

“I woke up at 2am, looked at the river heights and the Bureau of Meteorology was saying 12.4m, which was equalling the highest record, but I looked at river heights further upstream and knew it would be closer to 14-15m. That wasn’t a good night because it meant the water would be up into the second storey, and that proved correct, with a final river height of 14.4m.”

After completely submerging the ground floor, the water level reached 400-500mm in the second storey, destroying the suspended ceiling between the two floors, including a new air conditioner system installed nine months ago, as well as carpets and fixtures.

Thankfully, expensive devices like an

Noting the Lismore rebuild would be a months-long ordeal, he immediately sought a new location. He learned of a non-practising osteopath with rooms 15km away in Wollongbar, who happily transferred her lease to have the optometry practice operational within a few weeks.

“IT WAS FINE WHEN WE HAD A GOOD PLAN, BUT WE NOW KNOW 12.4M ISN’T THE MAXIMUM – IT IS 14.4M”

In a cruel twist, once Lamas began clearing his Lismore practice, the town was hit with a second flood. It was the final straw for a town that, in the past five years, has endured floods (2017), the worse drought in a century, worse bushfires in 50 years and COVID.

FERNANDO LAMAS, LAMAS + BROWN OPTOMETRIST

“It’s very overwhelming, but I’ve learned to do just a little bit each time, but still with the big picture in mind,” he said.

“I have realised this is my home. The community is what has driven the recovery.

It shows the benefit of living in a rural area.

We have had so many people help us.

Our community, patients, and friends have been the driving force that has helped us through this. We have to thank ACBO, Optometry Australia and suppliers like VMD and Luxottica.”

Elsewhere, Specsavers confirmed its entire Lismore store and equipment were lost in the floods, requiring a full rebuild.

Despite this, Specsavers staff provided replacement glasses free for customers who lost them in the disaster.

“We were walking through the flood waters for the second time in four weeks, and that’s when my wife and I looked at each other and agreed that it seemed crazy to keep putting it all at risk. We own the building. It’s a big decision but we have decided to relocate to Wollongbar and see what happens with Lismore over the next six to 12 months – whether they move the town or put in place flood mitigation measures.

“The team, both optometry and audiology, including retail dispensers, have been able to provide important healthcare services at Specsavers Ballina and Tweed City,” a spokesperson said.

“We are very excited to announce that we will be fully rebuilding in Lismore Square in a much larger relocated premises – where Mathers/Noni B were previously located – to provide essential healthcare services to our much loved Lismore community. We anticipate re-opening in July 2022 and look forward to seeing everyone again then.” n

“We may end up with three practices, but right now I can’t keep risking so much money and the stress it’s putting on staff. It was fine when we had a

LONGER-ACTING THERAPIES SEEKING REG APPROVAL continued from page 3

rest of their lives,” the organisation stated.

With few reimbursed treatments for macular diseases, MDFA said it is perhaps unsurprising they appear high on the PBS list of medications. However, more therapies are entering this space with brolucizumab (brand name: Beovu) PBS-listed last October, and a port delivery system for ranibizumab (brand name: Susvimo) and faricimab (brand name: Vabysmo), a bispecific anti-VEGF, currently under review for reimbursement in Australia.

With a considerable year-on-year increase in anti-VEGF use from 2019-20 to 2020-21,

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INSIGHT June 2022

MDFA said it would be difficult to determine what directly led to this. However, with an ageing population, it estimates an additional 5,500 patients each year are diagnosed with nAMD and could benefit from anti-VEGF. It also estimates about 55,000 nAMD patients currently receive anti-VEGF treatment. The increase (~10% per year) is in line with the combined increase in aflibercept and ranibizumab scripts.

Overall, MDFA said Australian ophthalmologists were quick to recognise the revolutionary nature of anti-VEGF treatments when they first became available 15 years ago and were pioneers in determining the most efficient treatment approach. It said

Australia is recognised among the world’s best for the treatment and management of macular diseases, with patients supported by a robust healthcare system.

Anti-VEGFs are sightsaving treatments.

“The recent commitment by both major political parties ahead of the Federal election to reject the proposal to cut the Medicare rebate for intravitreal injections will see this reputation maintained,” MDFA said.

“Additionally, one new anti-VEGF treatment was recently listed for reimbursement and two more – which promise of longer intervals between treatments with the same efficacy – could enter the market soon, demonstrating Australia continues to benefit from new and innovative treatments.” n

PBS SCRIPT PRICE TO BE SLASHED UNDER NEXT GOV The maximum price Australians pay for Pharmaceutical Benefits Scheme (PBS) scripts will be slashed, in a move set to benefit thousands of patients with eye diseases.

Just how much people pay for PBS medicines in future will depended on the outcome of the federal election, which was held several days after this issue went to print.

In what would be an Australian-first reduction in the price of governmentsubsidised medications, from 1 January 2023 the Liberal party promised the maximum price Australians pay for PBS medicines (PBS General Co-payment) would drop from $42.50 to $32.50, a 24% saving.

injections which are among the most heavily subsidised treatments in Australia, costing the government more than $650 million annually during the past three years. In fact, aflibercept (Eylea) is the country’s most costly PBS drug at $443 million for 365,000 prescriptions.

Under a Liberal government, the policy would mean those taking one medication a month could save $120 a year, or those taking two medications a month could save $240 a year. It would culminate in an annual $150 million hip-pocket saving for around 19 million Australians without a concession card, reducing script costs to 2008 levels.

Meanwhile, in response, Labor said it would reduce the maximum co-payment even further, from $42.50 to a maximum of $30, a reduction of 29%.

Labor said its policy would save Australians more than $190 million in out-of-pocket costs. A person taking one medication a month could save $150 a year, with those taking two medications a month saving up to $300 each year.

The script savings would flow through to patients requiring PBS medications for eye disease, including anti-VEGF

Prime Minister (at the time of writing) Mr Scott Morrison said his economic plan would deliver cost of living relief

VEI29751_INSIGHT AD_HALF HORIZONTAL_235x144_FEB22_FA_OL.indd 1

to millions of Australians who will save hundreds of dollars every year on the cost of essential and lifesaving medications.

The maximum price would be $30 under Labor, and $32.50 under the Coalition.

“This is the single most significant change to the cost of and access to medications since the PBS was introduced more than 70 years ago,” he said.

“There is a clear choice at this election.

Australians can vote for a stronger economy under the Coalition, who always delivers affordable medication and cost of living relief, or a weak economy under Labor, who stopped listing medicines on the PBS in 2011 because they could not manage the economy.”

Labor leader Mr Anthony Albanese said his government would strengthen Medicare and the PBS. “Cost of living pressures are real.

Everything is going up under the Morrison Government. These changes to the PBS are necessary because we need to make sure that Australians can afford the medications they need,” he said. n

24/2/22 4:30 pm

NEWS

POLICYMAKERS PROMISE EYE INJECTION REBATE WON’T BE CUT Macular Disease Foundation Australia (MDFA) has had an undertaking by both major political parties that they won’t implement an MBS Review Taskforce proposal to cut the intravitreal injection rebate by 69%, in a major win for the eye health sector.

The organisation announced on Monday 2 May that Federal Health Minister Mr Greg Hunt – who exited politics after the 21 May election – is supporting the MDFA’s call to reject the proposed rebate cut, if the Coalition returned to government.

Shadow Minister Mr Mark Butler’s office has also confirmed to MDFA that the Labor party would not be considering the recommendation if elected.

The election had not taken place at the time of writing.

Regardless of who won the election, it will be welcome news for MDFA, macular disease patients and ophthalmologists who have campaigned for a long time on this issue, and were not expecting a decision prior to the election. It also coincided with MDFA’s Macula Month awareness campaign held annually in May. The ophthalmic sector has been alarmed ever since the independent Medicare Benefits Schedule (MBS) Review Taskforce for Ophthalmology recommended the government slash the MBS fee from $310 with a rebate of around $250, to a $96 fee with a rebate of around $75.

Economic modelling commissioned

by MDFA estimated the proposed cut would trigger out-of-pocket costs for neovascular age-related macular degeneration (nAMD) patients to balloon from the current $1,900 per year to $3,900 per year – double if the disease impacts both eyes.

Ophthalmologists were concerned about prohibitive costs affecting patient treatment adherence. Clinics providing bulk-billed eye injections said the proposed fee would have made it difficult to continue providing the service and would have likely needed to start charging out-ofpocket fees.

However, at the time of writing it was not yet clear whether this undertaking from both the Liberal and Labor parties

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IN BRIEF n

would impact the fee ophthalmologist get for intravitreal injections.

MDFA said Hunt had confirmed the specific recommendation regarding the patient rebate for intravitreal injections was not under consideration.

He invited the foundation to be part of the Implementation Liaison Group established to review the recommendations and to ensure it would not lead to unintended consequences for patients or barriers to access treatments.

“Our priority is that Australians get access to this critical treatment to save sight. Optimal health is central to decision making,” Hunt said.

MDFA CEO Ms Dee Hopkins added: “MDFA welcomes this decision by the two major parties. Out-of-pocket costs are a driver of patient adherence to treatment. Our modelling showed that the proposed cut would have resulted in an additional 47,000 Australians experiencing permanent vision loss or blindness in the next five years.”

Since its introduction in Australia 15 years ago, Hopkins said sight saving injections have revolutionised the management of multiple neovascular macular conditions, including nAMD, diabetic macular oedema, and retinal vein occlusion.

While MDFA supported many of the 19 recommendations made by the MBS Review Taskforce, it had concerns about the impact of the proposed rebate cut to patients in a system that is already challenging for many to access.

Government data shows that 25% of patients receiving eye injections drop out of treatment after the first 12 months, leading to irreversible vision loss or blindness.

MDFA research found 29% of patients on this treatment considered delaying or stopping due to costs while 40% had considered delaying or stopping due to travel issues accessing their nearest eye doctor.

“We look forward to working with the government of the 47th Parliament to ensure all Australians have improved access to sight saving treatment – particularly as our population ages,” Hopkins said. n

“OUT-OFPOCKET COSTS ARE A DRIVER OF PATIENT ADHERENCE TO TREATMENT” DEE HOPKINS, MDFA

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PLASTIC NEUTRAL

CooperVision announced its one-day contact lenses distributed in Australia and New Zealand are now plastic neutral. The initiative is made possible through a global partnership with Plastic Bank, a social enterprise that builds ethical recycling ecosystems in coastal communities. For every box of CooperVision one-day contact lenses distributed in Australia and New Zealand, CooperVision purchases credits that fund the collection and recycling of ocean-bound plastic into the global supply chain, that is equal to the weight of the plastic used in its one-day contact lenses, the blister and the outer carton packaging. Plastic Bank collectors in coastal communities receive a premium for the materials they collect, which helps them provide basic family necessities.

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SMART GLASSES

New smart glasses developed by EssilorLuxottica and Facebook have been awarded at two renowned design competitions: iF Design Award and Red Dot Design Award. Launched last September and available in Australia, the eyewear won two prizes at iF Design Award 2022: the Design Award in the User Experience discipline, and The Gold Award in the Product discipline, the highest recognition in the competition. In the Red Dot Design Award, Ray-Ban Stories was awarded in the product design category, winning the top award, the Red Dot: Best of the Best. This prize is reserved for the best products in a category that stand out for groundbreaking design.

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OPTOMETRY SCOPE

New legislation signed into law in Virginia, US, will allow doctors of optometry to provide certain office-based laser procedures for glaucoma and post-cataract care. According to the American Optometric Association (AOA), the new law enacted on 9 March amends the state’s optometric scope-of-practice act to authorise qualified optometrists to perform optometric laser procedures, including YAG laser capsulotomy, selective laser trabeculoplasty and laser peripheral iridotomy. “Virginia becomes the eighth state – and third since 2021 – to expand its scope for these contemporary procedures, affording Virginians’ greater opportunity to access primary eye healthcare services from their local doctors of optometry,” AOA said.

INSIGHT June 2022

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NEWS

AUSSIE PARENT PERCEPTIONS OF EYECARE PROFESSIONALS REVEALED IN NEW SURVEY see ophthalmologists.

A survey of more than 500 Australian parents of children who see eyecare professionals has revealed the biggest barriers to care during COVID-19, common reasons for seeking a second opinion and perceptions about the expertise of ophthalmologists and optometrists, including the level of care in corporate vs independent settings.

“It’s possible that this is due to the likelihood that the children needing to see specialists will have more complex eye conditions, and may feel confused about their child’s condition and treatment.

The '2022 Little Aussie Eyes Report' is the third such survey compiled by Sunshine Coast-based Kids Eye Gear.

Fifteen percent of parents have taken their child for a second opinion after an initial diagnosis.

According to the report, parents reported that COVID-19 impacted the eyecare of more than one in four (26%) Australian children who have vision issues and see an eyecare professional.

eyecare impacted, compared with one in four (26%) that see an optometrist. Overall, 46% of parents said they had barriers to attend appointments during the pandemic.

This was largely the result of delayed and cancelled appointments and the impacts of lockdowns and restrictions.

Children in regional areas were harder hit; 22% of kids in the five capital cities were impacted, but this increased to 32% for their regional counterparts.

Children with more serious eye conditions – typically those that see ophthalmologists – were more impacted by the pandemic than those children with more standard vision problems.

More than one in three children (36%) that see an ophthalmologist had their

“The majority of parents were happy with the diagnosis and treatment they were given for their child’s eye condition. But, 15% of parents have taken their child for a second opinion from another eyecare professional after their child’s initial diagnosis.

“There were a variety of reasons for seeking a second opinion but it largely came down to being referred on to a different type of eyecare professional, poor rapport with the eyecare professional, not trusting the initial diagnosis to be correct, for ‘peace of mind’ in the diagnosis and treatment, wanting to pursue care in the private system, and the child still struggling with vision even after correction.”

“When it came to specific barriers to attending eyecare appointments in the past two years, the main issues for these families were not being able to bring children or partners to appointments due to appointment restrictions, appointments being delayed by the clinician, and not feeling safe to attend appointments,” the report stated.

When asked if all optometrists provide an equal standard of expertise and care, one in three parents agreed, but the same number also believed they don’t.

The survey found 89% of parents feel supported in their child’s eyecare treatment. Interestingly, those that see optometrists are more inclined to feel supported and feel well informed about their child’s eye condition than those that

When looking more specifically at optometry practices, the report said the majority of parents (40%) believe large chain store optometry practices offer the same level of expertise and care as independent optometry practices. n

IMPLANT MAY BE BETTER FOR ABORIGINAL DMO PATIENTS A pioneering study out of WA has shown that a longer acting intravitreal dexamethasone implant (DEX-implant) may lead to better outcomes in some Aboriginal patients with diabetic macular oedema (DMO) compared with the standard of care, anti-VEGF injections.

With findings published in the RANZCO journal Clinical and Experimental Ophthalmology last month, the Lions Eye Institute (LEI) OASIS Study has been heralded as a world-first clinical trial in ophthalmology to exclusively recruit Indigenous patients.

Led by Associate Professor Hessom Razavi with co-authors Dr Joos Meyer, Ms Carly Fry and Associate Professor Angus Turner, the research team outlined

12

a 15% (9.5 letter) visual advantage for patients who received DEX-implant.

the impracticality of frequent intravitreal anti-VEGF injections for many Aboriginal patients with DMO. The trial recruited 38 Aboriginal patients – involving 52 eyes with DMO – from WA randomised to receive a three-monthly DEX-implant (Ozurdex), or monthly intravitreal bevacizumab (Avastin).

In an article written for The Conversation, Razavi said the results showed patients who received DEXimplants gained four extra letters on a standard eye chart, equivalent to a 6.2% improvement in their vision from baseline.

Those who received the anti-VEGF agent, meanwhile, lost 5.5 letters on average, representing an 8.9% decline.

Taken together, the results represented

He said the disparity was most pronounced in country towns, where the DEX-implant had a 37% (24 letter) advantage over the anti-VEGF agent.

A/Prof Hessom Razavi.

“Over 12 months, patients who were meant to receive four dexamethasone implant injections, received an average of 3.3 injections. This meant that, on average, they received 82.5% of their intended treatments,” Razavi said.

“Anti-VEGF patients, meanwhile, received 7.2 of their scheduled 12 injections. This equated to only 60% of their intended treatments, and reflects the difficulty of attending monthly appointments in the real world." n

INSIGHT June 2022

OP0621-46 HR

SEE YOURSELF DOING WHAT YOU LOVE WORKING AT OPSM MEANS YOU’RE PART OF SOMETHING BIGGER. At OPSM, we are obsessed with eye care and offering our customers the confidence in how they see the world. Our advanced technology enables us to look deeper to ensure we give the best care to every customer. When you join OPSM, you work with world class technology including the Optos Daytona ultra wide field scanner.

You have many opportunities for continuing professional development through financially supported industry training, mentoring, graduate induction, peer learning communities and product training. You are rewarded with a competitive salary and bonus scheme to recognise your contribution. You have career flexibility through our extensive store network. Most importantly, you can make a real difference in the way people see the world not only from your consulting room but also by participating in our OneSight outreach program. #DoWhatYouLove

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

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NEWS

SURGEON FIRST IN AUSTRALIA TO PERFORM SMILE PRO LASER SURGERY Vision Eye Institute (VEI)’s Associate Professor Michael Lawless has become the first Australian surgeon to perform successful SMILE Pro laser eye surgery.

A/Prof Michael Lawless, Vision Eye Institute.

SMILE Pro represents the latest advancement of the original SMILE technique.

It uses the VISUMAX 800, the newest generation of Zeiss femtosecond lasers. Compared to its predecessors, VISUMAX 800 is a step up in terms of safety, accuracy and patient experience, according to VEI. “It has a significantly shorter laser time and reduced potential for transcription errors. In addition, the speed of laser scanning virtually eliminates suction loss, creating a more comfortable experience for patients,” the institute said.

Lawless described operating with the VISUMAX 800 akin to driving a Tesla instead of an older, petrol car.

“By offering computer-assisted centration, cyclotorsion adjustment, and creating the lenticule cut in under 10 seconds (minimising suction time), VISUMAX 800 improves and refines the SMILE technique,” Lawless said.

Lawless was a member of the original group of Australian surgeons to obtain an excimer laser and was also the first surgeon in NSW to perform first-generation LASIK. Also among VEI’s doctors are the first surgeons to perform laser eye surgery in Victoria and Brisbane, the first Australian surgeon to perform LASIK surgery with the intralase femtosecond laser, and the first Sydney surgeon to perform SMILE VEI Chatswood has also performed the most SMILE surgeries for a single clinic in ANZ. VEI is one of the first in the Southern Hemisphere to have the VISUMAX 800 installed.

“It was a privilege to perform the first SMILE Pro surgery in Australia and New Zealand. I’m happy that our Sydney surgeons and patients will be able to benefit from this technology that takes SMILE and laser vision correction to another level,” Lawless added. n

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INSIGHT June 2022

MOST TRUSTED AUSSIE OPTICAL BRANDS REVEALED Specsavers has been crowned one of Australia's most trusted optometry brands, as judged by Reader’s Digest magazine’s annual consumer survey, while also being recognised in the Contact Lens Solution and Hearing Services categories.

The corporate optometry group was named as the Optometry category winner of the '2022 Trusted Brands' survey, followed by Luxottica-owned OPSM and Laubman & Pank which both received ‘highly commended’ recognition.

Specsavers also took out the Contact Lens Solutions category, with Johnson & Johnson Vision’s Acuvue and Bausch + Lomb’s Renu Fresh rated the next best.

With the introduction of Audiology to its business in 2018, Specsavers was ‘highly commended’ in the Hearing Services category alongside Audika, with Hearing Australia taking top spot in the category.

According to Readers Digest, its Trusted Brands survey is independently conducted by leading research company Catalyst Research. It invited more than 3,000 Australian adults, from every state and territory, to rate the brands they trust the

Specsavers featured in three categories.

most. Voted by Australians for the third year in a row, Specsavers said it was recognised as the brand that consumers see as “consistently offering value for money”.

“This is the third year we’ve been recognised, which is testament to all our partners and store teams working tirelessly in challenging conditions to ensure the consistent eyecare for all Australians,” Dr Ben Ashby, Specsavers director of optometry, said.

"It's great to see the public recognising us as a trusted brand, and even more so during the past 12 months.”

The 23rd annual survey of Most Trusted Brands was conducted across 41 countries with a global readership of more than 35 million people. n

AI SYSTEM NOW TGA-APPROVED FOR THREE MAJOR EYE DISEASES The Therapeutic Goods Administration (TGA) has approved a new AI software system that can screen for three major eye diseases in primary care settings.

The iPredict System was cleared for Australian use in February as a Class IIa device, with its manufacturer iHealthScreen also announcing CE certification for the European market.

According to the TGA’s public summary, the system can automatically screen people at risk of developing diabetic retinopathy (DR), age-related macular degeneration (AMD), and glaucoma.

An individual software application program or group of programs is used in combination with one or more retinal imaging devices, such as a fundus camera, for either point-of-care or remote, telemedicine use.

“The software provides analysis capabilities for the detection of

The software uses fundus images to determine the likelihood of disease.

retinopathy and other retinal diseases for early diagnosis and management in patients at risk, to prevent further deterioration and visual loss,” the summary stated.

Dr Theodore Smith, Professor in Ophthalmology and Neuroscience at Icahn School of Medicine at Mount Sinai, New York, added: “This technology could be particularly useful in identifying someone who has slipped across the boundary to progress into severity.” n

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NEWS

FIVE-YEAR DATA DEMONSTRATES iSTENT’S LONG-TERM EFFICACY AND SAFETY Half a decade of data on the second generation iStent inject has shown a significant The study enrolled 125 consecutive eyes reduction in treated with iStent. intraocular pressure (IOP) and medication burden in glaucoma patients.

While there are more than 200 publications on Glaukos iStent technologies, a new paper is the first peerreviewed publication to present five-year data on the device. Published in Advances in Therapy, it is based on a prospective longitudinal study which assessed five-year outcomes following implantation of two iStent inject second-generation trabecular micro-bypass stents, either with or without concomitant cataract surgery, in eyes with various severities of open-angle glaucoma.

The study enrolled 125 consecutive eyes treated with iStent inject (81 combined, 44 standalone) by a single glaucoma surgeon, Germany’s Dr Fritz Hengerer.

An impressive 97% of eyes (121/125) completed five-year follow-up.

Although the cohort had relatively high glaucoma medication burden preoperatively, nearly half of eyes were medication-free by the end of five years, while mean IOP decreased by nearly 10 mmHg.

IMI ROLLS OUT GLOBAL SURVEY ON MYOPIA MANAGEMENT The International Myopia Institute (IMI) has launched a global practitioner survey on the uptake of myopia management.

In recent years, the IMI has developed key evidence-based resources that can be used by eyecare practitioners to implement the best myopia management practices.

While there has been a growing academic interest in myopia management over the past years, IMI is also interested to know what is happening in clinical practice around the globe.

“Receiving feedback directly from eyecare practitioners would help IMI to identify areas that need further knowledge dissemination and understand factors that could hinder the practitioners to adopt best practice,” said IMI chair, Professor Serge Resnikoff.

The IMI survey on ‘myopia control attitudes and practice’ will build on data published in 2016 and 2019 to establish adoption of the latest evidence to address myopia epidemic and how this varies across the world.

“It is well established that clinical

Mean IOP decreased from 22.6 mmHg preoperatively to 13.8 mmHg in combined eyes (39% reduction), and from 25.3 mmHg to 14.6 mmHg (42% reduction) in standalone eyes. In combined eyes, the average number of medications reduced by 69%; the proportion of medication-free eyes rose to 44%. In standalone eyes, the average number of medications reduced from 2.98 preoperatively to 0.74 medications at five years (75% reduction); the proportion of medication-free eyes rose to 50%. n

16

INSIGHT June 2022

research can take several years to impact clinical practice. This survey will aid practitioners in benchmarking their practice, as well as identifying barriers to adoption,” said IMI chief scientist Professor James Wolffsohn.

IMI project director Ms Rebecca Weng said IMI ambassadors had been at the forefront in adapting the survey to their local languages and distributing it through their channels.

The survey is available in English, Danish, Greek, Italian, Russian, Spanish, Simplified Chinese, Traditional Chinese, Turkish and Vietnamese.

“The survey will provide IMI with insightful information to address what is required to bridge the gap between research and clinical practice,” Weng said. n

VISION EYE INSTITUTE LAUNCHES CPD PODCAST

According to the authors, the reductions in IOP and medication were similar in magnitude and consistency over time regardless of whether stenting was performed as a standalone surgery or in combination with phacoemulsification.

Among the paper’s key findings was that in both the combined and standalone groups, clinically and statistically significant reduction from baseline IOP was sustained at all follow-up time points through five years post-operatively.

The survey is available in 10 languages.

is now available. Huynh and Tenen are both highly experienced and respected cataract, corneal and refractive surgeons.

In the 37-minute episode, Huynh and Tenen discuss out-of-the-box questions to ask prospective laser patients to determine their suitability for refractive surgery, what to include in a referral letter and plenty of fascinating, real-life cases.

More episodes will be available in coming months.

Vision Eye Institute (VEI) has launched a new CPD podcast hosted by its clinical relationships manager for Victoria, optometrist Ms Kristina Iacovangelo.

Now streaming, the podcast titled SHARED VISION shares clinical pearls and insights from VEI’s team of ophthalmic surgeons on the topics that matter most in clinical optometric practice.

Episode 1 on refractive co-management with Dr Tess Huynh and Dr Abi Tenen

Each podcast in the series will be accredited by Optometry Australia (CPD hours available to optometrists only).

To be eligible to receive CPD hours, optometrists must listen to the entire episode and complete the attendance record/feedback form linked in the podcast description.

To listen, search for ‘SHARED VISION’ on Buzzsprout or any preferred podcast platform.

More episodes will be available in coming months. n

El th • • • • • • •

N F E i S I T

COMPANY

ESSILORLUXOTTICA SEEKS EYEGLASS CASES AND PACKAGING COMPANY TAKEOVER As it took 100% control of GrandVision and offloaded 177 stores in April, EssilorLuxottica announced a leadership reshuffle for the optical retail giant, including a new CEO. In a separate deal, the Franco-Italian company also revealed its intention to enter the packaging and eyeglass cases market, with plans to acquire a 91% stake in the Italian firm Fedon.

After almost three years, EssilorLuxottica reached the final hurdle in its GrandVision takeover that will see it drastically increase its retail footprint by around 7,000 stores across 40 countries, and an additional 37,000 staff.

On 4 April, EssilorLuxottica, GrandVision and the Optic Retail International Group BENE, a member of MPG Austria (ORIG/ MPG), completed a deal for ORIG/MPG to acquire 142 EyeWish stores in the Netherlands and 35 GrandOptical stores in Belgium. The sale of these GrandVision stores was a key condition set out by

optimising the service for the benefit of all industry players”.

the European Commission.

On 14 April, the company announced it had completed a statutory buy-out of GrandVision shareholders, seeing it take full control of the retailer.

The next day, EssilorLuxottica announced a major leadership overhaul of GrandVision, with Mr Stephan Borchert and Mr Willem Eelman deciding to step down from their respective roles as CEO and chief financial officer of GrandVision, effective 22 April.

Fedon produces eyeglass cases and optical accessories.

They will be replaced by Mr Massimiliano Mutinelli as the new president of optical retail for EMEA at EssilorLuxottica and head of Amsterdam corporate offices at GrandVision, and Mr Niccolò Bencivenni as the chief financial officer of GrandVision.

Meanwhile, in the Fedon deal on 11 April, EssilorLuxottica said it represented a step towards its vertical integration strategy, “aimed at achieving the highest quality standards along the entire value chain and

Fedon’s business groups comprise eyeglass cases and optical accessories including reading glasses, microfibre cloths, shopping bags and lens cleaning sprays that can be customised for individual stores.

“Thanks to cutting-edge technologies and dedicated innovations, the acquisition will allow to better fit eyewear and spectacles with the cases and packaging to ensure maximum protection and integrity of the product, for the benefit of the final consumer,” EssilorLuxottica stated.

“Furthermore, EssilorLuxottica will also leverage on the company to pursue its sustainability strategy, investing in the recyclability and circularity of the packaging materials produced by the company.”

The Fedon deal may be completed by the end of June 2022. n

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COMPANY

BEOVU OBTAINS DME INDICATION IN EUROPE The European Commission (EC) has approved anti-VEGF therapy Beovu (brolucizumab) 6 mg for diabetic macular edema (DME), marking the therapy’s second indication for the bloc.

Ophthalmic pharmaceutical giant Novartis announced the clearance on 31 March that applied to all 27 European Union (EU) member states as well as Iceland, Norway and Liechtenstein.

It comes after Beovu was first approved for neovascular age-related macular degeneration (nAMD) in Europe in 2020.

It’s also indicated for this disease in Australia where it has been listed on the Pharmaceutical Benefits Scheme (PBS) as a second-line treatment.

The EC approval was based on year one data from the Phase 3, randomised, double-masked KESTREL and KITE studies, which met their primary endpoint of non-inferiority in change in bestcorrected visual acuity (BCVA) from baseline versus aflibercept at year one, Novartis stated.

In both trials, following the loading phase, over half of patients (55.1% in KESTREL and 50.3% in KITE) in the Beovu 6 mg arm remained on a 12-week dosing interval through year one.

Aflibercept dosing was aligned to the approved EU label in year one of treatment. In aggregate, a numerically lower proportion of patient eyes treated with Beovu had intraretinal fluid, subretinal fluid or both at week 52 versus eyes treated with aflibercept (in KESTREL 60.3% in Beovu arm versus 73.3% in aflibercept arm; in KITE 54.2% versus 72.9%, respectively; testing for statistical significance was not performed).

“This approval marks a significant milestone for DME patients, many of whom are of working age and struggle with adherence due to the need to manage multiple comorbidities related to diabetes,” said Ms Jill Hopkins, senior vice president and global development unit head of ophthalmology at Novartis Pharmaceuticals.

“KESTREL and KITE were the first pivotal trials to assess an anti-VEGF on six-week dosing intervals in the loading phase, suggesting Beovu may offer fewer injections from the start of treatment through year one. The EC approval of Beovu in DME may thus help address unmet needs.” n

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INSIGHT June 2022

BAUSCH + LOMB COMPLETES EYECARE SPIN-OFF Ophthalmic giant Bausch + Lomb (B+L) has launched as a publicly trading company, completing its spin-off from its parent to operate as a pure-play eye health company.

B+L made the announcement on 5 May as it also unveiled the pricing of its initial public offering (IPO) of 35 million common shares at a public offering price of US$18.00 (AU$25) per share, equating to US$630 million (AU$906 m). The common shares have been approved for listing on the New York Stock Exchange and conditionally approved for listing on the Toronto Stock Exchange, under the ticker ‘BLCO’.

It comes after an August 2020 announcement that B+L would operate independently from parent Bausch Health.

"Today marks a tremendous milestone for Bausch + Lomb and an important step forward on the path to an independent company focused on eye health," said Mr Joseph Papa, B+L chairman and CEO. "Bausch + Lomb has long been associated with many of the most significant advances in eye health, and I am honoured to work alongside our

B+L has more than 12,000 employees.

12,000 global employees as we continue to focus on achieving our ongoing mission of helping people see better to live better all over the world."

As a fully integrated eye health company, B+L offers a comprehensive portfolio of more than 400 eyecare and vision-related products. It has projects in various stages of pre-clinical and clinical development, including new over-the-counter eyecare products, contact lenses, software and prescription medications for myopia management, next-generation cataract and LASIK surgical equipment, premium intraocular lenses, investigational treatments for dry eye and preservative-free formulations of a range of eye drops. n

LUMIBIRD MEDICAL UNVEILS NEW CAPSULO ND: YAG LASER Lumibird Medical has launched its new Nd:YAG laser platform, Capsulo, designed for efficient and accurate capsulotomy and iridotomy treatments.

On 19 April, the parent company of ophthalmic laser manufacturer Quantel Medical (France and Poland) and Ellex (Australia, Japan and US) unveiled the next generation laser system that it described as easy-to-use and versatile.

In a statement, it said the literature showed the incidence of post-operative secondary cataract varies anywhere between 10-50% within three to five years, demonstrating the need secondary cataract treatments.

“With the redesign of Quantel Medical’s flagship Nd:YAG Laser, Lumibird Medical delivers Capsulo; the next generation technology, continuing to support this important growing market need,” Lumibird stated.

Mr Matthew Metcalfe, anterior segment

laser product manager at Lumibird Medical, said Capsulo is built with exclusive high-quality optics delivering pristine clarity of view into the anterior and posterior segments of the eye.

“Advanced illumination with a variableheight light tower offers dual illumination angles of 16 and 7.5° for anterior and posterior laser applications,” he said.

The Capsulo Nd:YAG laser can be paired with the Quantel Medical Vitra 2 MultiSpot photocoagulating laser, also from Lumibird Medical, combining panretinal photocoagulation functionality through a single slit lamp.

Mr Jean-Marc Gendre, CEO of Lumibird Medical added: “Capsulo, when combined with the Vitra 2 photocoagulator, offers an ideal all-in one laser platform, and we are extremely proud to provide this highly versatile solution into the hands of discerning ophthalmologists.” n

RESEARCH

STUDY CONFIRMS VISION PROBLEMS LINKED TO ERECTILE DYSFUNCTION MEDICATIONS The risk of developing one of three serious eye conditions increases by 85% for regular users of common erectile dysfunction (ED) medications such as Viagra, Cialis, Levitra and Stendra, new research has found.

The eye conditions include serous retinal detachment (SRD), retinal vascular occlusion (RVO), and Ischemic optic neuropathy (ION). Two of the three conditions had previously been linked to ED medications only by anecdotal case studies, but those links are now confirmed for the first time by a large, epidemiological study, published in JAMA Ophthalmology.

Researchers at University of British Columbia (UBC) in Vancouver, Canada, analysed health insurance claim records of 213,000 men in the US who had not experienced SRD, RVO or ION in the year before they became regular users of ED medications. Researchers followed the records to see how many men developed one or more of the three conditions, and

how that rate compared to men who didn’t use the medications.

could be impacted,” he said.

After accounting statistically for other conditions such as hypertension, diabetes and coronary artery disease that are known to be associated with eye problems, they found users of ED medications are 2.58x Around 20 million ED more likely than non-users to develop scripts are dispensed SRD, 1.44x more likely than non-users to each month in the US. develop RVO, and 2.02x more likely than non-users to develop ION. Dr Mahyar Etminan, an Associate Professor in the Department of Ophthalmology and Visual Sciences at the UBC Faculty of Medicine, said regular users of ED drugs who find any changes in their vision should take it seriously and seek medical attention.

“These are rare conditions, and the risk of developing one remains very low for any individual user. However, the sheer number of prescriptions dispensed each month in the US – about 20 million – means that a significant number of people

The study showed only the statistical association between eye conditions and use of Viagra, Cialis, Levitra or Stendra. It did not prove that the drugs cause these conditions. However, ED medications function in a way that suggests some possible explanations.

“These medications address erectile dysfunction by improving blood flow, but we know that they can also hinder blood flow in other parts of the body,” Etminan said.

“So although our study doesn’t prove cause-and-effect, there is a mechanism by which these medications could conceivably lead to these problems. The totality of the evidence points toward a strong link.”

According to UBC, the potential risk of SRD and RVO is not addressed in the information currently provided to patients along with their ED medications, unlike the ION risk which has been demonstrated by previous research. n

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COMPANY PROFILE Modstyle’s Peter Bienvenu (left) and Mark Wymond in the company’s newly-built eyewear design studio.

THE CHANGING FACE OF MODSTYLE A new purpose-built design space has become the creative engine room for the two-man team behind some of the best-selling affordable frames in Australian independent optical practices.

F

amily-owned Australian optical wholesale company Modstyle was established in 1981 and acquired in 2016 by the Wymond family, who also own Eyes Right Optical and Sunglass Collective.

Providing a wide range of quality eyewear aimed at the affordable price point, Modstyle is the Australian supplier for Avanti, Eclipse, Kaleyedoscope, Inface, My Style, and Nifties brands. Its collections are currently stocked in more than 900 independent optometrists across Australia, New Zealand and the US. But many may not be aware that since the Wymonds acquired the company, they have added a new dimension to the business by taking control of the entire design and production process for certain brands within the portfolio, aimed at the broader, mainstream market.

To help with the creative process, Modstyle has just completed a fit-out of a new dedicated design room at its Scoresby premises on the fringe of Melbourne, affording managing director Mr Mark Wymond and Modstyle sales representative and procurement officer Mr Peter Bienvenu an opportunity to enhance the sacred creative process.

he explains. “Now, we're designing and creating our own frames in Melbourne, from scratch. We've been doing this for a while but now we are really keen to market ourselves in this space.”

Wymond describes Modstyle’s newly built design room as the start of a campaign to stake its claim as a company with quality, design-driven product that's suited to the Australian market.

To create the bespoke design room, the company built a mezzanine, which features a distressed timber wall merging into a vertical garden, and a four-metre table lit from beneath to illuminate see-through acetate placed on the table.

“On one wall, we have a whole peg board of acetates from the best acetate manufacturers in the world. On the other wall, we're showcasing our range of frames, either from our current collection or our prototypes,” Wymond says.

The design room also includes space dedicated to the creative process where Wymond and Bienvenu can sketch and discuss their design ideas uninterrupted.

Wymond says it’s all part of taking the company to a new level and becoming unapologetic about its positioning as an Australian eyewear design firm.

“Our day-to-day operations are getting busier. We desperately needed a space where we can dedicate ourselves to the design process,” Wymond says.

“In the past, Modstyle was like other companies, sourcing frames down the aisles in Hong Kong, and bringing them back to Australia,”

“Bringing this design room together has put everything in one place rather than being dispersed working in my office or in Peter’s office. Now

20 INSIGHT June 2022

The Avanti Kingston has been a surprise top-seller and an example how Modstyle can push the boundaries of eyewear design.

we've got one space dedicated to creating frames.”

A high level of focus and creative flow is vital to the frames design process, which will ultimately lead to better outcomes for the brands Modstyle represents, as well as stockists.

“You're visualising so much of how a frame is going to look and feel, how the acetates are going to work together, how the metals are going to complement the acetate. You really need to be in that creative head space. Even without interruption, it’s still a long process to conceptualise and create a frame from start to finish,” he says.

“We're very proud of the space that we've created. We don't get many opportunities to do a creative fit-out, but we had that opportunity here, and it’s a really nice space to work in. It allows for a more efficient design process, which results in better outcomes. We can lock ourselves away for a couple of hours, or a couple of days, without distractions, and with everything at our fingertips.”

PROFESSIONAL DESIGN FIRM Wymond is seizing an opportunity to mould Modstyle into a process-driven, professional design firm.

“Our design mantra is to make frames anybody can wear. We use the best quality acetates and the best quality hinges from around the world," he says.

“I've always been creative and enjoyed that space. When we acquired Modstyle, it was really thrust upon us to have to start this design process, but I want to professionalise the process, not do it the way it has always been done. I want to make it the most professional outfit we can."

With a unique selling point of being Australian-designed, Wymond and Bienvenu are breathing new life into the main brands in Modstyle’s collections, including Avanti, Eclipse and Kaleyedoscope.

Their design process begins with a simple sketch.

“Back in the 1990s, when Modstyle was quite a large company, it had some fantastic relationships with factories throughout Asia.

Without those existing relationships, we would not be able to get a production run in these manufacturers today because they're at full capacity, and not taking on new clients. But because we bought some of that goodwill through the acquisition of Modstyle – we were extremely fortunate to have this opportunity in that regard.”

With a large client base comprising hundreds of independent Australian practices, Modstyle can also easily meet the minimum requirements of its factory partners.

This affords Wymond and Bienvenu the freedom to experiment in areas where others may not venture. For example, although rose gold and transparent acetates are ‘on trend’ at the moment, they are experimenting with bold colours.

“We've found a bit of a push towards colours and bright, bold colours are some of our best sellers. Some of the boldest colours we've ever created are our best sellers,” Wymond says.

While this is great for those end-consumers who want their eyewear to stand-out, some practices also use these styles as a feature piece in the store to help brighten their frames display.

“We've always got enough volume to cover the minimum order, so we've tried some really out-there colours which have sold better than more traditional colours, like black or tortoise shell,” Wymond continues.

“Our 'lookover' frames, like the Avanti Kingston which features bright green frames with pink temples, sold out the quickest. We really went to town on that design and had some fun with it. But by having some fun, we've found a market for these really colourful and unique frames. To sell as well as they have has been absolutely unexpected.”

Ultimately with Modstyle, Wymond wants to create frames that they enjoy and are proud of.

“And that seems to resonate with our customers. That's where we can really push the envelope in a colour way that maybe other companies might be afraid to do,” Wymond says.

“As a family-owned business, strong family values underpin everything we do at Modstyle and plays a powerful role in the company’s culture and success. Our priority is to share our passion for fashionable, affordable eyewear with our audience regardless of age, gender and economic background.” n

“We basically start with a first initial sketch of our design. Then we select acetates and colour ways to suit that style of frame, and then develop a more technical drawing using CAD (computer aided design). We then send the design to our manufacturer for prototyping,” he explains.

When a prototype returns from the manufacturer, Wymond and Bienvenu review their design.

“A prototype is like a mock-up, with acetates we've requested; the basic shape, acetate, look and feel is all there. It’s enough to make the decision to go ahead or make further alterations to get it right,” Wymond says.

“We look at it all again. Is it the right shape? Can we alter it slightly? Is it the right acetate? Do we need to put a different temple tip on? All those questions are considered when we receive the prototype. Once we’re happy with the prototype, then we go into production."

Modstyle manufactures its ranges using mainly three separate factories: a titanium, acetate, and a stainless-steel factory.

“We've made sure these are the best in the business of what they do.

An affordable price point doesn’t mean lower quality, our warranty levels for Avanti are almost non-existent, and that’s because we are using world-leading hinges, and the most beautiful acetates from around the world,” Wymond says.

The design process involves sketches, CAD drawings and comparison of acetates and temples.

INSIGHT June 2022 21

MYOPIA

A MYOPIA FIRST:

Lens shows long-term efficacy New six-year data for Hoya’s defocus lens marks the longest study of a myopia control spectacle lens – and answers key questions about rebounding effects and whether the control effect is sustained over time.

S

ince the Australian launch of its MiYOSMART defocus spectacle lens in October 2020, Hoya Vision Care believes its innovation has spurred more independent optometrists into myopia management, many offering a proven intervention for the first time.

Anecdotally, optometrists are reporting benefits in prescribing the lens for young children that are yet to adopt a myopia treatment – or have been using less effective spectacle lenses. Others have found it an ideal option for kids not ready for contact lenses, or those that want to discontinue contact lens wear.

Initially, Mr Ulli Hentschel, national training and development manager for Hoya Lens Australia, says the lens found a home with well-established myopia clinics, but the company has seen rapid uptake in practices entering myopia management for the first time. This is particularly the case for practices that may have been reluctant to set themselves up for contact lens interventions.

Hoya’s defocus spectacle lens, developed with The Hong Kong Polytechnic University, incorporates Defocus Incorporated Multiple Segments (D.I.M.S.) Technology that causes a myopia controlling effect, while correcting vision, fitted in a children’s eyeglass frame.

“Providing an intervention that is safe, non-invasive and significantly easier to prescribe – while still offering similar efficacy as other best available interventions – has been a welcome addition to the myopia tool kit for many practices, especially for those who may have only been prescribing singlevision lenses previously,” Hentschel explains, noting that parents are also more familiar with spectacle lens use.

“And in the past six months, we have had many of these optometrists ask how they can take their myopia management to another level, which is why we’ve created other initiatives like partnering with Haag-Streit and Device Technologies to provide a pathway towards optical biometer ownership to measure axial length and provide a gold standard level of myopia management.”

Ease-of-use may be a key feature of the MiYOSMART lens, but optometrists ultimately won’t prescribe it unless there is evidence demonstrating its efficacy.

Last month at the Association for Research in Vision and Ophthalmology (ARVO) 2022 conference in Denver, Colorado, Hoya unveiled the results of a six-year follow-up clinical study on MiYOSMART, shared by Professor Carly Lam from the Centre for Myopia Research at The Hong Kong Polytechnic University who conducted the research.

It marked the longest study on a myopia management spectacle lens, and answered two key questions: is the lens' myopia control effect sustained over time? And are there any rebound effects after children cease wear?

It built on an original two-year, double-blind randomised trial1, published in the British Journal of Ophthalmology, that concluded children aged 8-13 years wearing MiYOSMART had 60% less myopia progression compared

22 INSIGHT June 2022

“HAVING SIX YEARS-WORTH OF DATA, PRACTITIONERS CAN EXPLAIN TO PARENTS THAT THE LENS CAN SUSTAIN THE MYOPIA CONTROL EFFECT OVER TIME” ULLI HENTSCHEL HOYA LENS AUSTRALIA

with single-vision wearers as measured by the axial elongation, and a 59% reduction in spherical equivalent refraction.

These findings have been central to Hoya positioning MiYOSMART among the leading interventions. Subsequent three-year data2 showed the lens continued to slow myopia progression, while patients who switched from single-vision to MiYOSMART had a significant slowdown in their condition.

The just-released six-year data at ARVO involved 90 children in Asia.

Importantly, Lam reported MiYOSMART’s myopia control effect was sustained over time for wearers. It also confirmed that patients who stopped wearing the lens showed no rebound effects compared to the initial myopia rates of progression during the two-year randomised control trial or with the general population. And the average cumulative myopia progression was less than 1.00 D and axial elongation 0.6 mm over six years in the D.I.M.S. group.3 Hentschel says the results are important for practitioners who can have confidence they’re adopting an approach backed by long-term evidence. It will also help to communicate to parents about the importance of longer-term treatment and what would happen if their child ceased wear.

“How long children need to wear the lens is a common question by parents, and in theory they should until they are in their late teens or an adult when progressions begins to stop naturally,” he says.

“Having six years-worth of data, practitioners can explain to parents that the lens can sustain the myopia control effect over time. And with respect to there being no rebound effect, if a child decides to stop wearing the lens in three to four years for whatever reason, the data shows that won’t be a wasted effort – but the best outcome would be for continuous wear beyond that.”

Hentschel also notes practitioners are seeing results that exceed the average 60% reduction in myopia progression, as reported from the clinical trials. The same trial has shown that myopia progression was stopped in 21.5% of the study population.

“We have had feedback from optometrist customers that have found some children have responded to MiYOSMART extremely well, slowing progression dramatically,” he says.

MORE THAN A LENS Hentschel says Hoya is exploring avenues to raise the bar of myopia management beyond MiYOSMART. An alliance with Haag-Streit and its local distributor Device Technologies Australia, a first-ever direct-to-consumer campaign and the launch of a children’s frame collection are all part of its plan to provide a comprehensive myopia platform so practitioners can address one of the largest public health issues of our era.

Hoya’s global sales and marketing agreement with Haag-Streit/Device Technologies – announced last October – creates a preferred partnership between the entities to offer practitioners “a one-two approach” to myopia.

This comes in the form of a diagnostic/monitoring device (Lenstar Myopia optical biometer) and treatment (MiYOSMART).

Ultimately, for practitioners prescribing MiYOSMART, it paves a smoother path towards ownership of a Lenstar Myopia so they can begin adopting axial length measurements in their management, considered a gold standard approach.

The instrument is based on Haag-Streit’s well established Lenstar 900 optical biometer – popular among cataract surgeons – but optimised for myopia management by incorporating specialised software, EyeSuite Myopia.

Hentschel says there has been growing interest in the program, which was explained in detail to delegates at April’s Australian Vision Convention (AVC) in Queensland.

The new Oliver Wolfe collection for kids features 15 models, each in two colours.

offering the lens and myopia management.”

Another important component of Hoya’s myopia efforts is to ensure practitioners are prescribing it correctly. That’s why it has partnered with global myopia authorities Dr Kate and Dr Paul Gifford, founders of the Australian-based Myopia Profile platform, to formulate an online accreditation process for MiYOSMART. Hentschel says it represents one of the first myopia control interventions involving optometrists, as well as optical dispensers.

Locally, in an unusual step for a lens company, Hoya is also set to launch an inaugural direct-to-consumer campaign for MiYOSMART, educating parents about the importance of intervention. It will also double as a marketing tool for practices prescribing MiYOSMART.

“It’s important for dispensers to provide an appropriate frame that works well with MiYOSMART, and it’s also vital how they communicate the process to parents and children. Until MiYOSMART came to be, myopia management was predominantly optometry-focused, but now it's really important the dispensing team and optometrist are across detail,” he says.

“Now that we have a critical mass of practices using MiYOSMART, we will soon start a campaign that will feature consumer-focused communications discussing the lens efficacy and raising myopia awareness among parents, including a call to action,” Hentschel explains.

Compatible frame selection was also part of the reason for Hoya to launch a new Oliver Wolfe Junior frame collection last November. While not exclusively developed for MiYOSMART, it has been designed with the lens in mind.

“We will have a dedicated MiYOSMART website parents can visit featuring a ‘practice locator’ to help them find the closest optometrist Children aged 8-13 wearing MiYOSMART had 60% less myopia progression compared with single-vision wearers as measured by the axial elongation.1

Hentschel says the company was frequently asked which frames would work well with MiYOSMART, so the new collection has been a welcome solution. Feedback from local practices has been encouraging, suiting the active care-free lifestyles of children at an affordable price.

“As with our original Oliver Wolfe series, if patients combine it with a Hoya lens, we sell it to the practice at a distributor-level cost, which is great value for the quality you get,” Hentschel says.

“What we are trying to achieve with MiYOSMART extends beyond supplying the lens; from these initiatives you can see it’s about trying to provide a whole platform of myopia management tools and resources that practices need to provide the best possible care.

“Whether it’s in the consulting room with the Lenstar myopia or a therapy that’s working extremely well in MiYOSMART, to the affordable Oliver Wolfe kids frames and communication with consumers, we are trying to raise the level of myopia management in Australia in an accessible way.” n REFERENCES 1. L am CSY, Tang WC, Tse DY, Lee RPK, Chun RKM, Hasegawa K, Qi H, Hatanaka T, To CH. Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomized clinical trial. British Journal of Ophthalmology. Published Online First: 29 May 2019. doi: 10.1136/bjophthalmol-2018-313739 2. Lam CS, Tang WC, Lee PH, et al. Myopia control effect of defocus incorporated multiple segments (DIMS) spectacle lens in Chinese children: results of a 3-year follow-up study.

British Journal of Ophthalmology Published Online First: 17 March 2021. doi: 10.1136/ bjophthalmol-2020-317664 3. Lam CSY, Tang WC, Zhang A, Tse D, To CH. Myopia control in children wearing DIMS spectacle lens: 6 years results. ARVO 2022 Annual Meeting, May 1-4, Denver, US.

INSIGHT June 2022 23

ZEISS FORUM with Integrated Diagnostic Imaging Different data. Different analyses. The complexity of information from today’s technologies seems to require that you have your own diagnostic assistant. Until now.

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Transforming data into turning points in care.

LEARNING OBJECTIVES: At the completion of this CPD activity, optometrists will have developed their knowledge of glaucoma management.

CPD

Including: • Identify barriers to glaucoma co-management • Understand the value of well-structured, mutually-agreed individualised collaborative frameworks for shared-care • Clinically identify which cases of glaucoma could be comanaged between optometry and ophthalmology • Establish a co-management frameworks focused on individual patient care

TRANSFORMATIVE COLLABORATION: 21ST CENTURY GLAUCOMA MANAGEMENT IN REGIONAL AUSTRALIA As the diagnostic armamentarium evolves, eyecare professionals are re-writing their traditional roles in glaucoma management. Using ‘co-managed case reports’, the authors trace two patients’ divergent journeys from initial optometric consultation to ophthalmology referral in Tasmania.

T

he cascading effects of glaucoma impacts individuals, families, communities and a broad range of healthcare professionals.

As the demographics of Australia change and the population of the country shifts, there is a growing need to develop new methods of collaborative care and provide timely and effective screening and treatment.

Because of the progressive nature of the disease, it’s critical to ensure everyone over 40 years old receives routine eye exams. Making a real difference means addressing key issues: cost, delayed diagnosis and loss to follow up.

BURDEN ON OPHTHALMOLOGY Glaucoma affects roughly 200 000 Australians, a further 200,000 have strong suspicion and a further 380,000 may be classed ‘ocular hypertension’. This represents around 4% of the general population and, if seen twice yearly, equates to 1.5 million glaucoma exams annually.3,4

1,2

This burden may be heightened in regional areas. For instance, in parts of northern Tasmania, there is just one ophthalmologist for every 45,000 people. This equates to 3,600 glaucoma assessments a year for each ophthalmologist in Northern Tasmania. This, of course, leaves little room for other conditions to be managed.

costs and wasted time and lighten the load on ophthalmology.

SYNERGY OF EQUIPMENT AND ETHOS Our Specsavers practice in Launceston is a large, seven-room clinic with access to a Topcon Maestro and a ZEISS CIRRUS OCT. As per our protocol, every patient is screened first with the Maestro; those with suspicious results then go on to have CIRRUS scans. Our practice has the Humphrey Field Analyzer 3 (HFA3); a Pachmate pachymeter; a CLARUS ultra-widefield camera; a 4-mirror gonio lens; a Perkins, iCare and standard non-contact tonometers; and we run ZEISS FORUM Glaucoma Workplace software.

Locally, there are two ophthalmology practices that also use a CIRRUS OCT, HFA and ZEISS FORUM Glaucoma Workplace software.

We have found that collaborating with these practices allows for more definitive ‘like-for-like’ analysis, regardless of the location of scans. We are also able to send raw DICOM files of HFA and OCT data to be downloaded into FORUM

ABOUT THE AUTHORS: Damon Hannay BOptom Optometry Director, Specsavers Launceston, Tasmania

Dr Dean Cugley MB BS (Tas) FRANZCO Ophthalmologist, Launceston Eye Institute, Tasmania

OVER-REFERRAL It’s vital that patients with isolated findings such as elevated intraocular press (IOP) or large optic nerve cupping are evaluated by their optometrists – but not automatically referred unless a comprehensive clinical picture is found.

Ultimately, optometrists who have command of relevant clinical equipment are more likely to provide long-term care for the patients who don’t require referral, which will eliminate unnecessary

Figures 1A & 1B (next page) – Screening OCT shows retinal nerve fibre layers and Ganglion cell layers within normal limits.

INSIGHT June 2022 25

CPD

Figure 1B: Corresponds with caption on page 25.

software at each practice.

This synergy of equipment and ethos has meant we have been able to develop a comanagement protocol that lightens the burden of glaucoma care for the ophthalmologist, ensures prompt follow up and encourages informed referral and optimum treatment.

CASE 1 – NORMAL TENSION GLAUCOMA Patient presents at optometrist A 62-year-old female presented for a routine eye examination in September. She was on no medications, had no family history of glaucoma and denied any relevant ocular history.

IOP with iCare tonometer was 9 mmHg in each eye. Screening OCT with Topcon Maestro (Figure 1A and Figure 1B) showed retinal nerve fibre layer (RNFL) and ganglion cell layer (GCL) maps within normal limits for both eyes.

Pachymetry was thin at 480 microns.

Ophthalmoscopy revealed a deep inferior notch at the right disc and more careful examination with the Maestro OCT showed obvious relative inferior thinning of the RNFL compared to the fellow eye.

We went on to perform 24-2C visual field testing and CIRRUS OCT which, given its retinal tracking function, allows for more consistent readings when looking at progression over time. It also allows for data importation into the ZEISS FORUM Glaucoma Workplace platform.

Glaucoma Workplace collates data from the HFA3, CIRRUS OCT and CLARUS ultra widefield camera to provide two valuable functions: 1. Structure Function Single Visit Reporting – allowing for simultaneous and overlapping

26

INSIGHT June 2022

analysis of visual field plots comparing to associated structural damage.

thinning with no disc haemorrhage or nerve fibre layer defect.

2. Structure-Function Guided Progression Analysis (SF-GPA) software allowing for a multi-modal comparison of OCT, HVF and true-colour fundus images over the full time series in a user-friendly, single screen interface.

There was no evidence of cystoid macular oedema. There was corresponding right disc and field abnormalities consistent with early right glaucoma. See the combined assessment in Figure 3.

The patient was diagnosed with normal tension glaucoma and started on Xalatan. Her response was checked in a month and was found to be 6 mmhg. The patient was then referred to a local glaucoma specialist as per clinical guidelines for confirmation of treatment plan and comanagement.

Patient is referred to ophthalmologist In November, the referred patient presented at the Launceston Eye Institute (LEI) with high suspicion of normal tension glaucoma. History revealed no ocular trauma, medications associated with optic neuropathy, or medical comorbidity such as migraines or Raynaud’s phenomena. There was no known family history of glaucoma.

The ocular examination revealed normal colour vision bilaterally and visual acuity of an unremarkable anterior segment with no signs of pseudoexfoliation (PXF) or pigment dispersion syndrome with open angles on gonioscopy and no significant crystalline lens opacity. IOP was 7 mmHg bilaterally on Goldmann applanation tonometry at 10:25am.

Pachymetry revealed central corneal thickness (CCT) of 482 microns right and 478 microns left. Fundoscopy revealed optic discs of normal vertical height (1.7 mm) size with cup-to-disc ratio (CDR) 0.65 right with inferior notch and 0.55 left with borderline inferior

Compared with the optometric assessment, the visual field was less marked and the RNFL more marked, again on CIRRUS OCT. (The former may be due to some degree of patient familiarisation effect with the visual field test, and the latter due to assessment through an undilated pupil).

Diagnosis A diagnosis of normal tension glaucoma with adequate intraocular pressure (IOP) response and tolerance to first line prostaglandin. Target IOP was set at 7 mmHg (20% reduction in IOP). First choice agent of prostaglandin analogue was appropriate and tolerated well since commencement.

This case was classified as ‘early glaucoma’ (< 6dB HVF loss and no loss within central 10 degrees).

Discussion This is an ideal case for optometry-led glaucoma management due to the adequate initial response to first-line therapy. The patient was seen again approximately six months after the initial consultation, and the patient in fact questioned the need for ongoing reviews with an ophthalmologist. Instead, she preferred optometry reviews. She was duly discharged back to optometric led care.

Guidelines for referral back to ophthalmology review were communicated, and would

Figure 2: The baseline Structure-Function report from Case 1. There is a clear inferior RNFL focal loss in the right eye associated with a superior field defect in the matching sector.

This clinical picture is clearly much more suggestive of glaucoma.

represent unstable disease which may include:

period (clinically or on OCT of RNFL / GCL)

• U nknown disease velocity (first presentation, lost to follow up etc.)

• C oncern of anterior segment angle compromise, typically in phakic patients

• I OP fluctuations of 3 mmHg or more above target IOP (determined during initial baseline medical assessment)

• M edication issues, such as suspected side effects, intolerance or compliance issues – for example cystoid macular oedema, prostaglandin associated orbitopathy etc.

• S tructural changes in the previous three-year

Patient returns to the care of the optometrist After two years of stability (see right eye Guided Progression Analysis summary Figure 4), the patient was discharged back to optometrist for ongoing six-monthly monitoring. The shared use of progression software and the initial strong communication between optometry and ophthalmology

Figure 3: Visual field/OCT assessment in Case 1.

INSIGHT June 2022 27

CPD

allowed for an excellent patient outcome with reduced cost and stress on a regional ophthalmology clinic.

This patient can be safely followed in a primary care setting with the knowledge that any future progression or issues can be shared with the collaborating ophthalmologist.

CASE 2 Patient presents at the optometrist A 70-year-old female presented for her first eye examination at our optometry practice complaining of gradual reduced vision in both eyes. She reported a history of being diagnosed with glaucoma around five years prior but had not been seen in the last four years and had stopped treatment around the same time.

Gaining an insight into a patient’s individual barriers to care is the first important step in trying to steer her journey in a new direction.

Discussing the factors leading to this decision revealed three common challenges in glaucoma care: 1. S ignificant ocular irritation with latanoprost, with rapid symptomatic improvement on cessation 2. Out-of-pocket costs were financially limiting, and she felt therefore unable to return to her ophthalmologist to discuss alternate treatment strategies.

(Unfortunately, these concerns were not communicated to the treating ophthalmologist at that time to discuss alternatives).

3. A lack of understanding of the disease

and relative early asymptomatic nature, meant because she felt her vision was ‘fine’ and that she would return only if she became symptomatic, which would likely represent advanced disease or other ocular comorbidity.

Breaking down barriers We were able to look at the StructureFunction report (Figure 5) together showing the significant GCL and RNFL defects more evident in the right eye associated with the dense superior field loss. It was not hard to understand the consequence the untreated glaucoma had had on her vision. Deferring treatment at this point could be devastating.

We had a discussion about the different modalities of glaucoma therapy and the ability to tailor the management plan as needed. We discussed the frequent ocular surface irritation experienced with medical therapy in glaucoma and the ways in which this may be overcome.

Avenues available to minimise out-ofpocket costs through the use of the public system and our optometry practice (where appropriate) were discussed. However, in this circumstance – given the advanced nature of her right eye disease – we recommended that an ophthalmologist should be taking the lead decisions.

The patient was started on Lumigan PF to determine what affect benzalkonium chloride (BAK preservative) may have been having on her initial experience. She was asked to touch base with us by phone a week later to ensure she wasn’t experiencing any side effects.

I also organised for her to see a local glaucoma specialist the following month for confirmation of treatment plan and to identify if and when surgical intervention might be warranted in light of relatively advanced disease.

Patient is referred to ophthalmologist At the LEI, we were referred a 70-year-old Caucasian female with established rightgreater-than-left visual field loss consistent with advanced glaucomatous optic neuropathy and symptomatic cataracts. She was tolerating preservative free-bimatoprost better than previously trialled latanoprost, suggesting a degree of BAK intolerance.

Figure 4: Right eye Guided Progression Analysis summary in Case 1.

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INSIGHT June 2022

The patient was seen promptly in light of the review in August. Clinical examination revealed significant cataracts, moderate angle shallowing with low risk of occlusion and no evidence of secondary causes.

The intraocular pressure was 23 mmHg (OD) and 20 mmHG (OS) after only two weeks of topical bimatoprost. There was established disc cupping bilaterally with no disc haemorrhage.

The combined assessment, shown below, corresponds with the optometrist referral assessment. It indicates advanced disease in the right eye (> 12dB loss and within central 10 degrees) with dense superior field loss and moderate in the left (6-12dB loss without loss in the central 10 degrees) with inferior arcuate scotoma. Again, there was disc field concordance but discrepancy between total and pattern deviation suggesting a degree of media opacity (that is: cataract).

The ophthalmology management plan included: • Discussions about the diagnosis of glaucoma, irreversible nature of established disease, extent of disease in her eyes, the plethora of treatment options and the importance of adequate treatment, follow up and compliance with both • Binocular estermann suprathreshold visual field examination to ensure visual field at current driving standard for private vehicle given extensive right superior field loss • Preparation for cataract surgery • Comprehensive and regular communication with the referring optometrist with updates and plan for post-operative spectacle update and thereby opportunistic IOP checks at these

BARRIERS TO GLAUCOMA CO-MANAGEMENT EXIST ...

BUT THEY CAN BE OVERCOME Co-management of patients with all eye disorders already exists informally. A formalisation of co-management strategies can serve to reduce cost and increase efficiency in our health system.

There continue to be barriers to formalised glaucoma co-management between optometrists and ophthalmologists, but as these case reports show, these barriers are surmountable.

Communication between clinicians – Absence of an established relationship between optometrist and patient, such that long-term management may not reliably be undertaken.

Lack of translatable data between clinicians – such as different platforms for visual fields and OCT which are not directly comparable.

Lack of patient awareness – This can be suggested at timing of medical referral or after a significant period of stability.

In general, a specific individual optometrist and doctor should agree to management of the patient rather than the patient being allocated to the ‘practice’ to ensure case ownership

A similar platform and related data sharing can maintain continuity of care with the streamlined transmission of familiar and trusted diagnostic reporting. .

Lack of formalised protocols or arrangements – Formalised protocols can be set up between clinicians that already have a sound working relationship through existing referral pathway.

(ZEISS will be one of the first to trial this solution with the release of its new cloudbased platform for sharing diagnostic reports called ‘FORUM Cloud Viewer’).

'RANZCO Glaucoma Co-managment Guidelines' provides excellent guidance for cases suitable for co-management, identified at time of referral.5

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

Before prescribing please review Product Information available via www.aspenpharma.com.au/products or call 1300 659 646.

A first choice for glaucoma management1

✔

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

Minimum Product Information: XALATAN® (Latanoprost 50 μg/mL) Eye Drops. Indication: Reduction of intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension.

Contraindications: Hypersensitivity to ingredients. Precautions: Change in eye colour due to increased iris pigmentation, heterochromia; eyelid skin darkening; eyelash and vellus hair changes; aphakia; pseudophakia; macular oedema; other types of glaucoma; contact lenses; severe or brittle asthma; herpetic keratitis; driving or using machines; elderly; children; lactation. Pregnancy: Category (B3) Interactions: other prostaglandins, thiomersal. See PI for details. Adverse Effects: Iris hyperpigmentation; eye irritation (burning, grittiness, itching, stinging and foreign body sensation); eyelash and vellus hair changes (increased length, thickness, pigmentation and number of eyelashes); mild to moderate ocular hyperaemia; punctate keratitis; punctate epithelial erosions; blepharitis; eye pain; excessive tearing; conjunctivitis; blurred vision; eyelid oedema, localised skin reaction on eyelids; myalgia, arthralgia; dizziness; headache; skin rash; eczema; bronchitis; upper respiratory tract infection; abnormal liver function. Uncommon: Iritis, uveitis; keratitis; macular oedema; photophobia; chest pain; asthma; dyspnoea.

Rare: periorbital and lid changes resulting in deepening of the eyelid sulcus; corneal calcification. See PI for details and other AEs. Dosage and Administration: One eye drop in the affected eye(s) once daily. Other eye drops should be administered at least 5 minutes apart. (Based on PI dated 2 March 2021) References: 1. NHMRC Guidelines for the screening, prognosis, diagnosis, management and prevention of glaucoma 2010 2. Australian Commission on Safety and Quality in Healthcare Active Ingredient Prescribing Guide - list of medicines for brand consideration December 2020 Aspen Australia includes Aspen Pharmacare Australia Pty Ltd (ABN 51 096 236 985) and Aspen Pharma Pty Ltd (ABN 88 004 118 594). All sales and marketing requests to: Aspen Pharmacare Pty Ltd, 34-36 Chandos Street, St Leonards NSW 2065. Tel: +61 2 8436 8300 Email: aspen@aspenpharmacare.com.au Web: www.aspenpharma. com.au Trademarks are owned by or licensed to the Aspen group of companies. © 2021 Aspen group of companies or its licensor.

All rights reserved. Prepared: June 2021 AF05768 ASP2528

CPD

Figure 5: Demonstrating the GCL and RNFL defects in Case 2.

visits and enquiry regarding compliance • C ontinuation of bimatoprost and review in two months An IOP check two months later revealed IOP of 15 mmHg right and 13 mmHg left indicating a good response to monotherapy.

Standard phacoemulsification cataract surgery was performed with significant improvement in visual acuity and IOP stability throughout.

At most recent review, the patient was

CONSIDERATIONS FOR AN OPTOMETRY-OPHTHALMOLOGY COLLABORATIVE CARE FRAMEWORK • W hat equipment is available at each practice?

• W hat are the levels of experience of the providers involved?

• What tests are expected at each visit?

• H ow will providers communicate results?

• Who will make the lead decisions?

• What factors dictate a change in plan?

• H ow will you involve the patient in the decision? Also: do they even want co-management?

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INSIGHT June 2022

referred back to the optometrist for a refraction update, which would present the opportunity for incidental IOP check.

This case was recommended to be ophthalmologist-led due to the established visual field loss and will be monitored closely for signs of progressive optic neuropathy and uptitration of therapy, if indicated.

CONCLUSION A well-structured, mutually-agreed individualised collaborative framework for shared-care has the potential to reduce cost, increase convenience and shorten wait times with no sacrifice to patient care.

Communication, trust and investment in such a team-based model between patient, optometrist and ophthalmologist is vital for success.

Transferable software platforms significantly improve ease of continuity-of-care between shared providers and potentially allows for earlier detection of progression and altered management plans.

The vast majority of optometrists have the training and resources available to support and implement collaborative glaucoma care.

While a broad national framework like the RANZCO and Optometry Board Australia guidelines are helpful, a local individualised discussion at a community level between optometry and ophthalmology clinics

can allow for a more tailored and likely better collaborative approach.

Meetings between individual optometry and ophthalmology practices to discuss all these factors allows mutually motivated professionals to discuss the best approach for their community in regard to glaucoma care. n REFERENCES 1. K eel S, Xie J, Foreman J, et al. Prevalence of glaucoma in the Australian National Eye Health Survey. Br J Ophthalmol. 2019; 103 (2): 191-195. doi:10.1136/ bjophthalmol-2017-311786 2.

Mitchell P, Smith W, Attebo K, et al. Prevalence of openangle glaucoma in Australia. The Blue Mountains Eye Study.

Ophthalmology. 1996; 103 (10): 1661-1669.

3.

Rochtchina E, Mitchell P. Projected number of Australians with glaucoma in 2000 and 2030. Clin Exp Ophthalmol.

2000;28(3):146-148.

4.

Chauhan BC, Garway-Heath DF, Goñi FJ, et al. Practical recommendations for measuring rates of visual field change in glaucoma. Br J Ophthalmol. 2008; 92 (4): 569-573.

5. The Royal Australian and New Zealand College of Ophthalmologists. Clinical Practice Guidelines for the collaborative care of glaucoma patients and suspects by ophthalmologists and optometrists in Australia [Internet].

Sydney: RANZCO; 2019 [cited 2022 Feb 15] Available from: https://ranzco.edu/wp-content/uploads/2018/11/Guidelinesfor-the-Collaborative-Care-of-Glaucoma-Patients.pdf

NOTE: Optometry Australia members can scan the QR code or visit the online version of this article at insightnews.com.au/cpd/ to enter their details to have their CPD hours automatically updated to their Learning Plan. Event ID: 90004169, Session ID: 10567.

AP PLY T H E

B R A K E S TO SLOW DOWN

MYOPIA

IN

CHILDREN

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

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

PBS information: this product is not listed on the PBS

Before prescribing please review full Product Information available via www.aspenpharma.com.au/products or call 1300 659 646 This medicinal product is subject to additional monitoring in Australia. This will allow quick identification of new safety information.

Healthcare professionals are asked to report any suspected adverse events at https://www.tga.gov.au/reporting-problems.

EIKANCE 0.01% EYE DROPS (atropine sulfate monohydrate 0.01%). Indication: To slow the progression of myopia in children aged 4 to 14 years. May be initiated in children when myopia progresses ≥-1.0 D per year. Contraindications: Presence of angle closure glaucoma or where angle closure glaucoma is suspected. In glaucoma susceptible patients, an estimation of the depth of the angle of the anterior chamber should be performed prior to the initiation of therapy. Known hypersensitivity to any ingredient of the product. Precautions: Risk-benefit should be considered when the following medical problems exist: Keratoconus - atropine may produce fixed dilated pupils, Synechiae - atropine may increase the risk of adherence of the iris to lens. Use in Children: atropine sulfate monohydrate should not be used in children who have previously had severe systemic reaction to atropine. Use with great caution in children with Down’s syndrome, spastic paralysis, or brain damage. Limited clinical evidence is available for the long-term safety in children and adolescents. Regular eye health clinical reviews recommended during long-term treatment, including the monitoring of anterior segment development, intraocular pressure, retinal health and myopia progression. Consider careful monitoring of anterior segment development with prolonged use in very young children. EIKANCE 0.01% eye drops should not be used in children less than 4 years of age. If children experience photophobia or glare, they may be offered polychromatic glasses or sunglasses. If children experience poor visual acuity, consider progressive glasses. Discontinuation may lead to a rebound in myopia. EIKANCE 0.01% eye drops are not indicated for use in the elderly. Possible effect on the ability to drive or use machinery due to poor visual acuity should be evaluated, particularly at the commencement of treatment. Pregnancy: Category A. Lactation: distributed into breast milk in very small amounts. Interactions: systemic absorption of ophthalmic atropine may potentiate anticholinergic effects of concomitant anticholinergics. If significant systemic absorption of ophthalmic atropine occurs, interactions may occur with antimyasthenics, potassium citrate, potassium supplements, CNS depressants, such as antiemetic agents, phenothiazines, or barbiturates. Concurrent use may interfere with anti-glaucoma agents, echothiophate, carbachol, physostigmine, pilocarpine. Adverse Effects: photophobia, blurred vision, poor visual acuity, allergy, local irritation, headache, fatigue. See full PI for other ophthalmic and systemic AEs. Dosage and administration: Treatment should be supervised by a paediatric ophthalmologist. Instil one drop into the eye as required for treatment. Minimise the risk of systemic absorption, by applying gentle pressure to the tear duct for one minute after application.

Should be administered as one drop to each eye at night. The maximum benefit of treatment may not be achieved with less than a 2 year continued administration period. The duration of administration should be based on regular clinical assessment. Each container is for single use, discard after administration of dose. (Based on PI dated 25 November 2021) References: 1. Approved EIKANCE Product Information, 125 November 2021. 2. Australian Register of Therapeutic Goods. Accessed 10-Dec-2021.

Aspen Australia includes Aspen Pharmacare Australia Pty Ltd (ABN 51 096 236 985) and Aspen Pharma Pty Ltd (ABN 88 004 118 594). All sales and marketing requests to: Aspen Pharmacare Pty Ltd, 34-36 Chandos Street, St Leonards NSW 2065. Tel: +61 2 8436 8300 Email: aspen@aspenpharmacare.com.au Web: www.aspenpharma.com.au Trademarks are owned by or licensed to the Aspen group of companies. © 2021 Aspen group of companies or its licensor. All rights reserved. Prepared: Dec 2021 AF06092 ASP2639.

ASPPH3008_Eikance_Insight FP_235x297mm_R2.indd 1

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CPD

LEARNING OBJECTIVES: At the completion of this CPD activity, optometrists will have developed their knowledge of Acanthamoeba keratitis.

Including: • Understand the prevalence, behaviour and risk factors associated with Acanthamoeba keratitis • Identify Acanthamoeba keratitis when it presents in the clinic and develop informed referrals for further treatment • Understand treatment protocols for Acanthamoeba keratitis • Develop intervention strategies that promote patient education and adherence on contact lens hygiene

A SPOTLIGHT ON ACANTHAMOEBA KERATITIS: HEALTHY CONTACT LENS WEAR Acanthamoeba keratitis is a rare but debilitating infection found mostly in contact lens wearers.

DR NICOLE CARNT discusses the critical role of optometrists in detection and informed referrals, as well as minimising the chances of infection in the first place.

INTRODUCTION TO ACANTHAMOEBA TROPHOZOITE A contact lens wearer washes their face in the bathroom sink when water splashes up into their eye. They blink and clear the vision, but let’s put the contact lens under the microscope (Figure 1).

Acanthamoeba keratitis is rare; for the 140 million contact lens wearers globally, only around 750 develop Acanthamoeba keratitis each year.1 However, the impact of the infection

is significant. Acanthamoeba keratitis patients have a 50% chance of losing significant vision and undergoing treatment over 12 months. 2 As the infection waxes and wanes, visionrelated quality of life is halved across reading, mobility and emotion domains.3 RISK FACTORS

Acanthamoeba keratitis is an opportunistic infection, and 85-90% of cases occur in contact ABOUT THE AUTHORS: A/Prof Nicole Carnt BOptom (Hons) PhD GradCertOcThe FAAO FBCLA Scientia Associate Professor, Deputy Director of Research, School of Optometry and Vision Science, Faculty of Medicine and Health, UNSW, Sydney Group Leader, Vision and Virus Immunology Collaboration, Centre for Vision Research, Westmead Institute for Medical Research, University of Sydney Associate Researcher, Institute of Ophthalmology, University College London

lens wearers.1 The role of contact lenses in the infection is twofold: they act as a vehicle to deliver and maintain contact with the ocular surface and they increase the chance of ocular surface irritation.

Most microbes in the tears, trapped behind or attached to contact lenses, don’t cause infection because of the remarkable defence the ocular surface has. However, when corneal cells are damaged, they produce mannose.

Acanthamoeba expresses a ‘mannose-binding lectin’ on the surface, which enables corneal attachment and infection.

Figure 1: Acanthamoeba trophozoite attaching to contact lens material. (Image courtesy of Professor Fiona Henriquez, University of the West of Scotland).

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Acanthamoeba is found everywhere, but the main avoidable risk factor is contact lenses mixing with water. In a recent UK study, it was shown that water activities were responsible

for 62% of the population attributable risk of Acanthamoeba keratitis in that study. That means over half the cases could be eliminated if contact lens wearers avoided water.4

Acanthamoeba exists in two forms, the feeding motile trophozoite (Figure 1) and the dormant resilient cyst. The cyst form can withstand extremes of temperature, pH and other stressors. It is also able to resist disinfection, antibiotics and other chemotherapy agents.

Though misuse of contact lens disinfection products has been associated with outbreaks of Acanthamoeba keratitis,4,5 typically the cases do not return to baseline following withdrawal of the solution.5 In addition, cases seem to be increasing in severity. 2 This suggests that Acanthamoeba is becoming more prevalent and virulent in the environment.

When I asked a 1,500-participant strong Acanthamoeba keratitis Facebook Support group what they thought the major risk for Acanthamoeba keratitis in 2017 (Figure 2), the second highest risk factor, was “lack of information”. Optometrists are in a powerful position to minimise the risk of this rare but devastating disease.

Aftercare provides not only an opportunity to educate contact lens wearers to adopt sensible attitudes to mixing tapwater and contact lenses but to review contact lens performance and make adjustments and upgrades.

DIAGNOSING ACANTHAMOEBA KERATITIS

Figure 2: ‘What is the major risk factor for Acanthamoeba keratitis?’ word cloud posted on the Acanthamoeba keratitis Facebook Group: Aug 2017.

Cornea and Contact Lens Society of Australia. (https://www.cclsa.org.au/tap/).

PREVENTION OF ACANTHAMOEBA KERATITIS

In 2020, we published a 200-contact lens wearer randomised controlled trial that demonstrated an improvement in water avoidance behaviour and less gram-negative toxins (like those produced by Pseudomonas, another water dwelling microbe) in contact lens cases.9

My team at UNSW has been looking just where in the environment and our bathrooms Acanthamoeba is. We have found that around 30% of Sydney bathroom sinks harbour Acanthamoeba.6

Optometrists looking for ways to persuade their patients to do the right thing can draw on the twin sciences of psychology and marketing which offer ‘gain-framing’ as one of the best ways to change behaviour.

Most of the organisms we found are from the T4 group, which is the most prevalent strain that infects the eye. Furthermore, we and others have found the exact same genotype in people’s eyes as in the environment.7 We have also found Acanthamoeba in 38% of samples taken from lakes and rivers across northern NSW, and the major dam feeding Sydney has around the same proportion of isolation.

With ‘gain-framing,’ your message is communicated in terms of its positive consequences. For example: “Did you know that tap water contains specific germs that like to live on your contacts? If you are about to swim or take a shower – remove your lenses first. This helps keep your eyes healthy and should allow you to safely wear contacts.”

It has been shown that, following flooding, there are increases in cases of Acanthamoeba.8 As the water recedes, the microbes multiply, and so does Acanthamoeba, which feeds on this concentration of microbes. We don’t swim in the ocean after flooding, so let’s remind our contact lens wearers to take a bit more care of their eyes and contact lenses then too.

In the early stages of Acanthamoeba keratitis, epitheliopathy occurs appearing as a grey-dirty, fragile epithelium. There might be pseudodendrites and/or perineural infiltrates (Figures 4a and 4b). The classic ring infiltrate, with its ground glass stromal infiltrate appearance and scleritis are indications of later stage disease (Figures 4c and 4d).

In early disease, pain may or may not be present, but photophobia is usually experienced. Acanthamoeba keratitis is usually monocular, although in rare cases, patients are affected in both eyes. It is not thought to be transmitted from one eye to the other, but rather bilaterally through dual inoculation.

Acanthamoeba keratitis is misdiagnosed in 30-50% of cases, most often, as Herpes Simplex keratitis due to pseudodendrites and/or the stromal infiltrate.1 Perineural and ring infiltrates can occur in severe bacterial keratitis, but these are rare and so for Acanthamoeba keratitis, these signs are considered pathognomic.

Repeated messaging is also crucial, so look for opportunities at each aftercare appointment.

Misdiagnosis not only delays treatment, but the treatment may also be detrimental to the outcomes. Corticosteroids are likely to be prescribed in stromal Herpes Simplex keratitis, but their use in Acanthamoeba keratitis prior to antiamoebic treatmentis is associated with a five times worse outcome (see Treatment section).10 Arguably the global expert on Acanthamoeba keratitis, Professor John Dart, says Acanthamoeba keratitis needs to be ruled out in a contact lens wearer before Herpes Simplex keratitis is diagnosed.

Another important role of the optometrist in preventing Acanthamoeba keratitis is providing optimal fitting contact lenses.

Urgent referral to a hospital eye service with experience in diagnosing and managing Acanthamoeba keratitis is crucial. Often

CHANGING YOUR PATIENTS’ BEHAVIOUR Contact lens wearers might equate drinking water and washing with water as safe – and don’t realise the dangers of mixing water with contact lenses. This is what prompted Acanthamoeba patient and advocate, Ms Irenie Ekkeshis, to design the concept of ‘no water’ graphic for contact lens packaging. She lobbied the British Contact Lens Association, and they produced the first version of the graphic in 2014 (Figure 3).

Since then, it has been adopted in the US and in 2021 it was launched in Australia by the

Figure 3: ‘No-water’ design courtesy of the Cornea and Contact Lens Society of Australia.

INSIGHT June 2022 33

CPD

and are subject to raw material supplies.

The outcomes of Acanthamoeba keratitis tends to be bimodal. Around 50% resolve in a three-month period, while the others go on to have a waxing and waning disease process that can last more than 12 months and up to four years. 2

Figure 4a: Pseudodendrites in Acanthamoeba keratitis.

Figure 4b: Perineural infiltrates in Acanthamoeba keratitis.

The severe cases are driven by inflammation, with ring infiltrates and scleritis (which is very painful) common. Retinal necrosis occurs in a small proportion of patients. In these severe cases, topical and systemic steroids are usually required for the pain and to dampen the inflammation.1 Although steroids should not be used prior to diagnosis, we have shown that concurrent with anti-amoebic treatment steroid use is not associated with worse outcomes.13 It is recommended not to start concurrent steroids in the first two weeks of anti-amoebic treatment. Persistent epithelial defects, fixed dilated pupils, glaucoma and cataracts are side effects of the intense and prolonged treatment.

Figure 4c: Stromal infiltrate in Acanthamoeba keratitis.

Figure 4d: Ring infiltrate in Acanthamoeba keratitis.

contact lens wearers with acute eye disease will present to the GP or non-ophthalmic emergency departments who do not have ready access to slit lamps. Creating a red eye triage at your practice or practices in your area enables a pathway for less misdiagnosis.

We are using nanoparticles to label Acanthamoeba – in a test tube now – but the goal is to do this with patients in the clinic. We and others have used hyperspectral imaging to show that Acanthamoeba has a different spectral profile compared to bacteria.12

We have found that late referral to hospital eye services experienced at managing Acanthamoeba keratitis is associated with poor outcomes related to misdiagnosis and mismanagement. 2 On the referral include the contact lens history and water risk factors as well as documenting the signs and symptoms.

TREATMENT CHALLENGES AND BEST PRACTICE

The gold standard for Acanthamoeba keratitis diagnosis is corneal scrape for culture, but it is only positive in 50-60% of confirmed clinical cases.11 Increasingly PCR swabs are being used, but PCR is not always definitive and is not available in all centres.

In vivo confocal microscopy, which is only available in large referral eyecare centres such as Sydney Eye Hospital, can be very informative as the cysts of Acanthamoeba can be visualised. However, the cysts can be confused with white blood cells, and it is difficult to diagnose Acanthamoeba keratitis based on in vivo confocal alone.

There are several groups globally working on better diagnostic techniques. In my lab, PhD student Mr Hari Peguda is working with Professor Mark Willcox from the UNSW School of Optometry and Vision Science and Dr Sophia Gu from UNSW Chemical Engineering.

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Rarely Acanthamoeba also causes skin lesions and fatal encephalitis, but greater than 95% of disease occurs in the cornea.

Acanthamoeba are eukaryotic which are the same as human cells and have been likened to macrophages in the active form.

In the cornea, Acanthamoeba can encyst and escape the host immune and drug treatment regime. The most successful agents are biguanides (0.02-0.08% polyhexanide, PHMB or chlorhexidine 0.02-0.2%, compounded) used in monotherapy or in combination with diamidines used off label (Brolene, May and Baker, UK and Desmodine, Chauvin, France).1 The diamidines are not effective against cysts and cannot be used alone. A clinical trial in Europe has just concluded and an application is being made for the first licensed product for Acanthamoeba keratitis (PHMB 0.08%). Up to now, patients have had to use compounded PHMB without the provision of product information, supplied in glass containers with stoppers that are easily tipped over, expire within a month

My group at the UNSW has found that some patients with genetic variation in inflammatory genes are more susceptible to severe outcomes, and this is partially replicated in proteins in their tears.14 It is hoped that in the future, topical drops that dampen the action of these inflammatory proteins will be available as a more targeted, gentle way to manage inflammation with less side effects.

Other treatments are in the pipeline including antimicrobial peptides (AMPs).15 AMPs are expressed on the corneal surface in response to Acanthamoeba and synthetic versions may be effective as a topical treatment and/or in contact lens solutions/coatings.

CONCLUSION Optometrists are in a powerful position to educate contact lens wearers about Acanthamoeba keratitis. They play a vital role in teaching them how to minimise their chances of contracting the disease; they provide increased clinical care by ensuring healthy contact lens fitting and they are critical in the detection of the infection and the provision of informed referral. n NOTE: All references can be found in the online version of this article.

NOTE: Optometry Australia members can scan the QR code or visit the online version of this article at insightnews.com.au/cpd/ to enter their details to have their CPD hours automatically updated to their Learning Plan. Event ID: 90004235, Session ID: 10701.

BUSINESS

PRIVATE OPTOMETRIC BILLING:

Why wouldn’t you?

Many optometry practice owners worry that introducing private billing will turn patients away and impact their bottom line. Insight speaks to four independents who have found the opposite to be true.

C

hanges to the optometric Medicare Benefits Schedule (MBS) introduced seven years ago, in January 2015, allowed practice owners to reconsider their billing structure.

With the fee cap on optometric services lifted and a 5% reduction in the patient rebate, practice owners suddenly had greater flexibility and autonomy with their billing structure. But some feared that charging a fee above the Medicare rebate would result in lost clientele.

Seven years on, that fear is still real for many – even when practice owners who have taken the leap insist that the worry of losing patients never materialised.

Insight talks with four independent optometrists with varying levels of experience who discuss their decision to introduce private billing, what it has meant for their business, and how to address awkward conversation with patients.

PLACE VALUE ON YOUR TIME With experience on his side, regional NSW optometrist and practice owner Mr Andrew Greer is a long-time convert to private billing. He purchased the Tamworth Vision Centre from the original owners in 2000, and joined Eyecare Plus in 2010, renaming the practice Eyecare Plus Tamworth.

He introduced private billing in 2015, and charges $75 for a comprehensive initial consultation – a fee he hasn’t altered. He has a full appointment book and profits have grown year on year.

“I have complete autonomy to set pricing – but it’s all at my own risk,” he says.

A veteran of 35 years, Greer recalls the “double whammy” changes to the MBS in 2015 and says this was the impetus for him to change how he billed patients.

“I had discussed it with [Sydney optometrist] Jim Kokkinakis about 10 years earlier – he was one of the few practitioners who was private billing,” Greer,

“IF PATIENTS PERCEIVE YOUR SERVICES ARE FREE, DO THEY REALLY VALUE WHAT YOU’RE DOING?” ANDREW GREER EYECARE PLUS TAMWORTH

the sole owner and optometrist in his practice, says.

“But the reason I did it in 2015 was because I saw an opportunity to explain to patients that introducing private billing was a direct result of the government changes to the MBS. It seemed the perfect time for a change.

“Changing from bulk-billing to private billing is a leap of faith. You may lose a little, in terms of patients, but I was fine from the get-go.”

Greer says his success may partly be down to the mindset of the people of Tamworth, who are accustomed to paying for healthcare.

“Virtually no one gets bulk-billed at the GP in Tamworth, even seniors. About 60% of my patients are over 60 years of age, on pensions, and they’re happy to pay for my eyecare expertise,” he explains.

Greer lists his fees and the corresponding Medicare rebate, if applicable, on his practice website, so existing and potential patients can determine how much a visit will likely cost, which he says saves staff needing to explain pricing.

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BUSINESS

Even so, his staff are well-versed on the subject.

“It’s imperative for them to understand why you’re changing your billing structure. They need to be on board, and they need to be consistent with delivering the message to patients.”

Greer firmly believes bulk-billing simply “doesn’t work” if you’re trying to run a viable modern optometry practice but concedes it’s challenging to convince optometrists to believe in themselves.

“Generally speaking, I think optometrists are embarrassed to ask patients to pay for their services. I’ve been in the profession for 35 years and my peers and I started our careers in the bulk-billing era, when it was the norm. But times have changed. Now I question why anyone would bulk-bill. If patients perceive your services are free, do they really value what you’re doing?,” Greer says.

This is where educating the patient and explaining what you’re doing comes to the fore.

“That’s where they buy in. You can explain to them what you’re doing, in terms of clinical assessment, why you’re doing it, and you can demonstrate the results. That’s a really important part. They see you as a professional, not a free professional – there’s a big difference,” he explains.

“OUR OPTOMETRISTS ARE SPENDING MORE TIME WITH PATIENTS, BETWEEN 30-45 MINUTES FOR A STANDARD CONSULTATION, AND THEY SHOULD BE REMUNERATED ACCORDINGLY” SANDY LAMBERT EYECARE PLUS DURAL practice owners from doing it. Optometrists need to believe what they’re doing is worth paying money for. If you provide a comprehensive initial consultation for $59.05 (10910) – or $29.60 in the case of MBS item 10907 – you don’t value your own time.”

‘OUR OPTOMETRISTS ARE SPENDING MORE TIME WITH PATIENTS’

“But if you’re bulk-billing, that’s essentially perceived as a free eye test.

That’s a loss leader. It opens up the potential to over-prescribe to meet conversion rates in KPIs. That’s not fair on the patient.”

For practice manager Ms Sandy Lambert, introducing private billing into an established independent optometry practice has been surprisingly smooth sailing.

Greer has used his profits to invest back into the business. That includes an OCT machine, two visual field analysers, video slit lamp and “everything that opens and shuts; you need it in modern optometry”.

Lambert co-owns Eyecare Plus Dural in NSW with optometrist Ms Rosemary Peate. They employ two additional optometrists, both long-term employees, an optical dispenser and a receptionist.

“But it’s not covered by bulk-billing $59.05 for a comprehensive initial consultation (MBS item 10910). Patients accept that entirely. This is seven years down the track from when changes were introduced to Medicare, and most, if not all, of my patients have experienced being charged for eyecare,” Greer says.

Lambert has been working in the practice, which was established more than 30 years ago, for 18 years and purchased a 50% share in the business in March 2018 when the previous part-owner retired.

Improvements to the Medicare rebate process have also helped with the transition to private billing, Greer says.

“The joy of the Medicare system is the immediate reimbursement/rebate.

Patients get their money back in their account before they’ve left the practice.

It does make a difference.”

By his own admission, Greer is astonished that private billing is not yet the norm in optometry.

“If my practice didn’t privately bill patients, we’d be far less profitable. Every time this subject bobs up, I get frustrated we’re discussing it again. The question isn’t how to introduce private billing or why – it’s why not,” Greer says.

“The important message is you don’t lose patients if you introduce private billing. That’s always a fear but it’s unfounded. It’s a real fear – it stops

As recently as November last year, Lambert and Peate introduced private billing.

“We’d been talking about it for a while but had been too scared to make the leap,” Lambert says.

“But our optometrists are spending more time with patients, between 30-45 minutes for a standard consultation, and they should be remunerated accordingly. It’s about our optometrists being paid for their work and their skills being valued.

“In addition, prior to introducing private billing, patients were often surprised that they didn’t have to pay for a standard consultation. So, based on that sentiment, we thought private billing would be well-received.”

That notion proved correct, and Lambert says there has been barely any pushback. Perhaps unconventionally, the practice opted against making any formal announcement of the change to their billing structure.

Instead, they inform patients individually when making a booking.

“When we book in a patient, we send details of the appointment in an SMS and explain how much an initial consultation will cost, how much the Medicare rebate is, and how much additional photography or scans will be.

So, our patients are pre-warned via SMS, or we explain over the phone. We don’t make too much of it,” Lambert says.

At Eyecare Plus Dural, an initial comprehensive consultation for an adult is $89 (and patients may receive a Medicare rebate of $59.05 [10910] or $29.60 [10907]), while children are charged $65 (for an initial consultation). The Medicare item number and hence rebate depends on what both the patient and the consultation qualify for under Medicare billing requirements. The practice bulk-bills some patients at the treating optometrists discretion. For ultra-widefield imaging, the practice charges $80 for adults ($40 for children/ students) or $50 for traditional retinal imaging ($25 for children/students).

For Beckenham Optometrist in Sydney’s Northern Beaches, cross-subsidising its clinical services with spectacle sales was not a sustainable business model.

36 INSIGHT June 2022

PRESENT CHANGES IN A ‘PALATABLE’ WAY FOR PATIENTS Optometrist and sole business owner Ms Rowena Beckenham established Beckenham Optometrist in Avalon Beach, NSW, 22 years ago as a

greenfield practice. The business moved seven years ago to a site three times the size, and is located in a high socio-economic area on the Northern Beaches, with a mix of professional, double-income, and retiree populations.

“WE NOW PROVIDE A FAR HIGHER LEVEL OF SERVICE AND SUPPORT, ALL WHILE FACING INCREASED COMPETITION IN THE DISPENSING MARKET”

“Over the years I’ve invested in staff and technology. We now provide a far higher level of service and support, all while facing increased competition in the dispensing market. To expect we could cross-subsidise our clinical services with spectacle sales is just not sustainable in the longer term,” Beckenham says, adding that the practice continues to bulk-bill select patients, including students and pensioners.

ROWENA BECKENHAM BECKENHAM OPTOMETRIST

“When the practice re-located in 2015, it was a bit of a no-brainer to introduce private billing at that point in time."

Beckenham, who is the NSW director of ProVision, believes the key to successfully implementing private billing is having staff understand it’s the right move for patients and the business. Effectively, Beckenham Optometrist couldn’t provide its staffing and the level of service without the funding model.

Beckenham Optometrist has continued to invest in technology and upgrade equipment since introducing private billing, including a Rodenstock DNEye Scanner last year.

To establish her pricing structure, Beckenham took into account Optometry Australia’s (OA) recommended fees, which she says are as relevant now as they were then (OA regularly updates them).

She also focused on communicating her practice’s new fee-paying structure, including training staff and notifying patients.

“It’s about changing mindsets. I presented it to patients in a way that was palatable. GPs in the area are not bulk-billing. Patients are used to the concept of paying and getting a rebate back – and with interactive claiming, it is automatically back in people’s bank account.”

She urges any practice considering private billing to use discretion: “I believe it’s our professional responsibility to ensure equitable access to eyecare.

“But as optometry evolves and we add more to our scope-of-practice, and the gap with Medicare rebates grows wider and wider, we have to find a way to fund our clinical skillset.

“My advice to others is – why wouldn’t you introduce private billing? It hasn’t impacted my bottom line. On the contrary, we can now do more.”

GRAPPLING WITH THE DETAILS Optometrist Dr Jonathan Ucinek opened his independent practice in the inner north-east Adelaide suburb of Northgate in December last year, marking his first venture as a self-employed small business owner. He’s in the midst of a conundrum about setting his private fee structure.

BUSINESS

Ucinek completed a Doctor of Optometry at The University of Melbourne and joined OPSM North Park upon graduation. After nine months, he began locuming at the end of 2018 for 12 months. He then joined Eyes & Vision, a practice with six locations in South Australia, shortly before COVID hit in 2020.

The early career optometrist always wanted to open his own practice. That plan transpired last year when he opened a practice at an existing practice location that closed several months prior. He inherited the store fit-out and patient base and renamed it Northgate Eye Care.

While the previous practice owner wasn’t a ProVision member, Ucinek has joined the nearly 450-strong network. One of the challenges of opening a “partially greenfield” practice has been establishing practice fees.

Under the previous owner, the practice offered a combination of bulk-billing and private billing. Ucinek is bulk-billing patients whilst he deliberates over how to structure practice fees and implement private billing.

“There is a lot to take into consideration, including varying models of eyecare. To run a bulk-billing practice you need patient volume – and need to see 15 to 20 patients a day as well as cross-subsidise eyecare and running costs with sales,” he says.

In addition to industry advice from ProVision, Ucinek has also sought guidance from OA. “I looked at Optometry Australia’s recommended fee list, which advises charging $128 for a 30-minute comprehensive initial consultation, with a Medicare rebate of $59,” Ucinek says, but believes this is too high for his patient demographic.

“It’s challenging. Using OA’s fee calculator, which can factor in my business loan, for a 45-minute consultation, the suggested fee is $140 a patient to cover operating costs. If I was bulk-billing, it would only be $59 of the $140 required to cover the true cost of providing quality eyecare services.”

He adds: “I don’t want to subsidise, or cross-subsidise. I’ve got modern equipment, including an OCT, corneal topography and optical biometry, and I’ve invested in a digital slit lamp, so I can educate patients about their eye health. I’m trying to find that balance, as on one hand I’ve made a significant investment in equipment, and on the other hand, I want to place value on the professional service delivered.”

Ucinek is also looking at what other optometry practices in his area are charging. He doesn’t wish to compete on price, but also knows patients are price-conscious during COVID times.

“There is another independent practice 1.8km from my practice, and The Optical Superstore is 2.5km away. There is also OPSM, Specsavers

“ON ONE HAND I’VE MADE A SIGNIFICANT INVESTMENT IN EQUIPMENT, AND ON THE OTHER, I WANT TO PLACE VALUE ON THE PROFESSIONAL SERVICE DELIVERED” DR JONATHAN UCINEK NORTHGATE EYE CARE and Costco Optical near me,” he explains.

“I want to start off on the right foot. I don’t want patients or potential patients to have a misconception that eyecare is free. At the previous practice I worked (Eyes & Vision), we charged for our services – and patients appreciated the service they received.

“In terms of fees, I’m considering a minimum $20 out-of-pocket for a comprehensive initial consultation; above the 85% Medicare rebate of $59.05 (10910). I think that’s the most people will be willing to pay at the beginning,” he says.

Ucinek intends to use his discretion to waive fees if patients can’t afford it and will continue to bulk-bill children under 16.

But setting fees for imaging is the “really tough part”.

“I’m informing patients there’ll be a flat fee; $94 for non-concession, and $78 for concession. But it makes it hard to maximise value. For example, a full fee-paying patient who requires an initial consult, OCT and biometry and retinal photography, will be charged $94. But on their second visit, they may only be charged $78 for OCT.” He is also planning to place point-of-sale materials in the practice to help patients assimilate when he introduces private billing but is confident in discussing it with patients.

“At my previous employee (Eyes & Vision), I supported a $20 out-of-pocket fee, explaining to patients that unfortunately Medicare doesn’t cover the cost of providing a consultation. I’m experienced and well-versed in having that conversation.” n

Since starting Northgate Eye Care in December 2021, Dr Jonathan Ucinek has thought hard about the fee structure.

38 INSIGHT June 2022

PEAK BODY GUIDES OPTOMETRISTS THROUGH BILLING MAZE Optometry Australia has developed a suite of resources to support optometrists make the switch from bulk-billing to private billing. It also shares advice on how to successfully implement private fees.

O

ptometry Australia (OA) advises optometrists are not obliged to privately bill patients but if they choose to, they may be selective of who to bill.

Before introducing private billing, Optometry Australia advises practice owners to consider their demographic and what surrounding practices are doing.

Some practices continue to bulk-bill certain patient groups, including pensioners, seniors, veterans, healthcare card holders, children and low-income earners.

There are two main categories of private billing, according to OA, and practice owners may choose to offer a combination of both options.

Patients can be charged a private fee for the optometric consultation, and they receive a Medicare rebate that is less than the practice’s fee. This may be for initial comprehensive and subsequent initial consultations, subsequent consultations or contact lens consultations where the patient is eligible for a rebate.

Alternatively, patients can be charged a private fee for any additional tests that are non-Medicare rebateable items. These may include OCT, digital retinal imaging, topography and some contact lens consultations.

There is no minimum or maximum fee that practice owners must charge, leaving them free to determine what they consider to be most appropriate fee.

But before introducing private billing, practice owners should consider their current patient base and demographic, including the socioeconomic environment, and what surrounding practices are doing.

Individual business needs, including how much it costs to provide clinical services, and personal beliefs on healthcare, should also be factored in.

OA has developed a fee calculator tool to help practice owners determine the cost of their clinical services and imaging, as well as a recommended fee list, guidelines and a webinar on introducing private billing. These resources are restricted access for members only.

Importantly, practice owners cannot charge a gap payment, which means they cannot accept a patient’s Medicare rebate for their consultation and then charge an extra fee in addition to the rebate for that clinical service.

However, practice owners can charge a private fee for additional clinical testing not covered by the Medicare rebate, such as retinal imaging and pachymetry.

Also, when practice owners issue a receipt for their clinical service and diagnostic imaging, these must be individually itemised, OA advises.

OA also recommends practice owners carefully monitor and evaluate fees and the impact they have on the practice. Optimal usage of electronic Medicare claiming means that after paying for their consultation the patient receives their rebate on the spot, minimising their immediate out of pocket expenses.

NOTIFYING PATIENTS THAT FEES APPLY There are no hard and fast rules when it comes to notifying existing or potential patients that fees apply but as OA attests, some practices have found success using various methods.

Practice owners may consider packaging care to provide patients with options, and providing a script for staff when patients make

appointments, or when requesting full payment or to explain temporary out-of-pocket fees.

Although not as common, practice owners can publish pricing on their website to avoid explanations at reception or provide in-practice resources, such as posters or OA’s recommended fee list.

The organisation also advises providing a clear explanation to patients about the value of service they are selecting. In choosing to privately bill, OA’s top four tips are to embrace the change, train and support staff, educate patients, and communicate changes clearly to patients.

Optometry Australia believes optometrists should receive fair remuneration for the clinical services they provide and urges optometrists not to apologise for charging a fee, and to avoid using terms such as ‘unfortunately’ and ‘regrettably’.

“Have a clear billing policy that all staff are aware of and ensure staff understand changes in billing policy. Training is important so staff can easily explain changes to patients.”

Generally speaking, OA says patients have a poor understanding of Medicare and bulk-billing but warns optometrists not to make disparaging remarks about the government.

“Medicare fees are relatively static and don’t cover the cost of investing in technology required to provide quality eyecare,” OA says. “Highlighting clinical risk factors to patients and the benefits of additional services can help educate them."

OA says advising patients before their appointment of what they will be required to pay is essential as well as using multiple channels to communicate fees, including notices at reception, websites, and patient recalls, such as letters and emails. n

INSIGHT June 2022 39

PROFILE

GETTING TO KNOW

h t i m S y a r r Mu

Murray Smith, Optometry Australia president.

As he takes charge of the Optometry Australia presidency, MURRAY SMITH is drawing on his keen observations from a near-decade of involvement with the peak professional body and his compassionate leadership style to enact change for the profession.

A

n optometry graduate from Queensland University of Technology (QUT), optometrist Mr Murray Smith has worked in corporate and independent practices on Queensland’s Sunshine Coast, Darwin, Hobart, and now Melbourne, where he currently practises at Eyecare Plus Clifton Hill.

He has also worked as a clinical optometrist in an ophthalmology practice, trained eyecare nurses in Papua New Guinea with The Fred Hollows Foundation and volunteered in Timor L’Este.

“I chose the profession of optometry to help people, and my early career speaks to that in the communities I have provided eye healthcare, either voluntarily or in paid employment,” Smith says.

As his family commitments grew and travelling in pursuit of diverse work experiences became challenging, Smith settled in Melbourne, but knew he wanted to do more than clinical practise.

“That was my motivation to get involved in the peak professional body of optometry and really be part of progressing the profession and ensuring the Australian community has access to quality eye healthcare.”

Smith’s involvement began in 2013 as a board director of Optometry Victoria, then as Optometry Victoria president from 2016 to 2018, leading up to the amalgamation of Optometry Victoria and Optometry South Australia in 2019.

He joined the national Optometry Australia board in 2019 and served as vice-president under immediate past president Mr Darrell Baker for two years prior to becoming president.

“I believe that organisations need continual renewal and fresh input to thrive and progress. To that end, I believe strongly, aligned with current governance thinking, that directors should be on boards for a limited time, between six to nine years. And that’s in my plan,” Smith says.

Despite the competing challenges inherent in the role of president, Smith

40 INSIGHT June 2022

says he keeps members’ interests front and centre.

“I never waiver from the fact that our members come first, and that Optometry Australia is creating value for them. This is in the DNA of every OA director and every member of OA’s operational team,” Smith says.

“When it gets tough, I ask myself ‘is this in the best interests of our members?’ ‘Is this in the best interests of the profession?’ The answer must absolutely always be ‘yes’.”

KEY PRIORITIES Thus, it comes as no surprise that Smith’s highest priority is creating value for members, which he says can be achieved through delivering on the goals within the organisation’s shared (at national and state level) Strategic Plan.

“The Strategic Plan encompasses my priorities of building leadership and governance skills across the profession, ensuring that the OA board reflects the diversity of our profession, that we evolve scope and mitigate the vast issues around patient access to tertiary eyecare,” he says.

“Climate health is also on our agenda, with the growing body of evidence of the impact of climate on our health and wellbeing. Critically we need to ensure that OA, and the organisation more broadly, is ‘fit for purpose’.”

Smith is taking the baton on high-profile issues his predecessor raised during his tenure. Immediate past president Darrell Baker made it clear before departing that optometrists in Australia are “underutilised” and could help solve some longstanding issues if allowed to work at their full scope.

“This is a message we have been sending strongly to our federal representatives in the lead up to the federal election, and we are pleased to have our members supporting us in making this point heard through their local advocacy,” Smith says.

“Our state organisations have also been progressing various opportunities to ensure the skills of optometrists are most effectively used in state health systems and local care pathways.”

The organisation will soon launch a resource to support optometrists looking to extend their glaucoma practice and provide more collaborative care with ophthalmologists.

But Smith believes more can be done.

“We have a highly-skilled optometry workforce that we could be utilising more effectively to ensure patients get timely, affordable access to eyecare, and to reduce the pressure on our over-burdened public eye health system,” he says.

“I will continue to push to see the better utilisation of optometrists across our health system and for the scope of optometry practice to evolve to meet the changing eye health needs of Australian communities.”

One area OA has been vocal about is the potential for a greater optometric role in intravitreal injection clinics and prescribing of oral therapeutics.

“Across many areas of Australia, we have a significant access issue for patients requiring regular intravitreal injections. We need to look closely at how we can adapt our systems to improve access efficiently and effectively,” Smith says.

“We believe that better utilisation of our skilled, and well-distributed, optometry workforce can be a part of a system that better meets more patients’ needs.

“Optometrists and ophthalmologists are both motivated by supporting patients to get the eyecare they need. We hope by prioritising patient need, our professions can work together in developing solutions.”

MAXIMISING EVERY DOLLAR Smith believes succeeding in achieving the organisation’s highest priorities is dependent on an organisational structure that can execute the strategy in the most effective and resource-efficient way.

“We need to maximise every dollar that members contribute. The one constant is the challenge of funding within a federated structure. There are historical documents in the organisation’s archives from 60 and 70 years ago that are equally as relevant in reflecting the situation we face today,” Smith says.

“Optometry is a small profession and we don’t have the large pool other

Murray Smith’s optometry journey has taken him to Kimbe, West New Britain, in Papua New Guinea, where he has performed voluntary work.

associations have to draw on in terms of membership. The challenge decades ago and today is how do we fund services, support and, importantly, innovate to continually progress in an environment when we have six organisations within the federation, trying to work with scarce resources.”

Optometry Australia, the national body, receives a portion of its income from the five state organisations, under a constitutional fee agreement.

In addition to these funds, OA contributes substantial money raised from external sources and non-member revenue.

“The first thing we do is pay private indemnity insurance for every one of our members, which equates to 85% of the profession. The rest is distributed across our four strategic pillars; Lead, Engage, Promote and Endure,” Smith explains.

“Thirty per cent goes to Lead which future-proofs the profession through initiatives including advocacy to government, the health sector and evolving scope.

“Forty per cent is spent on Engage activities and is all about members, CPD, advisory services, practice support and keeping members upto-date. Fifteen per cent goes towards Promote and covers raising awareness of the value of optometry in health and wellbeing through our consumer campaign ‘Good vision for life’ and extensive promotion and activities with other health professionals.

“The remaining 15% of our funds are committed to making it all happen. Under the pillar of Endure we focus on quality governance, executing all our plans and ensuring the organisation is sustainable and progressive. One dollar spent by OA supports and benefits more than 5,000 optometrists, creating exceptional value as we can work at scale.

This is part of maximising scarce dollars, though there is more we can do collectively across our six organisations,” Smith says.

Smith, who took up his post as president in November 2021, can serve a maximum of three one-year terms in which he plans to address some of the profession’s major challenges.

“The last two and a half years have been a powerful reminder about the challenges of assuming we know what is just around the corner. That said, I think over the coming period optometry will need to embrace the challenges posed by the changing eye health needs of our communities, particularly those posed by an ageing population, increased prevalence of diabetes and increasing rates of myopia,” he says.

The Modilon Hospital Eye Clinic, in Madang, Papua New Guinea.

“As a profession, I also expect we will be challenged as we try to support the ongoing evolution of our profession. Resistance to change is inevitable. This should not take away our resolve to support our profession to develop so we can provide the eyecare our communities need.” n

INSIGHT June 2022 41

FEATURE

WHERE IN THE WORLD CAN ORTHOPTICS TAKE YOU?

From Cairns to Fremantle and Singapore to Dublin, a career in orthoptics can take people places they never thought possible.

Under the theme: ‘Where can orthoptics take you?’ this Orthoptics Awareness Week (30 May - 3 June), Orthoptics Australia in partnership with Insight, shares anecdotes from Australian-trained orthoptists to showcase just some workplace destinations within the profession.

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INSIGHT June 2022

WHERE CAN ORTHOPTICS TAKE YOU?

THOMAS HO

NATALIE AINSCOUGH

LOCATION:

LOCATION:

Orthoptist for the South Metropolitan Health Service at Fremantle and Fiona Stanley Hospital Group (FSFHG) – Western Australia.

Co-Owner, Adelaide Orthoptics and Orthoptic Clinical Coordinator, Women's and Children's Hospital, Adelaide – South Australia.

I love travelling and seeing Australia. When I was doing my orthoptics training at University of Technology Sydney (UTS), I went to Townsville and Albury–Wodonga for placements where I saw children with strabismus and white cataracts in adults in just the first hour.

After I graduated and worked in Sydney for six months, I decided that I wanted to help low-resourced cities, and so I moved to Hobart to work as a sole orthoptist in a private clinic. Ophthalmologists truly relied on my orthoptic skills and assessment. If a child with a large esotropia needed surgery, the ophthalmologist will use my measurements and recommendation of which muscle to operate on.

I am now working at Fremantle hospital in WA where our catchment area expands from Perth to Margaret River and Kalgoorlie. I have the opportunity to see a lot of blow-out fractures, complex ocular motility cases and teach doctors on how to perform cover tests.

During the past 15 years I’ve had the privilege of working as an orthoptist in the UK and Australia, with opportunities I never imagined when starting university.

Five years into my full-time NHS career I had itchy feet, like many 25-year olds, and decided working overseas for two years would fulfil my wanderlust.

Fast forward nine years, and I’m still here in South Australia, and orthoptics has helped me become the co-owner of Adelaide Orthoptics, the coordinator and lead orthoptist of an ophthalmology team at the Women’s and Children’s Hospital and an Australian citizen.

Nowadays I work in public and private healthcare, and in areas I never considered. Some lesser-known roles include; educating families of babies and children requiring contact lenses, supporting patients who need prosthetic eyes and assisting with NDIS plans.

The best part is I still get to spend time in clinic working with patients of all ages and abilities, and as part of a wonderful team. Looking back, 17-year-old Natalie did a good job of choosing her career.

KYLIE GRAN

ALLYN ETHEL ESCUDERO

LOCATION:

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Orthoptist/clinic coordinator - Latrobe University Orthoptic Eye Clinic – Melbourne, Victoria.

Previously, an orthoptist in Norway.

Orthoptist at iPrime Vision & Eyecare Specialists – Davao City, Philippines.

With a passion for working with children, an interest in strabismus and sense of adventure, the opportunity to work as an orthoptist in Norway was too good to pass up. Working as a traditional orthoptist, assessing children with eye movement and vision disorders, or adults with strabismus, post-concussion symptoms, neurological conditions and endocrine disease, there was much to learn. Alongside immersion in a new language and culture.

Whether working in a small seaside hospital, or in the large University Hospital in Oslo, an orthoptist is an important and valued member of the ophthalmic team in Norway. Orthoptists work autonomously within hospitals or private practice, with responsibility for the treatment and follow up of their own patients. They are also integral in the pre-operative assessment of patients with strabismus, often providing ophthalmologists with recommendations for the type and amount of strabismus surgery required.

The experience has made me a better orthoptist. I thoroughly enjoy passing on the experience gained to orthoptic students attending the orthoptist-led internal clinic at Latrobe University.

With 112 million Filipinos, orthoptic services are scant in the Philippines with only four orthoptists working with ophthalmologists or optometrists in private practice or hospital settings. This prompted me to move back to the Philippines after completing my degree at UTS in late 2020.

I am currently affiliated with iPrime Vision & Eyecare Specialists. I primarily see paediatric patients with strabismus, and amblyopia, and am actively involved in myopia management. I also see low vision and neuro-ophthalmology patients whom I manage in collaboration with optometrists, ophthalmologists or neurologists, prompting me to approach cases holistically and keeping myself abreast of the latest in eye health by attending webinars by Orthoptics Australia and other organisations.

My everyday patient encounters are unique and a continuous learning experience that tasks me with exploring all possibilities to provide them with the best quality of life, which truly defines my purpose as an orthoptist. After a year in the practice, I’m blessed to have the sense of fulfilment to provide orthoptic care to the Filipinos, especially the people who need it most.

INSIGHT June 2022 43

WHERE CAN ORTHOPTICS TAKE YOU?

LINA LI

DENISE BARTOLO

LOCATION:

LOCATION:

Orthoptist at Alice Springs Hospital – Northern Territory.

Orthoptist at Women’s and Children’s Hospital Adelaide – South Australia.

I travelled to Alice Springs just after Sydney’s June 2021 lockdown.

Feeling fresh and excited after the quarantine period, I was greeted with the wonderful Alice Springs Hospital Eye Team and since then every day has been challenging, exciting and fulfilling.

Working in a rural hospital as a solo orthoptist has strengthened my clinical reasoning and improved my confidence and communication.

I’ve had the privilege to work with subspecialty ophthalmologists such as paediatrics, anterior segment/cornea, uveitis, glaucoma and medical retina who come to the hospital.

I’ve encountered various severe eye conditions; for example, end-stage diabetic retinopathy and traumatic eye injury. Most Mondays, I go on outreach visits with the eye team to provide eyecare for patients more than 500km away. I also had the opportunity to start orthoptic clinics to monitor amblyopia management or help reduce the wait time. This is in addition to the unique experience of trying to learn the languages of the communities of the Aboriginal and Torres Strait Islander people, and their way of life.

Currently, at the Women’s and Children’s Hospital, I have the privilege of meeting and connecting with children of all ages and abilities. I have complete autonomy, running various orthoptic-led clinics. I’m encouraged to upskill in areas that interest me; most recently I’ve fulfilled my hopes of performing B-scans and ultrasound biomicroscopy.

I have been living in Adelaide for three years now and not only do I love what I do and the diverse opportunities that Adelaide provides as an orthoptist, but I love the state, lifestyle and people that have made Adelaide home.

JACK O’DONNELL

LOCATION:

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Orthoptist at Christchurch Hospital – New Zealand.

Orthoptist in Cairns – Far North Queensland.

Moving to a new country during the pandemic was challenging, but has accelerated my career and is the best decision I’ve made. The work and life experience in the two years since graduating has been invaluable. My orthoptist position at the hospital is all I could ask for; primarily working in paediatrics, specialising in strabismus and amblyopia management. It's immensely engaging.

Additionally, I have a significant role in adult retinal, corneal, neurological, thyroid and glaucoma clinics. Each week is different, and this variety keeps things fresh and exciting. Whether I’m running my own clinic, performing tasks like biometry, or pre-testing patients, I love every second.

Living just an hour from the slopes is amazing during the ski season too.

There’s no limit to where you can go as an orthoptist.

INSIGHT June 2022

When a position became available to sub-specialise in these areas I jumped at the opportunity.

DAMON GODDARD

Orthoptics has taken me further than I could have predicted. In 2019 I was fortunate to participate in an eye screening mission to the Philippines. Then, at the beginning of 2021, I accepted a position at Christchurch Hospital.

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After graduating from Latrobe University, I was eager to start my orthoptic career in Adelaide following a wonderful experience there as a student. I was offered a graduate position in an Adelaide ophthalmology practice, covering all sub-specialities. There, I gained essential orthoptic skills and discovered my passion for paediatric ophthalmology, strabismus and neuro-ophthalmology.

I grew up in the regional Victorian town of Mildura (approx 40,000 population) and had travelled little. So, after finishing studying at Latrobe, I used orthoptics as a means to travel. I looked interstate and even internationally and landed in Cairns.

I joined one of Cairns’ three private ophthalmology clinics (there are no hospital clinics). Working in a rural Queensland setting was rewarding; patients range from typical cataract and pterygium cases to seeing retinal detachments weekly. Every two weeks we travelled to our satellite clinic (an hour and a half away) to see more remote patients, which was my favourite day. At the clinic I did everything from patient work up and assisting in intravitreal injections, to booking patients for surgeries and managing surgical lists.

While I liked the work, I loved Cairns. My free time spent in the beautiful Far North rainforests and beaches, visiting the Daintree Forest, the Tablelands, Port Douglas and Turtle Cove. The Cairns community and environment is wonderful, and orthoptics led me there.

WHERE CAN ORTHOPTICS TAKE YOU?

GARETH LINGHAM

MARYANNE GREGORY

LOCATION:

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Arnold F Graves Postdoctoral Research Scholar at Centre for Eye Research Ireland, Technological University Dublin – Ireland.

Senior Orthoptist at The Canberra Hospital – ACT.

Orthoptics first took me to the other side of Australia and then the other side of the world. I trained as an orthoptist in Melbourne, but moved to Perth upon graduating for employment. There, opportunities arose to complete a PhD and, subsequently, accept a job in Dublin, Ireland.

From Tasmania, to Sydney to Canberra. What a difference a generation or two makes. I haven’t had a formal interview for any of my orthoptic positions and when I worked at the Royal Alexandra Hospital for Children in Camperdown, Sydney, my interview was on my first day.

Since mid-2021, I’ve been based at the Centre for Eye Research Ireland (CERI) at Technological University Dublin. I’m part of a team aiming to prevent vision loss and blindness by developing a better understanding of eye diseases and their managements through use of new technologies, big data and conducting clinical trials. Working at CERI has broadened my understanding of the various challenges faced in the eye and vision sector globally but with advancements in technology, our ability to understand and address these challenges is improving. Having the opportunity to contribute to research that can prevent vision loss is humbling.

With a Diploma in Orthoptics from the Cumberland College of Health Sciences in 1975, I have worked in private and public systems, with time away to have a family.

Without orthoptics, I wouldn’t be where I am today and am enormously grateful for the opportunities it has presented.

Hobart and Launceston honed my skills in all orthoptic areas. The Children’s Hospital was my dream job – working with children.

In Canberra I was asked to assist in setting up the public Eye Clinic at The Canberra Hospital. This included procuring equipment to employing orthoptists and nurses, being part of the allied health network, and showing eye and other registrars how beneficial orthoptists are to the eye health team. And from supervising orthoptic students, contributing to the Orthoptics Australia and now working part time with the most vulnerable in our community, I’ve had a great career.

ZOE DEUXBERRY

KATE QI

LOCATION:

LOCATION:

Orthoptist at Singapore National Eye Centre (SNEC) and KK Women’s and Children’s Hospital (KKH) – Singapore.

Orthoptist at Surgical, Treatment and Rehabilitation Service (STARS) – Brisbane, Queensland.

After finishing my orthoptics degree at UTS at the end of 2020 I wanted to ensure my first job was in a clinic where I could continue to learn and grow my orthoptics skills, especially in strabismus. I searched Australia-wide and then expanded my search internationally.

I felt fortunate to be given the opportunity to work at SNEC and KKH (Children's clinic), especially in the middle of COVID. My roles at both centres focus mostly on paediatric and strabismus, as well as working with neuroophthalmology and oculoplastics.

My confidence and skills in seeing strabismus patients has grown increasingly over the last year. I have had the chance to see patients with varying types of eye muscle disorders and seeing patients from as young as four months old at the KKH Children's clinic, to as old as 95 years at SNEC. I know the experiences and skills that I’ve learned so far – and continue to learn – will follow me wherever my future as an orthoptist takes me.

I’m an orthoptist at STARS hospital in Brisbane, Queensland, a new non-acute facility, with the ophthalmology department designed to relieve pressure from Royal Brisbane Women's Hospital's surgical waitlist.

My responsibilities involve working closely with ophthalmologists to screen and work up new patients on the cataract and pterygium waitlist for surgery and seeing review patients that have had surgery with us, hoping to discharge them back to the care of their local optometrist. Additionally, I’ve taken responsibility of the cataract audit to assist the ophthalmology department in evaluating operative visual outcomes and determining if they meet international guidelines.

By moving to Brisbane from Melbourne early in 2021, I’ve had the unique opportunity to work alongside my senior orthoptist and collaboratively develop a new ophthalmology department at STARS. We had a successful 2021, servicing over ~1,500 cataract surgeries – and I’m excited to grow alongside the ophthalmology department and hope to see more orthoptists join us here in Brisbane.

INSIGHT June 2022 45

RANZCO

s n o z i r o h w Ne

IN OPHTHALMOLOGY

The RANZCO Congress never fails to attract a high-powered line-up of invited speakers. Part 2 of Insight’s conference coverage features interesting topics, including ocular CRISPR gene editing, arguments for cataract surgery simulation training and the need for true innovations in ophthalmology.

THE DAME IDA MANN MEMORIAL LECTURE

PROF ALEX HEWITT says ophthalmology is poised to harness gene editing to transform the care of patients with welldefined diseases, if diagnosed early.

In one of the most intriguing presentations of the congress, Tasmania-based preeminent ocular genetics expert Professor Alex Hewitt delivered a lecture entitled: ‘Dawn of Precision Ophthalmology in the Asia-Pacific’. It focused on adaptation of the CRISPR/Cas system to mammalian cells, a revolution set to reshape inherited retinal disease (IRD) treatments.

Hewitt kicked off his discussion describing his wonder at some of man’s most amazing achievements, including putting astronauts on the moon, and the work of SpaceX to launch and land 15-storey-high rockets, leading him to question why – with all these advances – all blinding eye diseases can’t be cured?

While ophthalmology is doing a great job in treating the major areas that make up 80% of blindness and vision impairment, he said there remained a significant portion with IRDs who have had little hope, until now.

Explaining the challenges of this cohort, he said it comes down to the complexity of the genome. As an analogy, he asked viewers to imagine expanding each of the 3.3 billion nucleotides that make up the genetic code, in each cell, to the size of a matchstick. Stacked end-on-end, it would have the ability to reach from Earth to the moon, back to Earth, then back to the moon again.

46 INSIGHT June 2022

“Genetic code is made up of four different bases/colours (A, C, G, and T) and this means each matchstick is one of four different colours. For genetic disease to manifest, only one needs to be a different colour.”

Hewitt said the exciting thing about IRDs is scientists can now readily identify the genetic cause for disease in seven out of 10 unselected patients.

On this front, he said Australia has led the way in many gene discoveries and dissecting genotype and phonotype correlations. With increasing availability of genetic testing, the industry is now rapidly reaching a point where it is possible to diagnose diseases much earlier, opening possibilities for new interventions.

He highlighted the case of young Melbourne boy Harry Feller who was born deaf, despite his family having no known history of deafness. Genetic testing confirmed he had Usher syndrome type 1F. With this early diagnosis, it gives Hewitt and other researchers a 10-15-year window to develop a treatment to prevent retinal degeneration.

Ultimately, where a patient is on the natural history of the disease trajectory will dictate which therapeutic intervention will be most amenable, with a major focus currently on gene editing. This encompasses the famous CRISPR technology, based on the ancient adaptive immune system of bacteria, and is an approach Hewitt is engaged in.

As Tasmanian Eye Institute (TEI) founder Professor Brendan Vote explained to Insight recently, in short, CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats)-based immunity involves bacteria capturing snippets of DNA from invading viruses and uses them to create DNA segments on CRISPR arrays. These DNA spacers between the repeats are like a ‘wanted poster’ for the virus that allows bacteria to ‘remember’ the viruses. If viruses attack again, the bacteria produce RNA segments from the CRISPR arrays to target the viruses’ DNA. The bacteria then use an enzyme (Cas9) to cut the DNA, disabling the virus.

Used as a therapy, the CRISPR system involves an endonuclease and a guide RNA sequence. The complex traverses the genome until it finds a

matching corresponding sequence where the enzyme is activated to cut both strands of DNA. Using this approach, in 2016 Hewitt and his team were first to report the application of CRISPR in a mammalian retina. Using transgenic mouse, they demonstrated up to an 84% reduction in gene expression, and importantly retinal function was maintained.

Hewitt pointed out this was ideal if the aim is to destroy a gene’s function, but if the goal is to correct a disease-causing variant, it’s a different story.

He outlined the ground-breaking work by various overseas researchers, including converting nucleotides from one to another, the engineering of base editors, and breakthrough efforts to overcome inadvertent edits, or off-target effects. The latter eventually led to the work of PhD candidate Peter Tran in Hobart, who was able to ameliorate the off-target effects with his work on base editors (by embedding the base editor inside the CRISPR enzyme), that could also, importantly, fit the construct into an adeno-associated viral (AAV) vector, commonly used to deliver gene-based therapies.

“With the off-target effects of base editors now sorted, this was terribly exciting and we have now gone on to show the technology and endonucleases (enzymes that recognise DNA sequence) that Peter engineered could be used to directly correct Harry Feller’s disease-causing variant,” Hewitt explained.

With more than 220 base editors now described, Hewitt said this could in future lead to a plug-and-play approach in the clinic, where it is possible to select base editors off-the-shelf for specific targets.

TASMANIA HOME TO NEW CRISPR CURES LAB With the ability to now diagnose, design and validate the genetic correction therapy, Hewitt points out the next big hurdle is production.

This is something he is addressing in Hobart with Vote and TEI, with what

has been described as Australia’s first dedicated Ophthalmic Gene Therapy Centre, involving the refurbishment of a disused water tank and an adjacent derelict heritage building.

This will become a PC-2 laboratory, which will function as a GMP (good manufacturing practice) production facility. With the hope of producing CRISPR blindness cures, it will operate over 840sqm of lab space, with the aim of linking the project with all active clinicians across Australia and New Zealand.

With production capability taken care of, Hewitt said the last pressing issue is the patient. On this front there are two major considerations, with the first being a redesign of the clinical trial framework for rare orphan diseases seeing Phases 1 and 2 condensed, with a greater focus on postlicensing surveillance.

Secondly, there’s a need to ensure patients would want to edit DNA. To explore this issue, Hewitt highlighted a questionnaire involving 12,000 people from 185 countries that found overall firm support for application of somatic gene editing. Interestingly, those who did not agree said they did not fully understand technology, so education could address this issue.

Hewitt concluded his discussion by stating: “The full clinical loop of the translation to gene editing technology is almost complete and we are set to transform the care of patients with well-defined, genetically characterised diseases, if diagnosed early.”

The lecture was rounded off with a Q&A session. The first question related to the pricing of personalised CRISPR therapies, noting that the first approved ophthalmic gene therapy Luxturna costs somewhere between $500,000 and $1 million per patient.

Hewitt said scalability of the technology is essential. A major issue with the current system is that when drugs are purchased, healthcare payers are paying for the failed R&D that has gone into the therapy.

A derelict water tank has been refitted to house the proposed Ophthalmic Gene Therapy Centre in Hobart.

INSIGHT June 2022 47

RANZCO

“So there needs to be a shift in the way medicine is subsidised in Australia and around the world. It is clear RNA therapies can be developed economically at scale, the best example is RNA vaccines – it is possible, there just needs to be a broader conversation about funding it equitably.”

Another intriguing question related to how such therapies would ultimately be delivered to the eye.

While the current focus is on AAVs containing the gene therapy, delivered via a subretinal injection, Hewitt anticipates viral like particles or lipid based nanoparticles, ideally as intravitreal injection, is where delivery may head in future.

CATARACT UPDATE LECTURE

DR DAVID LOCKINGTON says coming out of the pandemic, ophthalmology has a unique opportunity to enshrine simulation for safer surgical experiences.

Dr David Lockington has been a consultant ophthalmologist at the Tennent Institute of Ophthalmology, Glasgow, Scotland, since January 2014, with sub-specialist training in cornea, cataract and anterior segment. He’s also an ophthalmology trainer and the national simulation lead for the UK’s Royal College of Ophthalmologists.

The lecture entitled: ‘Ensuring a safe cataract experience for all through embracing the role of simulation’, considered historic teaching/training methods and their inadequacy. He also discussed simulation equipment, and how they ensure trainees have the knowledge and experience to perform surgical tasks before live surgery.

He initiated the presentation discussing that, as a trainer, he wants to “train without trouble”, which comes down to developing competent trainees first and foremost.

Lockington showed a graph demonstrating that to reduce avoidable harm, the top two criteria were “the presence of an identifiable modifiable cause”, and “reasonable adaptation to a process that will prevent future occurrence”.

He asked the awkward question, is a trainee an identifiable modifiable risk factor? And is simulation an adaption to a (training) process to prevent future avoidable harm?

“I would suggest it is,” he said.

When deciding if a trainee is ready for surgery, Lockington said too often ‘hope’ and ‘trust’ enters the equation. He highlighted the classic example of a hydrodissection when a trainee might miss the pupil snap sign. However, the trainer lets them continue when, suddenly, the nucleus sinks away because they haven’t realised they have split the posterior capsule with their violent hydrodissection.

Looking at his own work in Glasgow, Lockington said they were keen to highlight gaps in the trainee experience in terms of managing complications – posterior capsule rupture or vitreous loss – and experience using adjuncts – capsule tension rings – and organise the simulation accordingly.

By using simulators, Lockington said the program allows for mandatory inductions, mandatory laser training, and delivery of sub-specialty training prior to rotation. Trainees are given model eyes to take home, and were also challenged to perform as many procedures as possible in simulation.

The winning entry contained more than 50 procedures, saving costs for the training program and maximising training opportunities.

Interestingly, Lockington said the EYESI simulator in Glasgow in 2019 (pre-pandemic), was used an average of 16 times per trainee, with the monthly median duration of actual simulation being 719 minutes. In 2020, during the pandemic, with fewer real-word training opportunities, much higher use was reported, with 29 average occasions and a monthly median duration of 1,246 minutes.

“People are often concerned about cost of simulation, but I would ask what is the cost of a complication? Our project in this area shows prevention rather than management and follow up of a complication will always be much more cost effective, and that is why we engage in simulation,” he said.

Lockington pointed to Dr John Ferris – who designed the Simulated Ocular Surgery website – and his group who looked at trainee complication rates, if they had been trained on the EYESI simulator prior to cataract surgery. There was a 38% reduction find in those who had done simulator training, “which makes sense because … they were familiar with the steps and already well up the learning curve”.

If trainees aren’t prepared for complications like vitreous loss in cataract surgery, Lockington said this can lead to a ‘grief cycle’, including denial, anger and causing more damage, hence the importance of immersive simulation.

“Some people think you need some complications under your belt, but for the patient it matters, they can have higher retinal detachment risk (42 times) increased endophthalmitis risk (eight times) and may not get back to driving standards due to the CMO (cystoid macular oedema) you have induced,” Lockington added.

He rounded off his presentation with a popular quote among US Navy Seals that: “Under pressure you don’t rise to the occasion, you sink to the level of your training. That’s why we train so hard.”

He added: “This is why we want to simulate scenarios so we can take the complex and make it simple, rather than take simple and make it complicated because you don’t know what you are doing.

“There are real time and cost issues associated with ophthalmic simulation, which is often run on goodwill, with minimal/no time or finance allowance, it needs to be resourced properly. In summary, COVID has disrupted medical education and simulation has filled some gaps, but it should have been prominent the whole time. Coming out of the pandemic we have a unique opportunity to enshrine simulation for safer surgical experiences.”

He said trainee surveys often assess confidence, a notion that is wellmeaning but misplaced, with a greater emphasis needed on competence first, then naturally confidence.

He said a safe roadmap to surgical competence includes background knowledge (reading, watching, journals, books, magazine, webinars), practice foundation (simulation, EYESI, dry lab, wet lab), performing (under supervision, independently), review and refine (recorded surgeries).

Lockington said there were many great many simulation methods, and not only for cataract surgery, but barriers often include time concerns and resource costs, but the real resistance comes from a pre-existing culture with a poor understanding of the benefits.

48 INSIGHT June 2022

The ophthalmic surgery simulation suite at the Tennent Institute of Ophthalmology, Glasgow, Scotland. Image: Dr David Lockington.

THE FRED HOLLOWS LECTURE

A/PROF CATHERINE GREEN says it's important to employ design and systems thinking when solving some of ophthalmology's biggest problems.

To round off the congress, Associate Professor Catherine Green delivered the popular Fred Hollows Lecture, with a presentation entitled: ‘Disruption and innovation: Challenges and opportunities in ophthalmology’.

Green is a glaucoma specialist and ophthalmic educator based in Melbourne, and is head of the Glaucoma Unit at the Royal Victorian Eye and Ear Hospital (RVEEH), the largest specialist glaucoma service in Australia.

She discussed the potential for innovation brought about by COVID. And while it’s important to promote sustaining innovations that improve on current technology and systems, she said it’s also important to look for truly disruptive innovations that provide opportunities in ways not previously considered.

In a case study, in 2014 Green said RVEEH decided to discontinue general clinics in response to a need to improve cataract surgery throughput. An unintended consequence was that a third of patients attending general clinics had a glaucoma-associated diagnosis. But with nowhere to go, they were referred to the hospital’s glaucoma clinic. Prior to this, the glaucoma clinic was reserved for tertiary speciality care and was essentially keeping pace with demand. However, numbers soared reaching nearly 4,000 on the waitlist, sitting at less than 1,500 more than a year prior, without a real increase in capacity.

Faced with such a problem, Green adopted systems and design thinking.

Previously, the hospital had improved capacity without increasing resourcing with the establishment of a Glaucoma Monitoring Unit. It went from seeing 5,880 patients in 2006/7 to 6,812 in 2009/10, resulting in an almost 16% increased ability to see patients.

This coincided with new RANZCO Glaucoma Referral Guidelines, and an optometry-ophthalmology chronic eye diseases shared care initiative of RVEEH, which had high acceptability and uptake. RVEEH had also collaborated with the Australian College of Optometry (ACO) looking at GP referrals, which found a large proportion of patients did not need to be seen at RVEEH and could be discharged to the community or optometry care.

Based on this, the department was able to advocate for Glaucoma Collaborative Care (GCC) project, which commenced in 2016. Based at ACO, it included a multidisciplinary team of orthoptists, optometrists and ophthalmologists. It was vital the right patients were sent to the clinic, so it involved a consultant triage. Initially, it looked at new referrals and then took in patients on the waiting list. Continuing education was important for involved health professionals, and patients had a full glaucoma work up.

Green said the promising 17-month evaluation data showed 65% of the 1,024 clinic attendees had no glaucoma or were low risk with ocular hypertension or glaucoma suspect. The majority were safely seen in the community by optometrists or private ophthalmologists. This had a positive impact on the RVEEH wait list, with a 48% drop in those overdue for review and a 92% drop on the new patient wait list.

“This meant that patients we needed to be seeing with advanced glaucoma and adverse effects due to not being seen were being adequately looked after,” she said.

“But this still wasn’t enough, we still had a backlog of patients and oversubscription for our services, so what about patients who can’t be

discharged? The RANZCO guidelines indicate patients with early stable or moderate stable glaucoma need to be monitored, but not necessarily at each visit by an ophthalmologist.”

This led to the establishment of another initiative in 2019, the Glaucoma Community Collaborative Care Project (G3CP). This involved engagement of community optometrists in areas of high geographical demand, with patients recruited in the clinic. Underpinning this was education sessions for optometrists where they could interact with glaucoma consultants. A structured protocol was also followed and clinical outcomes sent to the hospital and reviewed by a glaucoma specialist.

After a year, G3CP had 70% uptake from patients offered participation, with the most common reason for non-participation being the RVEEH was more convenient. There was also high patient satisfaction, and it had excellent optometry engagement and satisfaction.

“So, we now have a proof-of-concept where we can now safely monitor lower risk glaucoma patients, and the other positive is we now have an established network of optometrists with whom we can collaborate,” Green said.

But there were challenges, including lower than projected recruitment (91 patients) due to it being done opportunistically in the clinic instead of systemically. However, a major issue was the exchange of information and the need for a digital solution critical to long-term sustainability and scalability, highlighting the issue of electronic health records and the management of clinical information. Another unanticipated issue was optometry workforce turnover, which Green said is a manageable problem and will have less impact if scaled up.

In early 2020, COVID-19 resulted in reduction of the RVEEH Glaucoma Clinic with the need to see only the most urgent patients initially. Monthly wait lists grew from around 2,000 pre-pandemic peaking to around 3,800, while the number of patients seen reduced from around 1,500 to around 1,000, dipping below 500 at one point.

However, triaging processes used during the pandemic has allowed the hospital to see all high risk and most moderate risk patients, but there is a growing backlog of overdue reviews. There’s also a likely backlog of new referrals with optometry also affected by lockdowns.

In terms of next steps, Green said with G3CP now established and the concept proven, there is a network of optometrists that need to be operationalised, with the program potentially expanded.

“It’s also a great opportunity to demonstrate the need for an improved digital health solution and we are certainly exploring options,” Green added.

She pointed to a 2020 JAMA Ophthalmology article showing that an existing health record with adequate clinical information was able to triage patients in a less labour-intensive way. Other examples of innovation include technological enablement, such as smartphone-based vision screening (PEEK, successful in Africa), rapid assessment and avoidable blindness (RAAB) eye health surveys, real time data reporting and analytics, training and support, and program design and planning tools.

But Green said it was important to consider innovation vs evidence and the need for robust data (Scott’s parabola, the rise and fall of a surgical technique). There’s also the need to consider cost effectiveness of new approaches (microshunt vs trabeculectomy).

“Innovation is needed now more than ever; sustaining innovation is possible, even without enabling tools – for example our rather non-digital, manual way of improving our glaucoma service was possible, if not completely efficient,” Green said.

“Improvements can be slow, and we need to persist, we also need to employ design and systems thinking when solving problems. And there is a need to strive for disruptive innovation in eyecare. Enabling technology does exist, we just need to work out how to apply it in a systemic way. And finally, as a profession, we need to consider how we might be disrupted, especially if we don’t innovate.” n

INSIGHT June 2022 49

EYEWEAR

Safilo Group CEO Mr Angelo Trocchia at the company’s Sydney premises recently.

‘SENZA PARETI’ –

SAFILO’S SEARCH FOR SUSTAINABLE SOLUTIONS Looking beyond its own walls for innovative ideas and creative solutions is becoming more crucial for Safilo’s longevity, Group CEO Mr Angelo Trocchia told Insight on a recent trip to Australia, as the Italian company edges closer to 150 years in business.

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lthough officially founded in Italy in 1934, Safilo’s origins date back to 1878 when a manufacturing site in the Venetian Alps began producing lenses and frames.

Today, Safilo is the largest eyewear creator, designer and worldwide distributor of sunglasses, optical frames and sports eyewear, second only to its Italian counterpart EssilorLuxottica. It operates several proprietary brands – Carrera, Polaroid, Smith, Blenders, Privé Revaux and Seventh Street – and more than 30 licensed brands.

From his Rome base, Group CEO Mr Angelo Trocchia oversees Safilo’s global operations, including 4,545 employees, five production facilities (in China, the US and three in Italy), a wholly owned commercial network of subsidiaries in 40 countries – including Australia – and more than 50 distribution partners in 70 countries.

Well-versed in managing big business, prior to joining Safilo, Trocchia was employed with British multinational consumer goods company Unilever for 27 years, including 19 as vice president of marketing, and five as president and general manager of its operations in Italy.

Trocchia, who has been Group CEO at Safilo for four years, was recently in Australia on business when he sat down with Insight to discuss the challenges and opportunities facing the firm as it seeks to establish itself as an industry leader in sustainability.

He says the concept of ‘no walls’, 'senza pareti' in Italian, is driving the

50 INSIGHT June 2022

company forward as it strives to uphold its values focused on people, sustainability and responsible innovation.

A qualified aeronautical engineer with extensive experience living and working abroad, Trocchia is guided by the conviction that “any problem can have a solution, you just have to look for it”.

It’s a mindset that may bode well for the Safilo boss, who participates in a marketplace where end consumers and stockists are demanding more environmentally-friendly products and greater supply-chain transparency.

“We’re looking for innovation not just inside our walls but looking at what is going on outside. I recently went to San Francisco, as we’re looking at some organisations there doing interesting things,” he says, without giving too much away.

“Looking at what is happening around us is more crucial going forward. I’m an extremely curious person. It’s a fundamental driver for me. All solutions can be found. Speaking as an engineer, when you have a problem, you concentrate to find a solution. It’s how you approach the problem.”

Trocchia is now applying his experience to the eyewear industry, zeroing in on Safilo’s digital transformation and sustainability goals.

“Safilo’s two major strategic directions – to be a digital company and enact sustainability measures – are both part of a larger journey. I believe we need to be serious about sustainability, but I intend it to be a journey, not something we simply turn on with a key,” he says.

“Although I only joined Safilo four years ago, the fact that the company is still here is an example of sustainability. We have a long-term horizon in front of us, and sustainability is at the heart of it. We’ve developed a strategic framework in line with the United Nations’ Sustainable Development Goals.”

Safilo’s 2020-2024 Sustainability Plan has three dimensions: people, product, and planet.

The company has made significant in-roads into sustainability with the introduction of rooftop solar, a decrease in water consumption, and the elimination of nickel galvanic treatments in its optical frames production process, as some examples.

“We’ve got a three-to-four-year plan in front of us,” Trocchia says. “People are a critical element of any company. You need the best people to win in the marketplace, and to remain current in society. In terms of the planet, we're looking at our manufacturing centres in China and Italy where we’re reducing our electricity and water consumption.”

According to a company report, rooftop solar installations have resulted in a 15.9% decrease in greenhouse gas emissions in 2020. It also achieved a 15% decrease in water consumption and saved 6.929 gigajoules of electric energy (1924.7 kilowatt hours) in 2020.

“We have clear targets for our factories in China and Italy, to reduce electricity and water. It translates into something we can measure. We’re also aiming for our car fleet to be 100% electric vehicles. In Italy, where we have our largest fleet, they are hybrid vehicles. Our next step is for the fleet to all be electric,” Trocchia says.

But Safilo’s greatest steps in sustainability seem to be in its product’s raw materials, exploring innovative solutions to make its glasses greener. The company has established partnerships with several raw material suppliers, all specialists in their respective fields.

“In this carbon world, you can’t do everything by yourself; you need to work with the best,” Trocchia says.

Safilo is currently working with at least four external companies.

Econyl, a company headquartered in Trentino, Italy, manufacturers an innovative and sustainable material obtained by regenerating synthetic (nylon) waste such as fishing nets, carpets and textiles, which Safilo has incorporated in its Tommy Jeans brand.

Eastman, a chemical company based in Tennessee, US, is a global specialty materials provider and pioneer in molecular recycling. This year, Safilo launched Eastman Acetate Renew and Eastman Tritan Renew in its sunglass and optical product range. Both products are part of a broad portfolio of sustainable resins now offered at scale by Eastman. The material will be launched in Europe’s Spring/Summer 2022 for Safilo’s Polaroid range.

Building on a 20-year partnership with specialty chemicals company Evonik, headquartered in Essen, Germany, Safilo will begin using Evonik’s Trogamid TmyCX eCO material for premium sun lenses. The first launch will be with its BOSS brand.

Safilo has also signed a strategic partnership with Coventya, a French company with more than 90 years’ experience in the development of specialty chemicals for surface finishing treatments. Safilo will be the first player in the eyewear sector to exclusively use ‘Metal X’, a new innovative Coventya patent that allows the use of precious metals in galvanic treatments to produce optical frames and sunglasses to be reduced by 90%.

Safilo's proprietary Polaroid brand will be among the first to benefit from new sustainable materials.

“Eastman, Evonik, Econyl, Coventya … we’re working on raw materials with these external suppliers, and translating those materials into our collections, closing the 360-degree loop,” Trocchia says.

The company says it has steadily

Polaroid is one of six proprietary brands in the Safilo portfolio, which also includes more than 30 licensed labels.

ENJOY A WORLD OF COLORS

increased the number of sustainable styles in its collections, both for owned and licensed brands. Several brands, including BOSS, Polaroid, Levi’s, M Missoni and Tommy Hilfiger, are now using bio-based plastic and recycled materials.

“Some generations of consumers are more sensitive to the topic of sustainability, and some have become more conscious since COVID. We see that trend towards more eco-friendly and recycled materials. The signs are there – it’s becoming more relevant. It goes above product or brand,” Trocchia says.

Eliminating the use of nickel, a silver-white metal traditionally used in galvanic finishing treatments for eyewear, has been an important milestone.

The company says nickel-free treatments have been implemented across all production lines and comply with all its quality standards, often stricter than required by current legislation.

“It’s logical to say let’s look to other people beyond us. It’s part of our strategic direction to collaborate on potential innovations in lens and frames materials. We will keep working with these companies and other suppliers because we’re very open-minded in what is such a technical field of expertise,” Trocchia says.

Outwardly open-minded, Safilo is not shying away from other social responsibilities too.

In response to the COVID-19 emergency, the firm repurposed some of its production lines to develop two types of certified Personal Protective Equipment (PPE) under the Polaroid brand. This included wrap-around, transparent protective eyewear, and a face shield designed for complete eye, nose and mouth protection.

“We launched Polaroid PPE products during COVID because we had both the capacity and the technology to do so. We produced and donated protective eyewear and face shields to doctors, nurses and healthcare workers in Italy, Mexico, Spain, Singapore and here, in Australia. We didn’t make any profit – it’s a small example of Safilo’s social responsibility.”

While Trocchia is taking a step-by-step approach to Safilo’s sustainability objectives, he says the company is committed beyond 2024.

“We’ve defined a clear framework, a clear structured approach encompassing the three pillars of people, product and planet.”

And it’s as relevant here as it is in Trocchia’s native Italy.

“Flying here to Australia, this ‘outdoors’ country, reiterates that sustainability is crucial for local companies too. Safilo’s Australian subsidiary is a fantastic company, with a great opportunity. Watch this space,” he says. n

INSIGHT June 2022 51

DISPENSING

SPECTACLE LENS COMPENSATIONS COMPENSATIONS OF THE LENS POWER AIM TO GIVE THE PATIENT THE CLOSEST EXPERIENCE TO THE POWER MEASURED DURING REFRACTION. NICOLA PEAPER OUTLINES KEY CONSIDERATIONS.

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ompensating the power of a spectacle lens simply means changing the power of the lens (read flat on a vertometer) so that the patient experiences the same power that they did under refraction conditions.

NICOLA PEAPER

“THE POWER OF THE SPECTACLE LENS NEEDS TO BE COMPENSATED FOR THE VARIANCES IN POWER THE POSITION OF WEAR CAUSES”

The most common compensation is that for position of wear. When we refract using a phoropter head or trial frame, the lens is presented to the patient with zero pantoscopic tilt (PT), zero face form angle (FFA) and a measurable corneal vertex distance (CVD). When the lens is dispensed into a spectacle frame it will invariably present with degrees of PT and FFA, and a different CVD. The power of the spectacle lens needs to be compensated for the variances in power the position of wear causes.

The compensation that we are perhaps the most familiar with is that for CVD as it is used during contact lens fitting where the wearing CVD is zero. With a refracting CVD of 13.5 mm and a refracted power over +/-4.00D, the compensation for contact lens fitting is around 0.20D. The internet has numerous calculating tools for these compensations.

It is important to note that both a refracting CVD and a wearing CVD are necessary for calculating. If the refracting CVD is not

Figure 1: Tilt angle of a spectacle lens.

given, then an average is used, usually around 13 mm. In 2002, Weiss et al1 found that the average phoropter head CVD over a group of 189 patients was 20.4 mm. If we compare the results of compensating a 4.00D lens (Table 1) it can be seen from this that use of the correct CVD is essential.

Compensations of PT and FFA are less well known but practitioners have long been able to calculate compensated powers for these. It is only recently, with the introduction of digital surfacing, that it has become commonplace for lens manufacturers to perform these calculations.

During a refraction light from a distant object is incident at right angles to the lens at the optical centre. When the lens is fitted to a spectacle frame the PT and FFA mean that light is incident at an oblique angle causing oblique astigmatism i.e. inducing a cyl. This means that if the script is -4.00DS, when the lens is worn in a spectacle frame some cyl will be present. The amount of cyl will be dependent both upon the power of the lens and the angle of tilt.

If we consider FFA alone and look at the effect different angles have (figure 1): Ordered power -4.00DS, FFA 20⁰, n=1.5 FSPH = F (1 + sin² θ/2n ) FSPH = -4.16

Refraction with trial frames results in zero PT, FFA and CVD, but when the lens is dispensed into a spectacle frame it needs to be compensated due to the position of wear.

52

FCYL = FSPH tan² θ FCYL = -0.55 Power experienced at vision point -4.16 / -0.55 x 90

INSIGHT June 2022

Rodenstock_AI_

Refracted power

Refracting CVD

Wearing CVD

Compensated power

-4.00D

13.0mm

10mm

-3.95D

-4.00D

20.4mm

10mm

-3.84D

+4.00D

13.0mm

10mm

+4.05D

+4.00D

20.4mm

10mm

+4.17D

Table 1: Compensated power for change in CVD of a 4.00DS lens.

Ordered power -4.00DS, FFA 5º, n=1.5 FSPH = F (1 + sin² θ/2n ) FSPH = -4.01 FCYL = FSPH tan² θ FCYL = -0.03 Power experienced at vision point -4.01 / -0.03 x 90 A second compensation needs to be calculated for induced prism due to base curve: △ = 100tanθ t/n F1 △ = 0.3∆ Base Out As this compensation includes base curve and centre thickness there is only a small amount

of induced prism for a minus lens. If the power was +4.00D then the induced prism would be 1.2∆ Base Out. A fully compensated lens is therefore calculated for the effect PT, FFA and CVD have on power including induced prism.

It is obvious that with the FFA of 20 it is essential to compensate the lens power otherwise the power the patient is experiencing is outside of tolerance and vision will not be optimal. However, questions are frequently asked about the validity of compensations on low powers with low amounts of FFA and PT, with respect to patient perception and manufacturing limitations.

It is important that a lens is produced with the greatest accuracy possible and, to this end, manufacturing tolerances are employed. The more accurate the order, the better the tolerances

work. Take for example the fitting of a progressive lens. We can measure PD to 0.01 mm but we cannot possibly fit with that accuracy. Tolerance to PD is 1.00 mm (independent of power). If the PD is 34.45 mm and is rounded to 34 mm then it is possible that the manufacturer can supply 33 mm. This would be inaccurate by 1.45 mm and outside tolerance on the original measurement.

Each of these compensations of the lens power are designed to give the patient the closest experience to the power measured during refraction. In each instance, the desired outcome is to optimise the ‘as worn’ spectacle lens performance to the patient’s visual experience outside the consulting room. n REFERENCES 1. R ichard A. Weiss et al, Clinical Importance of Accurate Refractor Vertex Distance Measurements Prior to Refractive Surgery. Journal of Refractive Surgery Volume 18 July/ August 2002. P444-448.

All formulae are taken from Brooks and Borish System for Ophthalmic Dispensing (3rd edition) p411 - 414

ABOUT THE AUTHOR: 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.

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RESEARCH PARTNERSHIP FOR CHILDHOOD CATARACT DIAGNOSIS ALARMED AT ANECDOTES FROM PARENTS THAT CATARACTS HAD BEEN MISSED IN CHILDREN, CATARACT KIDS AUSTRALIA HAS PARTNERED WITH ORTHOPTISTS TO IDENTIFY GAPS COMPROMISING EARLY DIAGNOSIS TO SUPPORT POLICY CHANGE.

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SANDRA STAFFIERI

MEGAN PRICTOR

ataract Kids Australia (CKA) is a registered charity for children affected by cataract. Its threefold mission targets families, healthcare professionals and researchers. In this article, we describe a common problem reported by families of babies and children with cataract, and how research collaboration between CKA and clinicianresearchers in orthoptics is yielding valuable data that we hope will help drive meaningful change in clinical practice.

‘Missed diagnosis’ – sadly, this phrase resonates powerfully with many parents of children with cataract. It is well-established that treatment outcomes for childhood cataract are severely impacted by delays in presentation, diagnosis, and treatment.

that led to the diagnosis of childhood cataract as reported by parents and caregivers. Of the 84 responses received from across Australia, the key findings were: • P arents were most likely to be the first to notice a problem, prompting review by a healthcare professional • 2 4% of children diagnosed with cataract were under 8 weeks of age • 2 5% of parents did not know whether the red-reflex test had been performed on their baby in hospital or at the 6-week well-baby check.

Amongst the free-text responses, whilst many parents received prompt and appropriate diagnosis and referral, others wrote of being told to ‘wait and see’ (after reporting an eye turn/squint); or of unsuccessfully raising their concerns with multiple health professionals over many weeks.

After CKA was established in 2017, it became clear to director Dr Megan Prictor – a parent of a child with cataracts – that parents, in sharing their experiences in Notably, 39 (46.4%) parents were the first online discussion forums, face-to-face to notice a problem with their child’s eyes or events and direct contact with the charity, vision.

This could suggest that either: were repeatedly describing that their child’s 1. The cataract was not present at the time cataracts were ‘missed’ or ‘found late’. of neonatal red-reflex screening, or Because late diagnosis of a unilateral congenital cataract can lead to irreversible amblyopia, decision-making about whether to proceed with lensectomy is complex and difficult. When diagnosis and treatment are delayed, the prognosis for visual rehabilitation after surgery can be very uncertain. Hence, it was alarming when CKA noted growing anecdotal evidence that cataracts had been missed.

Parents said that newborn red-reflex tests had been cursorily performed or skipped altogether; that their sense of something being ‘off’ with their baby’s eyes was repeatedly rebuffed by health professionals; and that they were told their baby’s misaligned eyes were ‘normal’ until the child turned one year of age.

In response, CKA formed a working group involving orthoptists, ophthalmologists and consumers (parents) with the ultimate aim of improving timely diagnosis of babies and children affected by cataract. Its first task was gathering more data about the problem.

In 2019, the organisation conducted an online survey to explore the referral pathway

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INSIGHT June 2022

2. The red-reflex test was either not done; not done by an adequately trained healthcare provider; or the diagnosis was missed.

Considering these preliminary findings, CKA – together with research orthoptists at the Royal Children’s Hospital (RCH) in Victoria – initiated an audit of all children diagnosed with cataract under the age of 5 years from January 2014 to December 2019.

The project aims to 1) characterise the presentation factors and referral pathway; and 2) assess their association with visual outcomes.

Identifying any gaps that compromise early diagnosis will support policy change, and the implementation of revised systems and processes. How effective is the red reflex screening at birth? Which children are being missed and why?

As we enter the final stages of data collection, to date, more than 150 patient records have been reviewed that met the inclusion criteria. We look forward to analysing the data and determining whether diagnosis and treatment is as timely as it

A survey found parents of children with cataract were most likely to be the first to notice a problem.

Image: Sarah Craven Photography.

should be to optimise visual outcomes. We plan to replicate the audit in other children’s hospitals in Australia.

This project is one of several workstreams underway with the CKA working group to improve diagnosis of childhood cataract and other paediatric eye conditions. Other activities include engagement with: state government policymakers about vision screening; national media to promote public awareness; and organisations representing healthcare professionals to ensure relevant knowledge and adequate skills development amongst clinicians.

Taken together, this work is a brilliant example of multidisciplinary advocacy coupled with research – in which orthoptists take a lead role. n

ABOUT THE AUTHORS: DR SANDRA STAFFIERI BAppSc(orth) PhD is the Retinoblastoma Care Co-ordinator/Senior Clinical Orthoptist within the Dept of Ophthalmology at RCH, Research Fellow, Clinical Genetics Unit at the Centre for Eye Research Australia, and an Hon. Fellow, University of Melbourne – Medicine, Dentistry and Health Sciences. DR MEGAN PRICTOR (LLB(Hons), PhD) is the Founding Director of CKA, a Founding Member of the Paediatric Vision Impairment Alliance, and an Editor with Cochrane Eyes and Vision.

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

MANAGEMENT

CLERICAL STAFF AND CLINICAL TASKS IF A PATIENT IS INJURED DURING TREATMENT, THE COMPETENCY OF ALL STAFF INVOLVED WILL BE SCRUTINISED. THE LEGAL LIABILITIES BECOME GREATER IF NON-CLINICAL SUPPORT STAFF ARE PERFORMING CERTAIN TASKS, WRITES KAREN CROUCH.

I

ncreasingly, for business productivity or convenience, non-clinically trained support staff are required to perform routine clinical tasks, including patient prep such as applying eye drops, pre-testing protocols or sometimes even testing itself.

KAREN CROUCH

“PRACTICE OWNERS SHOULD REVIEW THEIR INDEMNITY INSURANCE TO ENSURE IT COVERS NONCLINICAL STAFF”

The obvious question for practitioners and owners is whether this is risky for patients and practices? Understandably, it may be a necessary division of labour to service patients in a timely fashion and driven by commercial or environmental factors; for example the prolonged pandemic impacting staff availability coupled with an increase in demand for services. However, consequences may be severe for patients, treating staff and practice owners if proper precautions aren’t observed.

an unregistered nurse receptionist is likely to be more competent and therefore presents the safest option to protect patients, staff and practice owners; • Process by which the task was delegated: Was the delegation made with a clear knowledge that the receptionist was sufficiently competent and suitable to perform the task? This responsibility naturally falls directly on the supervisory staff (owners if relevant) who knowingly delegate such tasks;

• Patient consent: How are clerical staff presenting themselves to patients who have every right to know who will be administering their treatment and, if appropriate, details of related medical supervision by a Even a medically-trained and registered qualified practitioner? In the absence clinical practitioner must limit their of such information, the patient may practice and only provide services be giving an “uninformed, implied within their skill level and experience. consent” if the employee involved And so, the act of a clerical staff is not clearly identified as a clerical member performing clinical tasks must staff member rather than a clinician. be scrutinised.

Consequently, the patient may be The Health Practitioner Regulation deprived of the opportunity to either National Law (NSW) states non-medically refuse treatment or pose questions trained staff should not practise medicine about the level of oversight being nor hold themselves out to be a medical provided (refer to next point). If the person. However, industry associations patient isn’t adequately informed of such as the Medical Board of Australia these conditions and afforded the appear reluctant to specifically weigh right to make an informed decision, in on the topic, implying the practice the supervisor/owner failing to do may continue to be employed so will bear the responsibility for provided suitable, protective measures potentially greater penalties than exist and they are diligently adhered just treatment mishaps; to while recognising inherent risks of • Supervision: Is the task being sub-optimal performance. performed under the supervision What does this mean for non-medically trained staff who undertake clinical tasks as they too may be at risk, not to mention responsibilities of practice owners?

Research reveals diversity between clinics and the extent to which nonclinical staff undertake tasks that would typically be deemed ‘clinical’. On a regular or intermittent basis, there are certain factors to consider in assessing competency of support staff to perform clinical tasks, including: • Level of training: This is probably the most important factor. For example,

(whether direct or indirect) of a clinically-registered and trained practitioner and has the patient been informed accordingly? This requirement cannot be understated, particularly where a non-clinical staff member with reasonable experience is concerned, as supervision requirements have the higher potential to be overlooked.

In performing clinical tasks, a duty of care is owed to the patient. If a patient is injured during treatment, the level of skill, knowledge and competency of staff

Eye scan acquisition can sometimes be delegated to ancillary staff.

involved will be of direct relevance to issues of legal liability.

Medical practitioners may be held liable for the conduct of their nonmedical ‘practitioner’ employees if the abovementioned safeguards are ignored. Even if the policy does cover treatment by non-clinical staff, it’s important to carefully review terms and conditions that must be complied with.

Medical practice indemnity policies usually cover claims against employees or errors by unsupervised staff. Medical practitioners are more exposed if employees are unqualified, untrained and/or unsupervised. These policies commonly have exclusion clauses stating acts or omissions that are beyond training and outside terms of employment are not covered. Please review your staff skill mix, delegation procedures, employment contracts and insurance arrangements in this regard. n

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

INSIGHT June 2022 55

CAREER

People ON THE MOVE

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

RANZCO FINDS NEXT CEO TO REPLACE DAVID ANDREWS Mr Mark Carmichael has been appointed as the new CEO of RANZCO, effective 16 May. He previously served 10 years as CEO of the Australian Society of Anaesthetists – and prior to that CEO of the Australian Society of Otolaryngology Head and Neck Surgeons for five years. He holds a Bachelor of Health Science – Physical Education from the University of WA and a Masters in Business Management from the University of Technology, Sydney. He is looking forward to working with the RANZCO Board and staff to build on the strategic direction of the college and the specialty at large.

PROFESSOR STEPHANIE WATSON JOINS SYDNEY NANO FIRM Save Sight Institute’s Professor Stephanie Watson is starting a new position as Co-Deputy Director of Industry, Innovation and Commercialisation at The University of Sydney Nano Institute. Watson is Chair of the Ophthalmic Research Institute of Australia, Editor for the Cochrane Eyes and Vision, and Regenerative Medicine Theme Leader for Stem Cells Australia. She has appointments at the Sydney Eye Hospital, Sydney Children’s Hospital and Prince of Wales Hospital. Watson specialises in the anterior segment and is known for groundbreaking research in corneal stem cell treatment.

VISIONEERING TECHNOLOGIES APPOINTS NEW CHIEF MEDICAL OFFICER ASX-listed Visioneering Technologies has named Dr Kuang-mon (Ashley) Tuan as its new Chief Medical Officer. Tuan will be responsible for managing clinical research studies, such as the NaturalVue (etafilcon A) Multifocal randomised clinical trial for myopia control in children, helping identify and develop new products, and leading efforts to communicate findings in journals and scientific meetings. She will also lead a Professional Services team as it communicates technical information to eyecare professionals. Image: Ohio State University.

CORE EXPANDS SPECIALTY CONTACT LENS EXPERTISE The Centre for Ocular Research & Education (CORE) has appointed Dr Rosa Yang as a Clinical Research Associate, supporting the growing use of specialty contact lenses worldwide. Yang also serves as a Clinical Instructor at the University of Waterloo School of Optometry & Vision Science and is a practising optometrist. Her cornea and contact lens residency at the University of Waterloo focused on managing patients exhibiting corneal ectasia and severe dry eye with specialty contact lenses, as well as myopia control therapies, including orthoK.

MEDMONT INTERNATIONAL FINDS NEW MARKETING MANAGER Ms Marcelle Nadler, who has previously practised as an optometrist, announced she has started a new position as Senior Product Marketing Manager at Medmont International Pty Ltd where she will be heading up marketing. She recently finished her (remote) Product Marketing Manager role at NikonEssilor after year-long border closures meant she couldn’t make the move to Tokyo for the job. “I look forward to this new role at Medmont where I can once again combine my passions of marketing, optometry and strategy,” she said. Image: Linkedin

ESSILORLUXOTTICA MAKES CHANGES AT GRANDVISION EssilorLuxottica has announced a leadership reshuffle of newly acquired optical retail giant GrandVision. Mr Massimiliano Mutinelli (pictured ©Alberto Calcinai per Vision.biz) has become President of Optical Retail for EMEA at EssilorLuxottica and Head of Amsterdam corporate offices at GrandVision, replacing GrandVision CEO Mr Stephan Borchert. Mr Niccolò Bencivenni has become Chief Financial Officer, replacing Mr Willem Eelman, effective 22 April.

Do you have career news to share?

Email editor Myles Hume at myles.hume@primecreative.com.au to be featured.

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INSIGHT June 2022

2022 CALENDAR

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

JUNE 2022

AUGUST 2022

NOSA ANNUAL CLINICAL AND SCIENTIFIC MEETING

AUSCRS

VISION EXPO WEST

CCLSA ICCLC 2022

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

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

Sydney, Australia 15 – 17 October icclc2022.com.au

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

JULY 2022

6TH ASIA-PACIFIC GLAUCOMA CONGRESS

NORTH QUEENSLAND VISION

Kuala Lumpur, Malaysia 3 – 6 August apgcongress.org/

Cairns, Australia 9 – 10 July optometryqldnt.org.au/nqv

NATIONAL ACBO VISION CONFERENCE Online 9 – 10 July acbo.org.au

NSW RANZCO & OPHTHALMOLOGY UPDATES! Sydney, Australia 27 – 28 August ranzco.edu

SEPTEMBER 2022

OCTOBER 2022

EUROPEAN SOCIETY OF CATARACT & REFRACTIVE SURGEONS Milan, Italy 16 – 20 September congress.escrs.org

SILMO PARIS Paris, France 23 – 26 September silmoparis.com

PROVISION NATIONAL CONFERENCE Melbourne, Australia 21 – 23 October eventbrite.com.au

EYECARE PLUS NATIONAL CONFERENCE 2022 Broadbeach, Australia 28 – 30 October web.cvent.com

RANZCO 53RD SCIENTIFIC CONGRESS Brisbane, Australia 28 October – 1 November ranzco2022.com/

SPECSAVERS – YOUR CAREER, NO LIMITS Graduate Opportunities – Australia and New Zealand

All Specsa ve stores rs now with O CT

The Specsavers Graduate Recruitment Team have a select few regional opportunities remaining for the Specsavers ‘Early Bird Package’ which offers our highest sign on bonus ever. With continued growth in providing eyecare to patients across ANZ, now is an exciting time to join a company that is leading and defining the future of the optical profession. At Specsavers you will have access to cutting edge technology and be part of the driving force bringing Optometry into the forefront of the healthcare industry.

Interested in relocating to NZ?

Specsavers has a range of opportunities for NZ optometrists looking to return home. From North to South, we have fantastic opportunities for optometrists at all levels. You will have the chance to advance your skills and become part of a business that is focused on transforming eye health outcomes in New Zealand. Be equipped with the latest ophthalmic equipment (including OCT in every store for use with every patient) and develop your clinical experience across a range of interesting conditions and an ever-growing patient base. You’ll also have the support of an experienced dispensing and pre-testing team, the mentorship of store partners and access to an exemplary professional development program. There’s no place like home – so if you’re ready to return, let us help you.

Optometrist Joint Venture Partnership opportunity - Corrimal, NSW Corrimal is ideally located to take advantage of the 60kms of scenic coastal cycleways, with many of the city’s attractions such as Wollongong Harbour, and an array of restaurants, cafés, and shopping. Specsavers Corrimal is in Corrimal Shopping Centre and offers 3 Optical test rooms, 6 dispense points, 1 Visual Felds room, and 1 pretesting room. The store has 1176 frames on display and state of the art equipment including OCT, Humphrey’s HFA3, Tonoref, and a Corneal Topographer.

Earn up to $150,000 at Specsavers Wagga Wagga Specsavers Wagga Wagga is offering $150,000 package for an experienced Optometrist to join their team. We can offer a flexible roster, so you are able to have long weekends to explore this beautiful region. You will be working in a 4-test room practice, with a strong clinical focus to help make an impact the in community. Specsavers Wagga Wagga offers clinical and professional development in a supportive environment.

NSW & ACT Locum Availability Attention all locum optometrists! – as we enter the midpoint of the year now would be a great time to start looking at securing some work in the next few months and upcoming UIOLI period. Specsavers have regular weekend and block work in several regional, ACT, Newcastle, Central Coast and Wollongong locations. Accommodation and travel expenses in Regional, ACT and Newcastle will be covered. Central Coast and Wollongong can be negotiated if needed.

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

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

marie.stewart@specsavers.com or 0408 084 134 WA, NSW & ACT Optometrist enquiries:

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

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

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

SOAPBOX

EXPLAINING VISUAL SNOW SYNDROME disorder, triggered by LSD and magic mushrooms altering visual perception, can be very similar to the experience of VSS. There are many theories about the origin of the percept of visual snow, which include pathology in the thalamus, visual cortex or the areas involved in higher visual processing. The exact pathophysiology may vary slightly between patients, which could explain the main symptom of visual snow, but could also explain the variety of other entoptic phenomena and indirectly related symptoms such as tinnitus.

BY A/PROF CLARE FRASER

I

magine if your whole visual perception was like a poorly tuned television.

This is what patients with visual snow syndrome (VSS), a relatively newly recognised syndrome will describe.

Patients will complain of seeing continuous, uncountable, dynamic, tiny dots flickering across their entire visual field. They describe this as being like the static or the ‘snow’ on a poorly tuned analog television – hence the term “visual snow”.

This ‘snow’ is superimposed on the visual scene meaning there is no loss of visual acuity nor visual field defects on routine ophthalmic testing. The static is classically described as being black-andwhite, but can be colored. Patients also describe the presence of other visual phenomena including the persistence of afterimages, trail phenomena, photophobia, nyctalopia, and an increased awareness of normal entoptic phenomena (for example floaters). We found many patients with VSS also experience a highpitched tinnitus and tremor.

Diagnostic criteria for VSS have been published in an effort to capture the spectrum of the condition (Table 1). It has been reported up to 2% of the population in the UK have VSS. Despite this, VSS is a disorder that is frequently overlooked or misdiagnosed. The lack of recognition can make it a challenge for patients as well as clinicians and researchers.

While VSS could be thought of as a hallucination because there is no real-world correlate of the perception, it may be more accurate to consider it an illusion created by disordered visual processing. A syndrome called hallucinogen persisting perception

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INSIGHT June 2022

The average age of a large cohort of 1,100 VSS patients was 29 years old, though nearly 40% reported having symptoms for as long as they could remember. There was no difference between men and women reported however, in our own cohort of patients in Australia 75% of VSS patients were male. The prevalence of migraine and migraine with typical aura in VSS patients, 50-80%, is high in comparison with the general population. Some patients attributed symptom onset to a severe migraine attack. Others report the onset of symptoms to be associated with certain medication, trauma or infection. In cases where the visual snow was brought on by an inciting event such as concussion, or infection, management of the underlying cause may significantly alleviate the symptoms.

Psychiatric symptoms such as anxiety and depression are highly prevalent in patients with VSS and are associated with increased visual symptom severity and reduced quality of life. Therefore, treatment of psychiatric symptoms can offer an avenue for clinicians to help the patients improve their quality of life and ability to cope with other symptoms. In general, VSS seems to be non-progressive, though it does

fluctuate in severity within and between patients. During times of stress and other illness the symptoms can seem worse and treating the underling stressor or illness can help.

There have been no proven medical treatments to alleviate visual snow.

Though there are some case reports describing the use of lamotrigine, we have not found this to be helpful for most patients given the side effect profile of the drug. Tinted lenses may reduce how symptomatic the VSS appears to the wearer, but these will not cure the condition. There are some reports of orthoptic exercises being beneficial, but this has not been proven with rigorous scientific methods, and can be expensive.

An explanation, reassurance regarding progress and acknowledging the condition is often the first step to patients feeling less symptomatic. An honest discussion of the current state of research offers clarity and understanding which the patients generally find helpful.

Some patients who are more prone to introspection and anxiety can struggle if they become too enmeshed in patientled chat groups, so caution should be advised. However, others find the support of patients experiencing similar symptoms to be helpful. n Name: A/Prof Clare Fraser Qualifications: MBBS, MMed, FRANZCO Organisation: Save Sight Institute, The University of Sydney Position: Associate Professor of Neuro-ophthalmology Location: Sydney Years in profession: 22 years as a doctor.

Diagnostic criteria for visual snow syndrome 1

Visual snow: dynamic, continuous tiny dots in the entire visual field lasting longer than 3 months

2

Presence of at least two additional visual symptoms from the following: a) Palinopsia: afterimages or trailing of moving objects b) Photophobia c) Nyctalopia (impaired night vision) d) Other persistent positive visual phenomenon including (but not limited to): enhanced entoptic phenomena (excessive floaters or blur field entoptic phenomenon), kaleidoscope type colors with eyes open or closed, spontaneous photopsias

3

Symptoms are not consistent with typical migraine visual aura

4

Symptoms are not better explained by another disorder

Table 1: Proposed criteria for visual snow syndrome. Based on Metzler AI, Robertson CE. Visual Snow Syndrome: Proposed Criteria, Clinical Implications, and Pathophysiology. Curr Neurol Neurosci Rep. 2018:18:52. doi: 10.1007/s11910-018-0854-2.

AN EXPLANATION, REASSURANCE REGARDING PROGRESS AND ACKNOWLEDGING THE CONDITION IS OFTEN THE FIRST STEP TO PATIENTS FEELING LESS SYMPTOMATIC.

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