Insight July 2021 by Prime Creative Media

INSIGHT JULY

2021

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

Opponents are describing it as a defining moment for Australian healthcare.

CATARACT CLINICAL CARE STANDARD CONTROVERSY Anxious wait over whether Snellen acuity will be included as an indication for surgery.

ACCC AUTHORISES HEALTH FUND BUYING GROUP

Visionaries. They change how we see the world. Like the Eyecare Professionals who give people the greatest gift, the gift of vision. We’re here to celebrate and enable them. THE PRACTICE MANAGEMENT PUZZLE Pearls from leading managers to help make your practice run like clockwork.

No time like the present for a tree change Relocating to a beautiful regional town and embracing a relaxed lifestyle is now more than ever within your reach. You might be moving regional, but you still have access to the latest technology and support available. Our focus is to invest in you and ensure you have everything you need to succeed in your career, no matter where you are. While we offer a generous salary, we do not stop there – our professional development program is also world-class. Whether your chosen path is retail, dispensing or optometry, Specsavers can support your career journey. Going regional with all the support Specsavers offers, you will be able to enjoy the benefits of a supportive local community and see first-hand your positive impact of transforming people’s lives within your community. And with the latest technology, including OCT in all our stores, our optometrists from every remote town and region across our vast land are well equipped to improve detection, referral and diagnosis rates for a range of eye conditions. So, leave the hustle and bustle behind, settle into a change of pace. You might ask yourself why you didn’t make the change sooner!

Go to spectrum-anz.com or contact us: Partnership enquiries: Marie Stewart +61 408 084 134 Optometry vacancy enquiries: Madeleine Curran +61 437 840 749

INSIGHT JULY

2021

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

‘MANAGED CARE’ FEARS AS ACCC AUTHORISES FORMATION OF HONEYSUCKLE BUYING GROUP

An interim decision to allow a new buying group to collectively negotiate contracts with healthcare providers is a defining moment in Australian healthcare, says the Australian Society of Ophthalmologists (ASO), as it prepares to mount a challenge against the introduction of “US-style managed care”. The Australian Competition and Consumer Commission (ACCC) has authorised Honeysuckle Health and nib health funds to form and operate the Honeysuckle Health Buying Group that would act on behalf of health insurance companies and other health payers – referred to as “participants”. The buying group would then collectively negotiate and administer

contracts with hospitals, medical specialists, GPs and allied health professionals. Honeysuckle is an equal joint venture between nib and US-based health services company Cigna Corporation established in 2019. It operates independently from both entities. At the time of writing, the ACCC’s decision was a “draft determination”, meaning further submissions could be lodged until June 11 before a final ruling is delivered. The authority declined the buying group’s proposal to operate for 10 years, reducing this to five. The ACCC said that it received many submissions opposing the application, which included the ASO, Optometry Australia (OA), Australian Medical Association

counterparts who often entered low or ‘no gap’ arrangements with health funds.

Honeysuckle is a joint venture between nib and US company Cigna Corporation.

(AMA) and other health lobbyists. They were worried about the level of control insurers could possess over clinical care pathways. The potential size of the group was also unclear, with concerns it could have disproportionate market power. OA highlighted potential issues for smaller optical operators and their ability to compete with their larger

“This is a defining moment in Australian healthcare because we now have a major American health insurer with a market cap of US$90 billion dollars (AU$116 b) and 70,000 employees coming to Australia to partner with nib,” ASO vice president Dr Peter Sumich said. “This isn’t an experiment, nib has always expressed a long-term view on managed care in this country, which they call ‘network care’, and by bringing Cigna across, they’re importing the know-how and the methods to introduce managed care – it’s very clear to those in the continued page 8

BUSINESS AND TRACHOMA BENEFIT IN FED BUDGET A tax cut for Australian medical and biotech companies generating income from new patents, expansion of a traineeship wage subsidy and $19.1 million towards trachoma elimination are the main Federal Budget announcements affecting the ophthalmic sector. Federal Treasurer Josh Frydenberg’s big spending budget, unveiled 11 May, committed major investment towards aged care and mental health, but also delivered a further boost to Australian businesses and Indigenous health. Among the main business tax incentives was a one-year extension to the temporary “full expensing” scheme, allowing businesses with a turnover or income of less than

$5 billion to immediately writeoff assets they first use or install by June 30, 2023. For eyecare practices functioning as small or medium businesses the government committed to a tax cut to 25% from 1 July 2021. The government also unveiled a ‘patent box’ regime, meaning that income earned from new patents developed in Australia would be taxed at a concessional 17% tax rate – almost half of what large companies pay. It will apply to the medical and biotech sectors, with Frydenberg stating that Australia’s effective COVID-19 management has made it an even more attractive place for some of the world’s brightest minds.

The government is also spending an additional $2.7 billion to extend the Boosting Apprenticeship Commencements (BAC) program. The scheme – which involves a 50% wage subsidy of up to $28,000 for employees enrolled into appropriate courses – has triggered hundreds of enrolments into Certificate IV in Optical Dispensing courses in Australia. The demand-driven program is expected to support more than 170,000 new apprentices and trainees for newly commencing students signed up by 31 March 2022. The subsidy will be capped at $7,000 per quarter per apprentice or trainee. continued page 8

REACHING NEW DEPTHS WITH ITRACK While much of the spotlight around MIGS has focused on stent-based procedures, Dr Nathan Kerr says glaucoma surgeons should be excited by an entirely different approach by an Australian company. page 28

IN THIS ISSUE JULY 2021

EDITORIAL

FEATURES

MESSAGE RECEIVED If Federal Health Minister Greg Hunt is leaning towards allowing the proposed Medicare rebate cut for anti-VEGF injections, he may have cause to think twice. Advocates scored a decisive point in the ongoing battle to prevent a 69% drop in the fee and rebate for intravitreal injections – as recommended by the MBS Review Taskforce – after Macular Disease Foundation (MDFA) patron and media personality Ita Buttrose used the National Press Club platform to publicly highlight the ramifications of such an approach (see page 9).

CATARACT CONTROVERSY Why there is opposition to 6/12 visual acuity or worse as a threshold for surgery.

PRACTICE MANAGEMENT Experienced practice managers share their hard-won wisdom and practical tips.

Until now, the issue has felt confined to the ophthalmic sector and macular disease community, but Buttrose’s impassioned speech – and an op-ed across News Corp newspapers – has helped elevate the matter into public view, just as Minister Hunt and the Health Department consider the final report. While Buttrose’s profile and timing are vital, what’s more important is the fact she backed her assertions with modelling. Increasingly, the government wants organisations to lobby with hard data, more than emotion and anecdote. The PwC modelling data was sobering. It includes the prediction that higher out-ofpocket costs would increase eye injection drop out by 25%, causing an additional 47,000 Australians to experience severe vision loss and blindness.

ZEISS ANNIVERSARY The pioneer behind many ophthalmic innovations turns 175 this year.

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NEW REALM Thinking beyond conventional boundaries with contact lens technologies.

This would cost shift, leading to $168 million in direct costs to government in primary health, mental health care and early admissions to residential aged care, and an additional $2.6 billion in indirect costs through loss of patient and family carer productivity. Minister Hunt now has massive task if he’s to convince the public it’s worth tinkering with the rebate. He’s also got to consider what fills the void if the rebate is cut, because the public system isn’t equipped to immediately pick up the pieces, and bulkbilling will become untenable for many private clinics. MYLES HUME Editor

INSIGHT July 2021 5

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UPFRONT Just as Insight went to print, ALLERGAN secured an alternative product to address a shortage of its Prednefrin Forte eye drop. The company received Section 19A approval through the Therapeutic Goods Administration for Pred Forte prednisolone acetate 10mg/mL eye drops 5mL (UK), which it hopes will be available later this month. The eye drop is indicated for severe inflammation (non-infectious), such as acute iritis, iridocyclitis, scleritis, episcleritis, uveitis, resistant ocular allergy and inflammation

WEIRD

following surgery (where no infectious aetiology is suspected). Prednefrin Forte has been unavailable due to manufacturing issues and isn’t expected to return until early 2022. IN OTHER NEWS, Specsavers confirmed its first acquisition in the North American market. The British multinational purchased Image Optometry, which employs 55 people and operates 10 company-owned and eight franchise stores around Vancouver. Specsavers chief strategy officer Nigel Parker told Vision Monday: “Like many of our existing markets, such as the UK and Australia, the optometry industry in Canada is a full-scope, highly regulated environment which we are very familiar with, so it was

a logical step for us to welcome Image Optometry and its franchisees, colleagues and customers to the Specsavers family." FINALLY, Glaucoma Australia (GA) launched a new awareness campaign called ‘Begins With You’, to mobilise people with glaucoma to ask their family and friends over 50 to get tested. People are 10 times more likely to have glaucoma if a direct family member has the disease, while first degree relatives are at greater risk. “We want to see an Australia free of glaucoma blindness. We hope this new campaign empowers Australians with glaucoma to act and encourage their family and friends to look after their eye health,” GA CEO Ms Annie Gibbins said.

STAT

WACKY

A second Australian sportsperson has been ruled out after a retinal detachment. After Adelaide Crows AFL captain Rory Sloane was sidelined for several weeks after surgery in April, Roosters NRL hooker Sam Verrills revealed he played with blurred vision, which turned about to be the same injury, ruling him out for two months.

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A video of two proud parents learning of their 22-year-old daughter’s acceptance into optometry school has gone viral. Gurjiv Kaur, who lives in the US, filmed her parents reading aloud the letter. The video and their joyous response has garnered 9 million views.

Published by:

Publisher Christine Clancy

Researchers found the octopus has the most sensitive polarisation vision system of any animal tested. Their technology could soon be used by optometrists to screen for patients with low macular pigment levels, which can be linked to developing age-related macular degeneration. n

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INSIGHT July 2021 7

NEWS

'PATIENTS WILL EFFECTIVELY HAVE NO CHOICE' continued from page 3

industry what’s happening.” According to the ACCC’s draft ruling, the Honeysuckle application was amended so that large providers Medibank, Bupa, HCF, or HBF in Western Australia could not join the general buying group and acquire Honeysuckle’s contracting services for hospital contracting, medical gap schemes and general treatment networks. But those health funds can use Honeysuckle’s Broad Clinical Partners Program (BCPP) whereby Honeysuckle signs agreements with medical specialists so customers aren’t charged out-of-pocket costs for hospital treatment. This currently applies only for joint replacements but is proposed for other services in future. The ACCC did impose other conditions amid concerns about the potential “uncapped aggregation” for the BCPP that would likely be detrimental to the public, reducing competition between acquirers of medical specialist services. “To address this public detriment, the ACCC proposes to impose a condition of authorisation that [Honeysuckle] not provide the [BCPP] services to major private health insurers where this would result in the participants in the program representing more than 40% of the private health insurer market in any state or territory.” With there being two other existing buying groups – the Australian Health

Services Alliance (AHSA) and the Australian Regional Health Group (ARHG) – the ACCC believed the Honeysuckle proposal would become a new option for health funds that preferred to be part of a collective, increasing competition. “On balance, and with the proposed condition of authorisation, the ACCC considers that the proposed conduct is likely to result in a public benefit and that this public benefit would outweigh any likely detriment to the public.” BACKLASH EXPECTED Sumich expected more to come on the issue, with the ACCC’s scope limited to market competition only. “We believe the solution is going to lie with politics and it is likely that the majority of medical groups will mount quite a backlash; there is a lot of discussion about the best way of doing that,” he said.

"IT IS LIKELY THAT THE MAJORITY OF MEDICAL GROUPS WILL MOUNT QUITE A BACKLASH; THERE IS A LOT OF DISCUSSION ABOUT THE BEST WAY OF DOING THAT" PETER SUMICH, ASO

“Citizens will also be alarmed at what’s happening and they will be the ones who actually create the momentum to slow down progress. Australians want to have choice in their healthcare and US-style managed care depends on patients having less choice and accepting a packaged product.”

produced en masse, resulting in cheaper contract rates. “But in the medium to longer term patients will realise they’ve lost their freedom of choice. There are many stories in America, for example, such as the breast cancer patient who has the reconstruction performed by a contract surgeon who may not be a top plastics guy, but is a general surgeon who has an interest in that area, because that’s the package you accept. Or chemotherapy patients told they can have two rounds of treatment, but any more isn’t possible because that’s all that can be accepted.” In its submission, the Australian Society of Anaesthetists echoed similar concerns for patients who, for example, would be insured by nib (or a member of the Honeysuckle Buying Group) but whose medical specialist had not entered into a contract with Honeysuckle, therefore meaning favourable rebates would not be available to the patient if they continued to attend their chosen provider. “The patient will effectively have no choice of provider. The patient is disadvantaged by having to go outside of the preferred provider network of nib. There is a clear disadvantage to patients who pay the same premium but may get lower rebates for the same service due to the doctor or hospital they choose.”

Sumich accepted that, in the short term, patients who used health services through the Honeysuckle scheme would receive lower out-of-pocket costs. This is because agreements for care would be

OA did not have further comment to make beyond its initial submission and was still considering a further submission at the time of writing. n

MORE FUNDING FOR PUBLIC HOSPITALS AND PBS continued from page 3

The $121.4 billion health budget included $19.1 million to improve Australia’s trachoma elimination program, which the country hopes to achieve by 2022. This comes after failing to meet the 2020 elimination target. Public hospitals will continue to receive much needed investment, with $135.4 billion over five years, including funding under the 2020–25 National Health Reform Agreement (NHRA) and the National Partnership on COVID-19. This is up from $13.3 billion in 2012-13, to $25.6 billion in 2021-22 and $29.9 billion in 2024-25.

INSIGHT July 2021

2011 and by 2024-25 will fall to 19 cents.

Although there was no specific mention of increasing public cataract surgery capacity – which Vision 2020 Australia strongly advocated for – it’s hoped this funding will trickle down. For the Pharmaceutical Benefits Scheme, $43 billion will be spent over four years to address medication availability and affordability. According to The Fred Hollows Foundation, official development assistance (ODA) expenditure has fallen from $4.5 billion in the 2020-21 Federal Budget to $4.3 billion in 2021-22. Australia will now spend 21 cents for every $100 of national income on foreign aid. This is down from 33 cents in

Josh Frydenberg, federal treasurer.

“The government has supported the sector’s calls to End Covid for All with increased funding and vaccine support for our neighbours like Papua New Guinea. It’s also encouraging to see the two-year support package of $37.1 million to India,” CEO Mr Ian Wishart said. “But I would have hoped that Australia’s time of crisis would make us more sympathetic to the needs of others overseas, some of them our closest neighbours, beyond just the pandemic. Weak health systems anywhere in the world are a threat to all of us.” n

NEWS

REBATE CUT COULD BLIND 47,000 AUSTRALIANS, SAYS MDFA

Prominent Australian Ms Ita Buttrose has used a National Press Club address to reveal alarming new data showing that 47,000 more Australians will experience severe vision loss or blindness if a Medicare rebate cut for intravitreal injections is given the green light. The economic modelling was commissioned by the Macular Disease Foundation Australia (MDFA) and conducted by PwC in response to the MBS Taskforce's review into ophthalmology items. The data has since been passed on to Federal Health Minister Greg Hunt. Buttrose, an MDFA patron, used the Canberra speech on 5 May to warn that many older Australians would no longer be able to afford anti-VEGF treatments for diseases like neovascular agerelated macular degeneration (nAMD) if the Federal Government adopted a recommendation to slash the rebate by more than two thirds. “This treatment is highly successful in saving sight,” Buttrose said. “So why has the review taskforce recommended a reduction of 69% in the rebate for these eye injections? It’s a decision I find hard to fathom.” Under the current system, she said within the first 12 months of injection treatment, adherence rates drop by 2022% and then more than 50% by year five, leaving an estimated 80,000 Australians who progress to severe vision loss or blindness within five years. While there are several reasons for this, she said access and cost issues top the list because often there are limited or no eye health specialists near where people live, or they can’t access public hospital or bulk billed treatment. Currently, 29% receiving treatment are considering delaying or stopping due to costs, while 35% have cut back on expenditure such as food, groceries, other medicines and even mortgage payments to save their sight. “Out-of-pocket costs for this treatment are already prohibitive,” Buttrose said. “Economic modelling commissioned by MDFA, predicts the proposed rebate cut will result in out-of-pocket costs increasing from $1,900 to $3,900 a year on average – double for patients needing injections in both eyes. “This translates to an additional 47,000 Australians experiencing severe vision loss and blindness within the next five years.” With Australia delivering some of

IN BRIEF

Ita Buttrose with her uncle Gerard who has neovascular AMD.

the best nAMD outcomes globally, Buttrose used the address to call on the policymakers to reject the recommendation, and consider MDFA’s fully costed plans to improve access to sight-saving treatment. “This rebate reduction, if approved, will deliver some savings to government, but will effectively be cost shifting to other parts of the health and welfare system,” she said. “MDFA’s economic modelling forecasts an extra $168 million in direct costs to government in primary health, mental health care and early admissions to residential aged care. It’s estimated the proposed rebate cut would also lead to an additional $2.6 billion in indirect costs through loss of patient and family carer productivity.” The MDFA has developed three costed solutions to increase access to sight-saving treatment, including; new low cost-regional clinics, so patients can access treatment without needing to travel to metropolitan clinics that are already at capacity; increasing the number of healthcare workers who can give injections under the supervision of qualified ophthalmologists; and empowering patients to be better informed about fees so they can selfadvocate if they can’t afford treatment. “These models need both federal and state government investment. But the cost of doing nothing is much higher. Every 1,000 wet AMD patients left untreated costs the health system $20 million a year,” Buttrose added. In response, Minister Hunt said: "This [is] a report to government. There are many reports to government, and it’s not one which we have considered and determined yet. So I won’t pre-empt it. But our job is very clear, to make sure that every Australian has access to eyecare as early as possible.” n

CODE OF CONDUCT

Optometrists are being encouraged to express their views on a code of conduct applicable to them. The Australian Health Practitioner Regulation Agency has launched a public consultation that closes 6 July. CEO Mr Martin Fletcher said: “The updated code sets out the National Boards’ expectations of professional behaviour and reflects the professionalism that is a fundamental part of being a health professional. Importantly, the code describes the behaviour patients can expect whenever they see a registered health practitioner. We want to hear from patients, consumers, practitioners and others to make sure the updated code is relevant and useful to practitioners and better able to protect the public."

MYOPIA PAPERS

Three Australian academics in a group of leading global experts in myopia have contributed to the International Myopia Institute’s (IMI) much-anticipated 2021 white papers. Professor Padmaja Sankaridurg from BHVI, Professor Ian Morgan from Australian National University, and Dr Monica Jong from the University of Canberra have each been involved in authoring the papers that present the latest research, recommendations and updates in the field. They have been released in a special issue of the peerreviewed Investigative Ophthalmology and Visual Science journal, following the first series published in 2019.

ESSILOR CAMPAIGN

Essilor’s 'See More Do More' advertising campaign has returned for a second year to educate consumers about the range of lens technologies available to meet their lifestyle needs and encourage them to visit a local optometrist. The campaign, which started on 1 May across Australia and New Zealand, brings together the company’s flagship products including Varilux, Eyezen and Crizal lenses to raise awareness about the importance of vision care, particularly following COVID-19. The campaign includes outdoor advertising across street furniture and retail locations along with digital display and social channels. Designed to raise brand awareness and drive consumers to Essilor partner stores, the campaign is supported by a multi-pair promotion offer, together with in-store and merchandising materials.

INSIGHT July 2021 9

NEWS

HEALTHIA ANNOUNCES NEW OPTICAL ACQUISITIONS "FOR HEALTHIA TO BRING ONBOARD ITS FIRST TWO STORES FOLLOWING (TOC) JOINING IN DECEMBER 2020 IS A SIGNIFICANT MILESTONE"

Australian allied health group Healthia – which recently entered the optical arena with a multi-million-dollar acquisition of The Optical Company – has announced two practices will be joining its network. The ASX-listed firm has agreed to purchase Bernie Lanigan Optometrist, located in Townsville, Queensland, and The Eyecare Place in Abbotsford, Victoria. The practices are the first optical acquisitions since the establishment of Healthia’s new Eyes & Ears business division on 30 November, which was initiated by a $43 million takeover of The Optical Company and its 41-store portfolio. The total consideration for the new acquisitions (plus stock, less employee entitlements) is $620,000, with the practices expected to generate $1.4 million in revenue. Bernie Lanigan Optometrist was established in 1979. The practice was moved to the busy City Arcade in Townsville CBD in 2016 to offer a more convenient service for patients. Under the directorship of managing practising optometrist Ms Belinda Luu and directors Mr Charles Luu and Mr Phillip Luu, The Eyecare Place was established in 2010, and is located in Hive Shopping Centre, a community

The Eyecare Place, in Melbourne, joined the network last month.

shopping centre anchored by major retailers.

COLIN KANGISSER, HEALTHIA

will join our network in June. As part of Healthia, we have a mandate to grow the network and invite business owners to get in touch. We are in advanced negotiations for further additions and are confident that we will reach our mandated store growth.” Kangisser said TOC, as part of Healthia’s Eyes & Ears division, offered an ideal opportunity for owners to put in place an exit strategy to monetise their investment now and have some flexibility about the future. Options available to owners include immediate exit, phased exit, or Healthia’s Clinic Class Share program where owners retain some interest on exit and continue the journey with Healthia. Following sale, if the owner remains with the business, each location is said to maintain a sense of independence compared to more corporate options and the business will maintain high levels of eyewear and eyecare with the support of a back-office structure.

As part of the TOC acquisition in November, TOC founder CEO Mr Colin Kangisser was appointed CEO of Healthia’s Eyes & Ears division and is an executive director of Healthia. “For Healthia to bring onboard its first two stores following (TOC) joining in December 2020 is a significant milestone. Ultimately however, it is not growth just for the sake of growth, as the financial performance; quality of the location; and the people who will join us are amongst the determining factors,” Kangisser said.

“We have always considered ourselves like a family, we enjoy what we do and work together to ensure we all continue to feel engaged by our work and deliver great products and services to customers,” Kangisser said. n

“The addition of Bernie Lanigan Optometrist brings our network to 42 stores now and The Eyecare Place

GENE THERAPY TRIAL FOR DRY AMD UNDER WAY IN AUSTRALIA Australia’s first clinical trials of an investigational gene therapy for dry agerelated macular degeneration (AMD) has begun at the Centre for Eye Research Australia (CERA). CERA’s principal investigator of retinal gene therapy research and vitreoretinal surgeon Dr Tom Edwards performed the first surgeries to administer Gyroscope Therapeutics’ gene therapy, GT005, to patients at The Royal Victorian Eye and Ear Hospital in Melbourne recently. The therapy – delivered with a subretinal injection – is featuring in two studies called HORIZON and EXPLORE to evaluate its safety and effectiveness in treating geographic atrophy (GA) secondary to AMD. Around 20 Australians with dry AMD are expected to take part in both

INSIGHT July 2021

studies, which are Phase 2, multicentre, randomised, controlled trials. According to the company, GT005 is designed to stimulate a person’s cells to create Complement Factor I (CFI), a protein that is key to regulating the alternative pathway of the complement system. The goal is to slow the progression of dry AMD. “To deliver the gene therapy, the gene is combined with a safe, modified virus – known as a viral vector – which help it get into retinal cells,” Edwards said. “The therapy aims increase the production of [CFI] which regulates part of the immune system, known as the complement system. Too much activity in the complement system, has been strongly associated with the development of AMD.

“And it’s believed that increasing the production of this protein could dampen the system’s overactivity and reduce inflammation, with the goal of preserving a person’s eyesight.” Dr Tom Edwards (centre), with his surgical team.

Gyroscope Therapeutics’ EXPLORE trial is enrolling up to 75 people globally with GA secondary to AMD who have rare variants in their CFI gene associated with low levels of the CFI protein in their blood. HORIZON is evaluating GT005 in a broader group of up to 180 people with GA secondary to AMD. Participants receive two doses of GT005 administered as a single subretinal injection, and may be assigned to one of two treatment arms or the control arm and will be followed for 48 weeks. Both trials are enrolling at sites in the US, Europe and Australia. n

For the Visionaries

Visionaries. They change how we see the world. Whilst some go down in history, there are many who don’t. Like the Eyecare Professionals who change how thousands of people see every day. Who give people the greatest gift, the gift of vision. We’re here to celebrate and enable them.

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NEWS

ASO PLEASED WITH TAMWORTH OPHTHALMOLOGY EXTENSION BUT PERMANENT SOLUTION NEEDED An overseas-trained ophthalmologist whose ability to practise in Tamworth was under threat due to workforce distribution policy has been granted another extension until 2022, as work continues towards a permanent solution for an issue affecting many medical fields. Dr Kayvan Arashvand, an ophthalmologist who completed his training in the UK and moved to Australia in 2014, has had his Medicare Provider Number to practise in the regional NSW city (North West Eyes) extended until January 2022. It is the third time he has been granted an extension and gives the region some certainty after he was almost required to leave, potentially triggering an ophthalmology shortage. The Australian Society of Ophthalmologists (ASO), with the support of RANZCO, has been instrumental in working with the Federal Government to secure the extensions. “This stopgap measure will keep Tamworth safe for the rest of the year, but we are continuing our very strong efforts to ensure we don’t have to keep coming back every six months begging to keep an ophthalmologist who the community really wants to hang on to,” ASO president Associate Professor Ashish

Australian Society of Ophthalmologists president A/Prof Ashish Agar.

Agar said. “We are now working very closely with the federal health minister and health department to get a long-term solution – and not just for Tamworth, this is a national issue that affects every branch of medicine.”

"DR ARASHVAND CAN PRACTISE IN THIS REGION AND ACTUALLY SETTLE DOWN RATHER THAN LIVING IN AIR BNB ACCOMMODATION WHICH HE HAS BEEN DOING THE PAST 16 MONTHS" DAVID MOORE, NORTH WEST EYES

because it wouldn’t have had the capacity to provide other services. “If he leaves, the whole thing falls over, they won’t be able to do on call, and they won’t be able to retain their registrar as well, the implications are huge,” he said. Agar is hopeful the matter can be addressed, with the government examining the issue through a Distribution Advisory Group. It’s currently reviewing the methodology and will advise whether it is still appropriate. Dr David Moore, who founded North West Eyes in 2003 and employed Arashvand, said the decision provided some certainty. “Dr Arashvand can practise in this region and actually settle down rather than living in Air BnB accommodation which he has been doing the past 16 months,” he said.

At the heart of the matter is the government’s District of Workforce Shortage (DWS) system to determine the distribution of specialists in regional and remote areas of Australia.

“For me it means that we have him as one of a very few ophthalmologists in the region which drains a large part of our state and is chronically undersupplied.”

Because Arashvand is an international medical graduate under health law, he is required to work in a designated DWS for at least 10 years. Tamworth doesn’t have DWS status, but Agar said this was because the calculation was based on the town’s population, rather than the wider catchment. Agar said it was important for Tamworth to retain Arashvand

Moore hoped, in future, the assessment that determines an “area of need” will be changed to reflect the actual area and population that a specialist covers. n

NOVARTIS SECURES PBS RECOMMENDATION FOR AMD THERAPY An independent expert panel has recommended Novartis’s treatment Beovu should be subsidised through the Pharmaceutical Benefits Scheme (PBS) for neovascular age-related macular degeneration (nAMD) patients as a second-line anti-VEGF treatment. Beovu (brolucizumab) obtained Australian registration in January 2020, however efforts to have the drug listed on the governmentsubsidised medicines program have been denied on three occasions since November 2019. In the latest decision from its March 2021 meeting, the Pharmaceutical Benefits Advisory Committee (PBAC) recommended Beovu’s listing for

INSIGHT July 2021

the treatment of subfoveal choroidal neovascularisation (CNV) due to AMD in patients who are non-responsive despite first-line anti-VEGF treatment. “The PBAC considered that a secondor subsequent-line treatment option of brolucizumab in CNV due to AMD would be useful for patients who have ongoing exudation/fluid despite first-line anti-VEGF treatment,” the PBAC noted. “The PBAC considered the costeffectiveness of brolucizumab would be acceptable in the later-line setting as it is likely to be equi-effective to currently listed anti-VEGF agents (aflibercept and ranibizumab). The PBAC advised that brolucizumab would be required to join the risk sharing arrangement

Novartis supplies Beovu in Australia.

currently in place for ranibizumab and aflibercept in this indication.” A Novartis spokesperson told Insight the company welcomed the decision to recommend its drug for PBS listing in patients with subfoveal CNV due to AMD who have persistent disease despite prior antiVEGF treatment. “Novartis will work closely with the Department of Health to allow Beovu to be accessible in a timely manner by eligible Australians,” the company spokesperson said. In Australia, Beovu presents a third major anti-VEGF option on the PBS, joining the Novartis-distributed ranibizumab (Lucentis) and Bayersupplied aflibercept (Eylea). n

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NEWS

A THIRD OF AUSTRALIAN OPTOMETRISTS EXPERIENCING MODERATE TO SEVERE PSYCHOLOGICAL DISTRESS "YOUNGER AGE AND BURNOUT WERE SIGNIFICANT RISK FACTORS FOR PSYCHOLOGICAL DISTRESS"

New Australian research has revealed that many optometrists are struggling with their mental health, with those in the early stages of their career particularly susceptible. A pre-COVID survey of 505 registered practising Australian optometrists in mid-November 2019 revealed that 31% were experiencing moderate to severe psychological distress, with similar findings for depression and anxiety. One in four were also experiencing moderate to extremely severe stress. Optometrists under 30 were 3.5 times more likely to report moderate to severe psychological distress than those over 30, according to the survey. (Optometry Board of Australia’s latest statistics indicate there are 1,525 registered optometrists under 30. These early career optometrists make up the largest age group in the profession.) The survey results also demonstrated a prevalence of high burnout, as indicated by exhaustion (56% of respondents), cynicism (57%) and professional efficacy (23%). The study published in the journal Ophthalmic and Physiological Optics, titled ‘The mental health and wellbeing survey of Australian optometrists’, is the first to investigate the prevalence of mental health conditions and burnout

The survey also demonstrated a prevalence of high burnout.

STUDY AUTHORS

factors driving these issues and the most effective solutions,” Bentley said. “This is a complex problem requiring a variety of strategies that address both personal and workplace factors. At QUT School of Optometry and Vision Science, our plan is to introduce basic mental health and resilience training to students, to support and prepare them before they enter the workforce.” The study’s authors concluded that rates of mental health conditions and burnout reported by practising Australian optometrists were relatively high compared with the general population and other health professionals.

among optometrists using validated scales. Professor Sharon Bentley is head of Queensland University of Technology (QUT)’s School of Optometry and Vision Science. She led the research team and told Insight the proportion of optometrists affected and the level of severity were among the most surprising findings.

“Younger age and burnout were significant risk factors for psychological distress. Interventions are required to address these issues, particularly for younger optometrists, and could include workplace modifications and building resilience to improve personal mental wellbeing and ensure patient safety,” they noted.

The survey comprised three wellestablished mental health scales and an open-ended question inviting comments. “We were very pleased by the high response rate and surprised by the number of participants who chose to volunteer comments,” Bentley said.

Optometry Australia is also bolstering mental health support. It recognised the impact of COVID-19 and snap lockdowns on practitioners.

The most frequently mentioned work-related issues concerned retail pressures, workload and career dissatisfaction. “Further investigation is required to understand the specific

“These results further reflect those of another survey that [we] conducted in 2020, which highlighted 46% of members were anxious about their future." n

NEW DATA SUPPORTING HOYA'S MYOPIA SPECTACLE LENS New data published in the British Journal of Ophthalmology (BJO) has shown Hoya’s MiyoSmart lens continued to slow myopia progression in children after three years, while patients who switched from single vision lenses had an immediate slowdown in their condition. The ophthalmic lens maker – which released its myopia control spectacle lens in Australia last September – announced the results of a threeyear follow up clinical study of the lens centred on its patented Defocus Incorporated Multiple Segments (D.I.M.S) Technology. The new study was conducted by the Centre for Myopia Research at The

INSIGHT July 2021

Meanwhile, Hoya reported the group that moved from single-vision to MiyoSmart lenses showed “a significant and immediate slowdown” in the progression of their myopia.

Hong Kong Polytechnic University and follows up on the two-year study that previously demonstrated children aged eight to 13 wearing its defocus lens had 60% less myopia progression compared with those wearing single-vision lenses. The three-year follow-up study involved 120 children in Asia, comprising 65 from the original MiyoSmart lens group who took part in the previous study and 55 children who moved from a single-vision lens for two years to the MiyoSmart lens in the third year. At the end of the third year, results in the original MiyoSmart group showed that slowing in myopia progression over time was sustained.

Hoya's MiyoSmart lens.

“These findings provided further evidence that D.I.M.S lenses slowed myopia progression and axial elongation in children,” the authors noted. “The optimal age at which treatment should commence is still to be determined and further monitoring is required to ascertain the treatment effect over a longer period. We also plan to follow up on those children who discontinued wearing the D.I.M.S lenses to determine if rebound occurs.” n

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NEWS

VISION EYE INSTITUTE OPENS NEW NSW CLINIC The Vision Eye Institute (VEI) has opened a new clinic on the New South Wales Central Coast, taking its total network to 28 practices.

An initial review of medical standards and clinical management guidelines for driver licensing in Australia has clarified that orthokeratology therapy can be used to meet the standards for a conditional licence. Dr Rushmia Karim, VEI Tuggerah Lakes.

Australia’s largest private provider of ophthalmic care announced in May it had opened the new Tuggerah Lakes clinic under experienced Sydney ophthalmologist Dr Rushmia Karim who specialises in children’s eye health and has a special interest in neuro-ophthalmology. The clinic is VEI’s eighth in NSW, and joins a network with 12 clinics in Victoria, seven in Queensland and one in Adelaide, South Australia. VEI Tuggerah Lakes is located in the Kanwal Medical Complex (within the Wyong Public Hospital medical precinct). It includes a paediatric service and is equipped for ophthalmic consultations, diagnostic testing and minor procedures, while surgical procedures are performed across the road at Tuggerah Lakes Private Hospital. Its services include general eye checks and diagnosis and treatment of conditions such as cataract and lens surgery, general eye health, glaucoma and nerve-related vision problems. The clinic also offers vision correction assessments to assess patients’ suitability for laser eye surgery. Karim, the lead ophthalmologist, is an Australian-trained doctor, who gained her ophthalmology qualifications in the UK and has over a decade of specialist experience. She undertook her ophthalmic training at the highly regarded London ophthalmology vocational program, including Moorfields Eye Hospital. She also completed the Moorfields Eye Hospital fellowship program in paediatrics and squint surgery. Prior to her return to Sydney, she was the head of the Paediatric Eye Service at the Prince Charles Eye Unit at the Royal Berkshire Hospital Trust, Reading, UK. Today, she is also a skilled surgeon, performing cataract, lens and strabismus (squint) surgery in both adults and children. She also diagnoses and treats other eye conditions, including diabetic eye disease, macular degeneration, pterygium and dry eye. n

INSIGHT July 2021

PROPOSED CHANGES TO AUSTRALIAN FITNESS TO DRIVE GUIDELINES

The National Transport Commission (NTC) is currently reviewing the Assessing Fitness to Drive guidelines. The authority’s interim report also sets out the changes to diplopia and commercial licensing. “Specialist advice confirmed that a person is not fit for a commercial licence, either unconditional or conditional, if they have double vision when looking up to 20 degrees from fixation,” the NTC’s Assessing Fitness to Drive 2021 review: interim report states. “If they have double vision when looking beyond 20 degrees of fixation they are still fit for a conditional licence. Diplopia within the central 20 degrees refers to 20 degrees from central fixation and not 20 degrees across fixation. Minor text changes have been made to clarify this point.” During an initial consultation last year, the NTC said it received a request for guidance on the use of orthokeratology lenses to correct visual acuity. The agency said specialist advice was provided. “Orthokeratology lenses are considered

The guidelines may be released in December.

safe to use when driving as long as treatment allows a person to meet the relevant visual acuity standard. Corrective lenses must be worn as per the existing standards if uncorrected visual acuity cannot be achieved through this treatment,” the interim report states. Assessing Fitness to Drive is a joint publication of Austroads and the NTC, detailing the medical standards for driver licensing for use by health professionals and driver licensing authorities. The standards are approved by commonwealth, state and territory transport ministers. The NTC reviews the fitness to drive standard every three years. The most recent review was completed in 2016. The completed revised guidelines are expected to be published later this year in December 2021. n

ZEISS RELEASES NEW EDITION OF FIELD ANALYSER PRIMER Zeiss has released the fifth edition of its popular Field Analyser Primer, titled Excellent Perimetry. Written by perimetry experts Dr Mike Patella, Dr Anders Heijl and Dr Boel Bengtsson, the book is an introductory resource for automated perimetry, with a particular focus on visual field testing using the Humphrey Field Analyser. In the latest edition, the authors have sought to make the book more suitable for use in residency, and optometric training programs. They have expanded the basic principles section (Chapter 2) to briefly teach topics they previously assumed their audience already understood. “We have also expanded the chapter on the use of perimetry in glaucoma management (Chapter 9), providing increased emphasis on practical ways of using perimetric data to address common

Electronic versions are available for Australian eyecare professionals.

and important patient care questions,” they said. “We hope that those additions will also help experienced eye professionals take better advantage of perimetric data in their management of patients with glaucoma.” An electronic version can be ordered free of charge by emailing Zeiss at med.au@ zeiss.com. n

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RESEARCH

ARTIFICIAL RETINA CREATED IN SYDNEY USING A BIOMEDICAL PRINTING PRESS A Sydney researcher has combined industry experience working in sensor technologies and biomedical devices to develop The device is low-cost and printable. a printable device that acts like a retina – with potential to restore sight. Dr Matthew Griffith, from the University of Sydney’s School of Aerospace, Mechanical and Mechatronic Engineering, and the Australian Centre for Microscopy and Microanalysis, has created an electrical device from multicoloured carbon-based semiconductors. It uses absorbed light to fire the neurons that transmit signals from the eyes to the brain, acting as an artificial retina. The device can be printed using the same, low-cost method as newspaper printing, with a high-speed roll-to-roll press. Griffiths said similar technologies are being developed, but his device differs in that it is made of carbon. “Other devices tend to be rigid and usually made of silicon or metal, which can present problems integrating with the human body that is soft and flexible. Our organic device is designed with this issue in mind,” he said. The device is intended to be printed on to soft and flexible surfaces from water-based inks that contain nerve growth factors and then inserted into a patient’s retina.

MDFA PROVIDES $1 MILLION IN GRANTS TO EIGHT PROJECTS Eight Australian researchers are taking their projects to the next level with a share of more than $1 million in research funding from Macular Disease Foundation Australia (MDFA). Australia’s Governor-General Mr David Hurley presented the grants in a ceremony marking a decade of the MDFA Research Grants Program, with this million-dollar investment bringing MDFA’s total commitment to $5.1m since 2011. The latest funding will support projects examining gene therapies, using novel imaging techniques, improving patients’ quality of life, and creating a macula in retinal organoids that could potentially help treat age-related macular degeneration (AMD) and other macular conditions. MDFA awarded six research grants, worth a total of $935,000, to Associate Professor Chi Luu from the Centre for Eye Research Australia, Professor Justine Smith from Flinders University, Associate Professor Matthew Simunovic from the Save Sight Institute at University of Sydney, Ms Diana Tang from Macquarie University, Dr Sheela Kumaran from UNSW and Dr Yvette Wooff from Australian National University. An additional $90,000 through The Grant Family Fund will fund two new early-career researchers undertaking innovative ‘blue sky’ research into macular disease. The

Clinical trials for an eye test that can detect Alzheimer’s disease before it damages the brain could be under way in less than two years, according to world-first research led by Western Sydney University.

Early experiments examined the growth of mice neuronal cells on to the semiconductors in a petri dish, after which the electrical activity of the neurons was tested.

Researchers produced unique antibodies that detect rogue proteins called ‘amyloid beta oligomer’ that accumulate in the retina and have been linked with Alzheimer’s disease.

“Not only did these cells survive – they grew and maintained neural functionality,” Griffith said. “The next step is to control where they grow by printing nanopatterns. This is so in future, we can direct them to grow into specific bodily locations, like a spinal cord or retina.” n

“Scientists have previously known that these rogue proteins accumulate in blood, but this is the first time they’ve been found in the eye before disease manifestation,” research senior author Associate Professor Mourad Tayebi said.

INSIGHT July 2021

recipients were Dr Ting Zhang and Dr Anai Gonzalez Cordero, both from University of Sydney, who are investigating AMD at a cellular level. MDFA CEO Dee Hopkins said the organisation did not expect to finance eight projects, but this round of funding is testament to the depth of talent among young Australian researchers. “This announcement underlines the sheer volume of gifted researchers – particularly early-career researchers – that Australia is producing,” Hopkins said. “All eight of these projects show great promise, but I’m particularly excited by the applications from younger researchers that aim to shift existing paradigms in macular disease research.” Hopkins said MDFA funding often snowballed into larger investments from the NHMRC and other funding bodies. n

EYE TEST TO DETECT ALZHEIMER’S DISEASE DRAWS CLOSER

Once the relevant neurons reconnect to it, the retina will regain lost functionality when stimulated with light. At this stage, Griffith and his team have conducted experiments using neurons from the spinal cord and eyes of mice.

Gene therapies and a retinal organoid program were among the recipients.

“This could lead to a better

Immunohistochemical staining in the brain and retina of three-month-old mice.

understanding of Alzheimer’s disease and new diagnostic approaches which could enable the first routine eye-check for Alzheimer’s disease.” The research was published in Alzheimer’s & Dementia: Diagnosis, Assessment & Disease Monitoring. n

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COMPANY

GLAUKOS PENS NEW DEAL FOR PRESERFLO MICROSHUNT Glaukos has signed a new license agreement with Santen Pharmaceutical for the Preserflo MicroShunt, obtaining exclusive Thomas Burns, Glaukos president. rights for the therapy in Australia, New Zealand and other territories. Under the new agreement, Glaukos – an ophthalmic medical technology and pharmaceutical company focused on novel therapies for glaucoma, corneal disorders and retinal diseases – has obtained commercialisation rights for the MicroShunt in the US, Australia, New Zealand, Canada, Brazil, Mexico and the remainder of Latin America. The device is yet to receive Therapeutic Goods Administration approval. The Preserflo MicroShunt is a late-stage glaucoma treatment performed via an ab-externo approach. The system helps drain eye fluid and reduces intraocular pressure (IOP) in patients with primary open-angle glaucoma whose IOP is not controlled when using maximum tolerated glaucoma medications or where glaucoma progression warrants surgery. It consists of a proprietary, biocompatible material called SIBS [poly(styrene- blockisobutylene-block-styrene)], and is a flexible, 8.5-mm-long tube with planar fins to help fixate the device in the tissue through a micro-incision and prevent leakage and migration. The new agreement also provides Glaukos with full control over all development activities in the specified territories, including all clinical development and regulatory activities in the US following a transition period. Santen, a Japan-based firm, submitted a premarket approval (PMA) application to the US Food and Drug Administration (FDA) in June 2020 and discussions with the FDA remain ongoing. “We believe there is a strong appetite within the global ophthalmic community for the MicroShunt as a more elegant, ab-externo alternative to conventional filtration surgeries for late-stage glaucoma management,” Mr Thomas Burns, Glaukos president and CEO, said. n

INSIGHT July 2021

AUSTRALIAN MARKET CONTRIBUTES TO SAFILO’S POSITIVE Q1 SALES The Australian market has helped contribute towards first quarter (Q1) growth for optical powerhouse Safilo Group compared with the same period in 2020 and 2019. The company’s net sales reached €€251.4 million (AU$396 m) in Q1 2021, up 20% at constant exchange rates compared to Q1 2020, which it described as the first financial quarter to be hit by the outbreak of the COVID-19 pandemic. The company’s Q1 2021 net sales also rose compared to the same quarter of 2019, up 6% at constant exchange rates, which it credited to the “strong performance of the group’s own brands and core licenses, and to the significant contribution of the new brands in the portfolio effectively compensating the licenses terminated at the end of last year". Safilo Group named the US and Australia – which is set to become the company’s new South East Asia and Pacific regional headquarters – among its strongest markets. “The positive sales performance of the period was again largely driven by the United States and by a better-thanexpected contribution from the newly acquired e-commerce business,” a Q1 trading update stated.

Net sales rose 20% at constant exchange rates compared with Q1 2020.

“As anticipated, China, Australia and Middle-East markets were the other strong positive contributors of the quarter, while Europe resulted overall soft as [it is] still penalised by the persisting retail restrictions in a number of markets and distribution channels.” It continued: “The group’s sales in China and Australia confirmed the significant growth trajectory recorded in the second half of 2020, proving the effectiveness of the portfolio strategy the group has been implementing to build a more relevant and sustainable business in APAC.” In Q1 2021, Safilo’s sales in Asia Pacific equalled €13 million (AU$20.5 m), down 10.8% at constant exchange rates and 13% at current exchange rates compared to Q1 2020. n

COOPERVISION SECURES CE MARK FOR ORTHO-K LENS CooperVision’s DreamLite orthokeratology lens has secured European approval for slowing the progression of myopia in children and young adults. It’s the latest CooperVision myopia control product to gain the CE Mark, joining EyeDream and Paragon CRT ortho-k designs, MiSight 1 day soft contact lenses, and SightGlass Vision Diffusion Optics Technology spectacle lenses. The company says it has now built the world’s largest portfolio of evidencebased myopia control interventions, with its DreamLite night lenses used for myopia control with children who have a refraction of -0.75 D to -5.00 D and a cylindrical refraction with a maximum of -2.50 D.

The DreamLite orthokeratology lens.

A two-year study showed DreamLite reduced axial length growth by 63% percent among high myopes compared to the single vision spectacle lens control group – a total reduction of 0.32 mm. The lenses are currently available across Europe, the Middle East, and China.

RESEARCH

HUMAN GENE THERAPY SHOWS PROMISE FOR COMMON FORM OF CONGENITAL BLINDNESS A new gene therapy for one of the most common forms of congenital blindness was safe and improved patients’ vision, according to initial data from a clinical trial led by researchers at the Scheie Eye Institute in the Perelman School of Medicine (PSM) at the University of Pennsylvania. The therapy delivers working copies of GUCY2D to the eyes of patients who have severe vision impairments caused by mutations in the gene. Each of the first three treated patients in the trial experienced improvement in some aspects of vision, without serious side effects, with the new study published in the journal iScience. “We found sustained improvements in both day and night vision, even with a relatively low dose of the gene therapy,” the study’s lead author Dr Samuel Jacobson, a Professor of Insight-July2021-HP-Nova Eye Medical-PRINT2.pdf

Ophthalmology in the PSM said. The researchers said the GUCY2D gene is one of about 25 whose mutations cause problems in the retina, leading to severe vision impairment from birth or early childhood. This family of inherited retinal disorders, collectively known Profs Artur Cideciyan and Samuel Jacobson. as Leber congenital amaurosis (LCA), account for a considerable portion of blindness in children worldwide.

be followed for two years. In the new report, they described their findings after nine months in the first three patients treated.

Further, adults who have lived with the condition for decades can often have many intact light-sensing retinal cells despite their dysfunction, meaning the addition of functional copies of GUCY2D via a gene therapy could get those cells working again and restore some vision.

They said the first patient experienced a substantial increase in light-sensitivity in rod cells, which are more lightsensitive than cone cells and are chiefly responsible for low-light or night vision. This patient also showed improved pupil responses to light. The second showed a smaller but sustained increase in lightsensitivity in rod cells, starting about two months after therapy. The third showed no improvement in rod cell sensitivity, but did show significantly improved visual acuity, an improvement they tied to better function in the patient’s cone cells.

In 2019, Jacobson and co-investigator Mr Artur Cideciyan, a Research Professor of Ophthalmology in the PSM, began the first clinical trial of the GUCY2D gene therapy – initially in one eye per patient to

“These initial results from the first-ever trial of a GUCY2D gene therapy are very encouraging and will inform our ongoing and future trials of this therapy,” Cideciyan said. n

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eople living with diabetes are at risk of experiencing changes to their eyes over their lifetime, including potentially sight-threatening diabetic retinopathy (DR). Of an estimated 1.7 million Australians with diabetes, approximately 25-35% are likely to experience some form of DR – meaning potentially 600,000 Australians are at risk of preventable vision loss. Early detection and treatment are key to preventing DR vision loss. A prime motivation of the KeepSight program is to increase awareness among people with diabetes of the need for regular eye checks, to ensure any retinopathy is detected early. Specsavers Australia and New Zealand director of optometry Dr Ben Ashby says the company is reducing vision loss in people with diabetes by improving timely detection of DR and access to the collaborative eyecare ecosystem, while also using its own data to shed light on patient care within that ecosystem.

With two years of significant data following the journeys of patients with diabetes, Specsavers can identify trends in patient care, estimate the prevalence of DR among its patients, and identify opportunities to enhance care. PREVALENCE OF DIABETIC RETINOPATHY

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Since reporting started in December 2018, 6.4% of all patients seen at Specsavers have diabetes, aligning with currently reported national prevalence rates. Its data also supports government reporting which states the selfreported prevalence of diabetes is higher for males (8.4% of male patients seen at Specsavers) than females (5%).

to diabetic eyecare, ensuring patients with diabetes are reviewed regularly, even after referral, and referred again should the need arise.

Since 2018, 5.5% of patients with diabetes have been referred for specialist management. Of these, 14% had retinopathy classified as minimal (64% of these patients had another referrable condition, such as glaucoma or cataract, at time of referral), 35% (2% of all patients with diabetes) as mild-moderate, 8% (0.4% of all patients with diabetes) as severe and 5% (0.3% of all patients with diabetes) as proliferative DR.

“This can largely be attributed to a shift in the type of care provided during this time. While the total volume of patients with diabetes reduced during this period, the percentage of patients with diabetes presenting was relatively stable,” he says.

This breakdown follows reported relative frequencies of the different levels of DR among patients with diabetes. Interestingly, there is little difference in retinopathy prevalence between patients under 50, and those over 50, though proliferative retinopathy appears slightly more common in younger patients. In comparison with epidemiological studies, Ashby states that data based on optometric referrals will likely always give lower estimates for retinopathy. In line with the RANZCO referral pathway for DR, many patients with less severe retinopathy will be managed by optometrists. These patients will hence not appear in referral data, potentially skewing these numbers lower. In addition, in the past two years, 12.6% of patients referred for diabetic eye disease were referred more than once, with an average 364 days between referrals. Of these patients, 50% were referred with the same level of retinopathy, and 30% were referred with more severe retinopathy. Concerningly, 16% of these patients initially referred with severe nonproliferative diabetic retinopathy (NPDR) were referred again with proliferative retinopathy. Ashby says this speaks to the need for a collaborative approach

INSIGHT July 2021

Ashby adds that it’s interesting to note a defined “spike” in referrals during national COVID-19 restrictions last April.

“The likely inference is that patients at lower risk of retinopathy deferred appointments during this time, skewing attendances towards patients with urgent needs or more severe DR, who are more likely to require referral.” While Ashby says it’s positive to see a significant percentage of patients presenting with DR referred within appropriate timeframes, more work is required to ensure every Australian with diabetes accesses regular eyecare. Diabetes Australia CEO Professor Greg Johnson says diabetes management is time consuming and can be challenging for some people with the disease. “Diabetes is a complex condition and people with diabetes need to have a range of regular health checks and tests to manage their condition. This can place major demands on people’s time and sometimes things get overlooked or put off,” he says. “There are also many people with diabetes who are not aware they need to have their eyes checked. KeepSight is all about making it easier for people to book their regular eye checks. Once a person is registered with KeepSight they receive reminders and prompts when they are due for a check. It’s that simple.” n

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References: 1. Clareon® AutonoMe® Toric Directions for Use. 2. TDOC-0053487. 3. TDOC-0053516. 4. TDOC-0053488. 5. TDOC-0053511. 6. UltraSert CAD_77122679_C nozzle. 7. TDOC-0053803. 8.TDOC-0053579. § PANTONE 85%SSNGs PANTONE Based on aggregate results from in vitro evaluations in February 2017 of haze, and glistenings compared to TECNIS§§ ZCB00 CYAN (JohnsonMAGENTA & Johnson), Vivinex§§BLACK XY-1 (HOYA) and enVista§§ MX60 (B&L; Bausch & Lomb). §§Trademarks are the YELLOW 5405 COOL GREY 10C property of their respective owners. ©2020 Alcon Inc. Alcon Laboratories (Australia) Pty Ltd ABN 88 000740830 Phone: 1800 224 153 Alcon Laboratories New Zealand Auckland, NZBN 9249030206663 Phone: 0800 101 106 ANZ-CLA-1900003 Date of preparation February 2020

CATARACT

BLACK

AND WHITE CASE? SNELLEN

ACUITY AND CATARACT S U R G E R Y

INSIGHT July 2021

Australia’s eyecare profession is clear about how much weight should be given to 6/12 visual acuity when determining a patient’s suitability for cataract surgery, but this is potentially at odds with a new clinical care standard in development. Insight dissects the issue from a clinical perspective.

he contentious role of 6/12 visual acuity or worse as an indication for cataract surgery has been in the spotlight after featuring in an initial version of what is to become Australia’s first Cataract Clinical Care Standard, currently under development. Led by the Australian Commission on Safety and Quality in Health Care, it is being developed in light of a recommendation in the Second Australian Atlas of Healthcare Variation (2017). The Atlas reported sevenfold variation in the rate of MBS-funded services for cataract surgery across 320 local areas, and recommended the development of a clinical care standard to address this variation. The standard’s ultimate goal is to support clinicians and health service organisations to improve their pathways of care and access for people with clinically significant cataract. It also aims to ensure patients with cataract are offered surgery according to their clinical needs, and that they can make an informed choice suitable to their circumstances, in consultation with their healthcare professional. The Cataract Clinical Care Standard was developed in collaboration with a working group of clinicians, researchers and consumers. A public consultation was carried out between February and April in 2019. But it prompted submissions from leading ophthalmic bodies who were particularly concerned about the implications of using 6/12 visual acuity or worse (Snellen chart) as an indication for surgery.

The standard has since been finalised taking into account feedback from the consultation process and recommendations of international evidence-based clinical guidelines, while also weighing up the goals of the standard, and the role of the commission. At the time of writing, the commission wasn’t prepared to say whether 6/12 visual acuity has remained in the final document, which it said would be released shortly. RANZCO confirmed it had been consulted and is aware the standard has not been released in its final form. President Professor Nitin Verma says the college is therefore not able to make specific comments about what might be in the final standard and whether RANZCO will endorse it. With respect to Snellen acuity, which drew opposition from the eyecare sector during the public consultation phase, Verma says RANZCO does not believe that it is the most important factor in determining the threshold for cataract surgery. “Many factors need to be taken into consideration, visual acuity being just one,” he says, adding that RANZCO will make a more detailed statement when the final version of the standard has been released, depending on what it contains. IS 6/12 VISUAL ACUITY A RELIABLE MEASURE?

PROF GERARD SUTTON is concerned a proscriptive standard could create an implication that surgeons will need to justify their surgical decision if a patient has better than 6/12 visual acuity.

At its core, the Cataract Clinical Care Standard aims to address current variation in rates of cataract surgery between the public and private sectors, urban and remote areas, and for Aboriginal and Torres Strait Islander people compared with non-Indigenous Australians. Vision Eye Institute (VEI) consultant and one of Australia’s leading ophthalmic surgeons Professor Gerard Sutton, who is based in Sydney, has a keen interest in equal access to cataract surgery. He says addressing healthcare variation is important and much of the clinical care standards are worthwhile, but the eyecare profession is wary of the standards being too proscriptive. He shared with Insight some of his concerns – held also by the Australian Society of Ophthalmologists and Optometry Australia – about assessing visual acuity when determining a patient’s suitability for cataract surgery. The initial draft of the Cataract Clinical Care Standard proposed a patient is offered cataract surgery when they have a lens opacity that limits their vision-related activities and causes clinically significant visual impairment involving reduced visual acuity of 6/12 or worse, or disabling glare or contrast sensitivity. (Although not explicitly stated in the initial draft standard, the Snellen chart – invented in 1862 by Dutch ophthalmologist Herman Snellen – remains the most widespread technique in clinical practice for measuring monocular and binocular visual acuity.) The problem, Sutton says, is that visual acuity measured on a Snellen chart is “only a measure of high contrast visual acuity” and a patient with a clinically significant cataract can have better than 6/12 visual acuity. This means a patient can fail the proposed standard’s visual acuity threshold, jeopardising their contention for cataract surgery, despite their vision deteriorating to a point where cataract surgery would not only improve their vision but their quality of life too. “There is good evidence to support the theory that if you treat a clinically significant cataract, the flow-on impact, in terms of reduced hip fractures

from falls and so on, means patients can maintain independence,” he says. A statement from the commission on 21 May clarified the standard emphasises that a comprehensive assessment of both objective and subjective factors is undertaken when considering a patient for cataract surgery, to ensure a complete understanding of the impact of cataract on the patient’s quality of life. It went on to state the standard recognises “even with good visual acuity, some people can have disabling visual impairment due to cataract-related glare sensitivity or contrast sensitivity”, and that the impact of visual deficits can vary according to individual needs and a person’s reliance on their vision for work, or for maintaining their independence or quality of life. If this is the case, Sutton questions why 6/12 visual acuity needed to be included in the standard in the first place. He is concerned that if the standard is finalised in its original form, the majority of ophthalmologists in Australia would be considered to be performing outside of clinical care standards because in-practice, they take a more nuanced approach to assessing a patient’s visual acuity (an assertion supported by a recent survey detailed below). “There is an implication that if you don’t have visual acuity less than 6/12, the surgeon will then need to justify their decision to offer cataract surgery. Apart from constricting the surgeon’s medical sovereignty in the decision making it will also potentially allow health funds to start to restrict access. My position is that 6/12 should be out,” he says. Sutton describes the standard in its original form as potentially trying to restrict people having cataract surgery with an arbitrary number. Strong in his convictions about the inadequacies of the Snellen chart in cataract surgery, Sutton and his VEI colleague Mr Chris Hodge surveyed RANZCO Fellows to canvass their views on the use of Snellen acuity – and how much weight it should have in the prioritisation of cataract surgery. The survey results, published in RANZCO’s Eye2Eye magazine and reported by Insight, demonstrated that while 45.9% of respondents agreed Snellen acuity may be considered one part of an assessment to prioritise surgery lists, most (80.4%) indicated 6/12 is not the most important determinant for surgical intervention. “This finding appears to reflect global guidelines which do not place a hard limit on corrected visual acuity prior to undertaking surgery,” Sutton and Hodge reported. “The number of available, validated quality of vision questionnaires has increased in recent years, potentially providing more information on subjective complaints. Although only 8.3% suggested these are used routinely, 41.7% confirmed the use of their own non-standardised questions focussing on patient visual-based limitations in daily life.” VISUAL FUNCTION IN THE REAL WORLD

ASO vice-president DR PETER SUMICH says Snellen acuity does not allow for any nuance or individual variation in the visual requirements of a patient.

In March 2019, the Australian Society of Ophthalmologists (ASO) raised its concerns about the Cataract Clinical Care Standard consultation draft in a letter signed by former president (now vice president) Dr Peter Sumich. ASO’s submission made clear its position on visual acuity: “We believe Snellen acuity does not have a role in the indications for cataract surgery and should be removed from the criteria."

INSIGHT July 2021 25

CATARACT

The ASO denounced Snellen acuity as an outdated measure of visual function and suggested it remains in use because GPs and allied health workers understand it as a notion of vision. “Snellen acuity is only a test of black on white contrast in a dim room at standardised distance which does not equate to visual function in the real world,” it said. “In the real world, patients must function with glare, reflected light, oncoming headlights, dusk and darkness and rainy nights. Low contrast contour detection such as a shallow dip in a grey pavement which denotes a lower ground level can be missed by a cataract patient with the attendant risk of a stumble and fall.” ASO’s submission goes on to state that some patients are asymptomatic and record good Snellen acuity until they drive into the sun and the internal light scatter of the crystalline lens creates a white out. In the above situations, ASO’s submission states Snellen acuity may be better than 6/12 and may indeed be 6/6. In short, Snellen acuity is said to be unreliable and therefore has the potential to be misleading. “Snellen acuity does not allow for any nuance or for any individual variation in the visual requirements of a patient. It is the most basic, non-discriminating way to measure visual acuity. These assessments, these judgements, should be left to the eye professionals who know their patients, not bureaucrats,” Sumich says. Without the support of organisations within the sector at present, Sumich says it’s difficult to comprehend how the standard can be deemed relevant with 6/12 visual acuity. He says the eyecare profession has a unified position on combining modern clinical – and subjective – techniques to assess a patient’s eligibility for cataract surgery. “We know from studies that patients with untreated cataract are eight times more likely to fall, three times more likely to fall and fracture a bone, and have increased rates of depression and social isolation,” Sumich says. He says the standard in its current iteration is not based on medical advice despite the commission appointing experts for the exact purpose of providing said advice. AN OPTOMETRY PERSPECTIVE

Optometry Australia's MR SIMON HANNA says waiting for patient’s visual acuity to be 6/12 or worse can hamper their ability to receive surgery in a timely manner.

acuity is 6/12 or worse means the chances of them losing their driver’s license have sky-rocketed,” he says. “They could be waiting six, 12, 18 months, or two years, depending where they live,” he says. “For some, losing their license during that period can be isolating if they are unable to rely on others – friends or family – to drive them places.” Hanna says OA’s submission cited a study demonstrating that fall rates are higher for people on cataract surgery waiting lists. “The profession needs a cataract clinical care standard but assessing visual acuity to determine eligibility for surgery needs to reflect an individual, case-by-case assessment. It can’t be too proscriptive, it needs to be more open to an eyecare practitioner’s discretion,” he says. CATARACT REFERRAL FORM

Optometry NSW/ACT's MS AUDREY MOLLOY contributed to a Cataract Referral Form that considers the impact on quality of life, driving license status and the number of falls for potential surgery candidates.

In a separate clinical undertaking, the NSW Government’s Agency for Clinical Innovation (ACI) prioritised developing and piloting a cataract surgery referral form for outpatient clinics based on the recommendations from the Increasing Access to Cataract Surgery forum held in August 2018. Ms Audrey Molloy represented Optometry NSW/ACT on the ACI committee in 2019, specifically involved in revising the Cataract Referral Form. Molloy, an optometrist at The Eye Practice in Sydney’s CBD and strategic communications and member liaison at Optometry NSW/ACT, says the cataract referral form does not include any mention of 6/12 (or any other) visual acuity level. “As the form implies, referral for cataract needs to consider aspects of a patient’s vision and quality of life other than visual acuity,” she says. “The form also records the impact on quality of life as well as driving license status and the number of falls the patient may have had over the previous year.” Molloy says there were a large number of stakeholders involved in the discussions, but the outcome was to ensure the form included several criteria for referral in addition to best corrected visual acuity. Importantly, as she points out, ‘best corrected visual acuity’ is not the same as ‘pinhole acuity’ – the latter being measured with the pinhole occluder.

Optometry Australia (OA) also made a submission to the Cataract Clinical Care Standard consultation draft in 2019. Mr Simon Hanna, professional development and clinical policy manager at OA, represented the organisation on the standard’s working group established in 2017, and remains a member. “Our [OA] submission noted support for many elements of the draft standard and primarily raised concerns with the requirement that patients have a visual acuity of 6/12 or worse before they are considered eligible for surgery,” Hanna says. He says waiting for patient’s visual acuity to be 6/12 or worse is effectively putting them “behind the eight-ball” to receive cataract surgery in a timely fashion. “A patient going on to a cataract surgery waiting list when their visual

INSIGHT July 2021

Quoting from Review of Optometry, Molloy notes: “The pinhole occluder works along the same basis as pupil constriction in bright conditions causing an improvement in visual acuity. Through a smaller pupil, the effects of minor ocular irregularities—such as refractive error or paracentral cornea or lens opacities—are diminished.” She adds: “Pinhole acuity is commonly better than best corrected visual acuity as measured by a referring optometrist, yet pinhole acuity is commonly the criterion used during triage for surgery waiting lists at the hospital. This can result in a patient with best corrected visual acuity of 6/15, for example, measuring 6/9 on pinhole acuity and being declined surgery.” The ACI work on the cataract referral form was completed in mid-2019 and Molloy has not been involved since. n

Carl Zeiss Pty Ltd, NSW 2113 AUSTRALIA. Carl Zeiss (NZ) Ltd, AUCKLAND 1026 NZ.

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GLAUCOMA

REACHING NEW DEPTHS MIGS has triggered a shift in the glaucoma paradigm, enabling surgical intervention that bridges the gap between medical management and invasive surgery. While much of the focus has been on stent-based procedures, DR NATHAN KERR says surgeons should be excited by an entirely different approach by Australia’s Nova Eye Medical.

t’s easy to overlook the masterful design and impact of minimally invasive glaucoma surgery (MIGS) procedures available in the modern-day surgeon’s armamentarium.

Available in Australia since 2014, the introduction of such technology has provided an entirely new field of interventional glaucoma therapies, promising better patient outcomes and an enhanced safety profile much earlier in the disease process. MIGS of the trabecular micro-bypass stent variety account for most procedures performed locally today due to their longevity, safety, effectiveness, and greater accessibility through Medicare. But other procedures are beginning to cement their place. The R&D underpinning these microscopic devices that work to improve aqueous outflow is quite remarkable when you consider they are among the smallest human medical implants known. The Glaukos iStent inject W measures about 360 microns in height and diameter, while the larger Ivantis Hydrus Microstent is just the size of an eyelash; each angle, outlet, material and coating of these scaffold-like structures serving a special purpose, along with sophisticated injector systems. Another MIGS procedure featuring high levels of precision engineering – but with an entirely different approach – is the iTrack ab-interno canaloplasty microcatheter by Australian company Nova Eye Medical. At merely 250 microns, the first-of-its-kind system is equivalent to several strands of hair, yet within that it contains an infusion pathway for the delivery of ophthalmic viscosurgical device (OVD) and an illuminated fibre optic tip to keep the surgeon informed of its position.

INSIGHT July 2021

In a delicate balancing act, the system’s internal guide wire is designed to provide just enough rigidity to push past occlusions in the Schlemm’s canal, but also sufficient flexibility to avoid forging a new pathway into the collector channels or suprachoroidal space. And the system is capable of providing tactile feedback on the patency of the canal which, when combined with the ability to adjust the volume of OVD delivered, enables the surgeon to customise OVD delivery on an individual patient basis and thus optimise clinical outcomes. Every element has been meticulously designed so that it impacts on all points of resistance in the trabecular meshwork, Schlemm’s canal and the collector channels via a two-step process of catheterisation, followed by pressurised viscodilation. Leading glaucoma surgeon Dr Nathan Kerr is among a handful of ophthalmologists performing iTrack in Australia. He believes the system’s ability to address all potential points of blockage in the conventional outflow pathway makes it one of the most comprehensive MIGS procedure available. He hopes it will be more widely available to Australian surgeons soon. “While safe and effective, stent procedures treat a focal area of the drainage system, and tend to only address upstream, more proximal areas of blockage, and don’t always address the downstream collector channels,” he explains. “But the iTrack goes further by treating the entire drainage system, including all three areas of resistance to aqueous outflow. Not only addressing the trabecular meshwork, iTrack treats the entire 360 degrees of Schlemm’s canal, helping to dilate it and break herniations. It also features pressurised viscodilation, which helps dilate Schlemm’s canal, as well as the distal downstream collector channels which we think are important in glaucoma.” ITRACK IN AUSTRALIA iTrack’s mechanism of action has been built on the pioneering work of Professor Robert Stegmann (South Africa) and Dr Murray Johnstone (US) more than two decades ago. It was eventually cleared by the US Food and Drug Administration in 2008, and originally performed via an ab-externo approach. Later, through a process of physician-led refinement, it became the ab-interno procedure it remains today. iTrack came to be Australian-owned after Adelaide company Ellex Medical Lasers acquired it from US-based iScience Interventional in 2014. The

company trades today as glaucoma-focussed Nova Eye Medical, following divesture of the Ellex laser and ultrasound business last year.

1999

Despite being an Australia-owned platform, iTrack has had limited uptake among local surgeons compared to counterparts in the US, Europe and Asia where it is routinely deployed.

Professor Robert Stegmann (Chairman of Ophthalmology, Medical University of South Africa) publishes seminal investigations for viscanalostomy, demonstrating dilation of Schlemm’s canal and clearance of the collector channels.

Although it has the relevant regulatory approvals, the company believes this is partly due to a lack of reimbursement available for its system in Australia. But there is now a concerted effort to change this. Its current focus is a Medicare Services Advisory Committee (MSAC) application regarding item number 42504. This current item for standalone MIGS only mentions trabecular micro-bypass stent surgery in its descriptor, excluding Nova Eye’s microcatheter technology. Its application to alter the wording has reached the third and final stage of the MSAC process, and has the support of the Australian and New Zealand Glaucoma Society (ANZGS), Glaucoma Australia and The Australian Society of Ophthalmologists (ASO). According to Nova Eye, the iTrack canaloplasty microcatheter meets the requirements of the combined-cataract surgery item 42705 – although this item number is also currently under MSAC review, with a view to harmonising its nomenclature in relation to item number 42504. Kerr remains hopeful of public funding for iTrack so Australians can access what he describes as a world-leading therapy by a homegrown company. “To me, there are no clinical limitations. It’s an effective procedure, it can be done with or without cataract surgery, and can be performed across all stages of the disease spectrum from mild, moderate to severe glaucoma,” he says. “For surgeons who are comfortable with the skill of intraoperative gonioscopy and implanting a stent, inserting a catheter is a very similar skill with a manageable learning curve. It’s also great you have 100% certainty that you’re treating the target tissue because of the illuminated tip, whereas it can be challenging at times to ensure stents are correctly placed in Schlemm’s canal.” After completing MIGS training under the world-renown ophthalmic surgeon Mr Keith Barton at Moorfields Eye Hospital in 2016, Kerr himself has performed thousands of cataract and stent-based procedures. He began implanting iTrack this year and, along with Sydney glaucoma specialist Dr Jason Cheng, is gathering data on the degree of intraocular pressure (IOP) reduction, speed of recovery and subsequent medication dependence. He says while stent procedures are safe and effective, he’s found iTrack features other capabilities that are appealing to glaucoma surgeons. Chief among those is safety. As an implant-free, complete tissue-sparing procedure, he says iTrack has demonstrated minimal endothelial cell loss (ECL). It’s an important issue that cataract and glaucoma surgeons are acutely aware of after

2002

Dr Murray Johnstone publishes first systematic in vitro examination of the histologic effects of viscodilation of Schlemm’s canal, relative to untreated controls.

Dr Nathan Kerr, glaucoma surgeon, Eye Surgery Associates and Centre for Eye Research Australia.

Alcon voluntarily withdrew its CyPass MicroStent – the first supraciliary stent – in 2018 due to ECL rates after five years. “As cataract surgeons we are particularly careful of corneal safety and minimising endothelial cell damage. While the stent procedures are safe, I think the iTrack gives you the highest level of endothelial cell safety because there is no stent left behind,” he says. “A theory for ECL focuses on aqueous preferentially draining to one focal point, and that is one of the reasons we think traditional procedures like trabeculectomy and tube surgery can have high rates of endothelial cell loss. Potentially that could hold true for stents. Because the iTrack increases outflow over 360°, there is no preferential outflow. Preliminary interim 12-month data show iTrack has some of the lowest rates of ECL – under 5% – which is similar to cataract surgery alone. This is important, particularly as we treat younger patients and those who do not have cataracts.” While MIGS procedures, in general, defer the need for more invasive procedures like trabeculectomy and tube shunts, Kerr says the restorative, non-destructive nature of iTrack also helps preserve the angle and conjunctiva for future treatments if required. “It allows all potential trabecular meshwork treatment options, including selective laser trabeculoplasty, a trabecular bypass stent, or a repeat procedure with iTrack. It also keeps open the opportunity for filtration procedures like XEN, Preserflo, or trabeculectomy in the future, so it’s really nice that you aren’t removing or damaging any of the trabecular meshwork or conjunctiva,” he says. IOP REDUCTION Alongside the safety profile, IOP reduction and medication dependence are the other key

2004

Canaloplasty is cleared by the US FDA for glaucoma.

2004

Development of prototype iTrack canaloplasty microcatheter. Data presented at the 2004 Annual Glaucoma Society meeting demonstrates increased diameter of Schlemm’s canal from 150 to 300 microns.

2008

The first generation iTrack is launched by iScience Interventional.

2011

Dr Richard Lewis et al publish prospective, three-year, multi-centre ab-externo canaloplasty data with iTrack.

2014

Nova Eye Medical (formerly Ellex Medical Lasers) acquires iTrack technology portfolio from iScience Interventional.

2015

In a world first, canaloplasty is performed via an ab-interno approach with iTrack (Dr Mahmoud Khaimi, Dean McGee Eye Institute, University of Oklahoma).

2021

Nova Eye Medical commences “MAGIC” prospective, multi-centre ab-interno canaloplasty trial with the iTrack canaloplasty microcatheter.

INSIGHT July 2021 29

GLAUCOMA

performance indicators glaucoma surgeons look for in MIGS procedures. Although it’s never been tested in a head-to-head study, Kerr says iTrack offers substantial IOP reduction rates comparable to stent procedures. In recent 24-month peer-reviewed data, published in Clinical Ophthalmology by US surgeon Dr Mark Gallardo, of El Paso Eye Surgeons, iTrack demonstrated a significant and stable reduction in IOP of more than 30% from baseline in both the iTrack-alone and iTrack+phaco (combined cataract) groups at 24 months. In iTrack-alone, IOP reduced by 34% from 21.6±5.7 mmHg to 13.8±3.1mmHg. Patients in the iTrack+phaco group achieved a similar IOP reduction, with the mean falling by 31% from 19.8±3.9 mmHg at baseline to 13.2±2.1 mmHg at the 24-month visit (P=0.512). There were similar reductions in mean IOP at the 24-month mark for cases of mild-to-moderate and severe glaucoma at 33% and 34%, respectively. Dr Nathan Kerr performing the iTrack procedure. The red illuminated fibre optic tip can be seen at eight o'clock in the Schlemm's canal.

The reduction in medication use was also statistically significant in both groups at 24 months, decreasing from 3.0±0.7 to 2.1±1.3 in the iTrack-alone group, and from 2.5±1.1 to 1.3±1.2 in the iTrack+phaco group (P<0.001).

WHAT’S ON THE HORIZON?

Professor Maya Müller and colleagues in Germany recently published 24-month data showing not only did iTrack achieve a reduction in mean IOP from 20.24 ± 5.92 mmHg (n = 25) at baseline to 13.67 ± 2.15 mmHg (n = 21, p < 0.001), it also reduced glaucoma medication usage from 1.92 ± 1.04 medications at baseline to 0.05 ± 0.23 medications at 24 months – with 80% medication-free at the 24-month follow-up.

Looking ahead, Kerr believes MIGS technology will continue to evolve, with real-time IOP sensor monitoring and drug release capabilities as potential next steps. He also expects the return of interventions that target the supraciliary route. For Nova Eye, it recently revealed its R&D team is developing a next generation iTrack system, aimed at improving ease of use for surgeons.

“Patients really do enjoy being medication-free,” Kerr says. “Some are no longer having to put in multiple drops, multiple times during the day, their eyes feel more comfortable and they can see better if they’ve had MIGS with their cataract surgery.”

Although further details of this program are firmly under wraps, it stated the iTrack design provides significant scope to broaden its clinical applications. What capabilities future iTrack models will harbour, only time will tell. n

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PRACTICE MANAGEMENT

SOLVING THE PRACTICE MANAGEMENT Experienced practice managers share their hard-won wisdom and practical tips on how to work smarter, not harder, across both optometry and ophthalmology practices.

unning a healthcare practice has its own set of challenges, and in the eyecare profession, subspecialities and specific equipment bring extra layers of complexity to the practice and patient management spectrum. Insight spoke with four experienced practice and business managers who have each carved a niche in different environments, from independent optometry, to ophthalmology and general practice. Some common threads stand out, including making decisions about practice management software based on meticulous research and cost-benefit analysis, and the importance of reliable support from the software provider. Changing ownership of software solutions and constant upgrades are unavoidable, and therein lies the paradox, as one practice manager has pointed out. They were considering changing their software system a few years ago to an improved version of an existing program, but, in their own words, “so many people flocked to it that support went down the tube”. As systems become more sophisticated and better integrated, they can help improve efficiencies, and reduce double-handling and human error. Our experts discuss new technology in their practices, and the importance of anticipating trends, from incorporating artificial intelligence and automation, to what patients expect as standard.

INSIGHT July 2021 31

PRACTICE MANAGEMENT

REVIEW AND REFLECT Mr Don Granger is, by his own admission, a numbers man.

customer relationship management (CRM) and supply chain, to name a few,” Kangisser says.

As general manager of Rolfe Optometry Group (part of Eyecare Plus) he draws on two skill sets to manage a network of independent practices in New South Wales; a background in accounting and business banking, and more than two decades’ experience in the optometry profession.

“All platforms should have a solid Service Level Agreement (SLA) and be focused on data security, upgrades linked to customer expectation and maintenance to keep their product as a leader. Consider what is important to you and go from there.”

He joined optometrist Dale Rolfe’s 10-practice network four years ago. Prior to that, Granger worked for optometrist Dr Tony Hanks for 17 years, before Hanks sold his business to George & Matilda Eyecare.

Kangisser has worked across The Optical Company, a group specialising in optometry services, retail and eyewear distribution with a portfolio of more than 40 practices for over 10 years, and says researching software is essential.

Rolfe Optometry Group, which currently employs 50 staff, has recently undergone changes at ground level which has impacted Granger’s day-today number-crunching. “We had 15 practices 18 months ago, but we amalgamated four, and closed one – their growth didn’t warrant the effort. This was a pre-COVID business decision enacted during COVID. We wanted to make fewer, but larger, practices perform better. Contract for strength. Now we’re on the lookout for new opportunities for growth,” Granger says. Measuring is key to practice management success, he says, but notes that the time and skill involved can be challenging for single-practice owner-optometrists. “I’m from an accounting background. I’m all about numbers; weekly numbers, monthly numbers, all measured, compared and evaluated against our KPIs,” Granger says. “Measuring regularly is key – you can see what you’ve done well, see what you can do better. You can review and reflect, compare year-on-year. Others act on historic data, but by then it’s 12 months too late. Some don’t have the luxury of analysing their numbers on a regular basis.” Financial figures aside, Granger measures patient communication too, looking at which platforms patients are using to make bookings, and whether those patients are new or returning. “In the past, we didn’t do online appointments, but we do now through MyHealth1st. I get to see results of online bookings and they’re growing. We’re seeing uptake among our over-60 patient population. Surprisingly, online bookings are utilised more by our existing patients than new patients, at a ratio of about 2:1. It seems our existing patients like the benefit or luxury of booking that way,” he says. While SMS is also a popular mode of communicating with patients, especially for patient recall, Granger says his data shows email communication is hit-and-miss. “Patients are reluctant to provide an email address because they don’t want to be bombarded with crap. We really only get about 20% of our patients prepared to give us their email address. They don’t read email. It is under-utilised but I don’t know how to get around it,” he says. Commensurate with his years in the industry, Granger is well-acquainted with the two main local practice management software systems in optometry; Sunix, now owned by Essilor Australia, and Optomate, now owned by VSP Australia. Both systems have their shortcomings, he says. “I think there’s a spot in the market for an improved optical practice management system,” he says. When Insight spoke with Granger, he was dealing with an IT issue at one of the 10 practices he manages spread across the Mid North Coast, Hunter region and Central Coast. As many practice managers can attest, bugs, corrupted data, and system outages can be par for the course of practice management software, which makes access to reliable support inherently invaluable. Mr Aaron Kangisser, general manager at The Optical Company (now part of Healthia), advises optometry practice owners to be aware of the pros and cons when investing in practice management systems. “Not all practice management systems are created equal. Each can have its strengths across reporting, user experience, customer profiles,

INSIGHT July 2021

“Within any industry, research is paramount to identify the right platform that provides for today and into the future – plus recognising the platforms that are widely used to determine those with the best horizon support,” he says. “Many people have experienced that a fully-bespoke option, whilst customised to needs, often results in platforms that are resource-heavy for changes and training.” He adds: “There will always be changes, however a platform with flexibility and support of a development team to update and evolve to keep their product relevant offers businesses a strong foundation and potential for growth.”

"I’M ABOUT NUMBERS; WEEKLY NUMBERS, MONTHLY NUMBERS, ALL MEASURED, COMPARED AND EVALUATED AGAINST OUR KPIS." DON GRANGER ROLFE OPTOMETRY GROUP

Optometry practices know too well the perils of system upgrades – an upgrade was the root cause of the IT crash Granger mentioned earlier – but Kangisser has some tips to manage this and minimise business disruption. “Many changes occur as part of cycled updates that are designed to address or fix issues and scheduling these upgrades to occur overnight so as not to impact trade is important,” Kangisser says. “Major upgrades where there is downtime always comes with risk but having the ability to identify impacts and pause to continue business whilst solutions are identified for minimal impact is always a preferred approach.” Kangisser says this involves practice platform partners working cohesively with IT, operations and finance teams so the technical, people and customer elements are factored into the planning, but also remaining nimble as the plan is carried out. “Ultimately the end result should be to benefit businesses and the customer-facing teams in stores being empowered by the changes that are designed to streamline activity,” he notes. Through their industry experience spanning many years, Granger and Kangisser also know the value of timely support and service from software providers. Again, Kangisser says research is paramount. “Identifying the right partner is very important as you have to be able to have both business-as-usual and business-critical discussions, so it’s important to approach any partner selection acknowledging this will always be the case,” he says.

“Partners establish their level of service based on your needs and capacity, but good partners also understand there will be periods of increased service as platforms update; partners scale; and expectations for data shift.” To maximise efficiencies, The Optical Company has integrated its systems. “We have actively integrated the people and product elements working closely and effectively with our PMS provider, so that the practice management platform plays a role as a pivotal business tool. Allowing for levels of access also ensures security and confidentiality are maintained and ultimately accuracy and integrity in the data,” Kangisser explains. DON’T GET SIDE-TRACKED BY SOFTWARE Practice manager Ms Lara Sullivan established Bayside Eye Specialists with her husband, Dr Laurence Sullivan, in 2006 employing a part-time orthoptist and part-time receptionist. Today, she manages 17 staff and the practice supports 10 ophthalmologists. Sullivan has renovated the Melbourne clinic three times in those 15 years to accommodate for growth and has employed two more staff since the start of 2021 to cope with a post-COVID influx of patients, and more complex diseases arising from treatment delayed because of the pandemic. A qualified nurse with a background in human resources, she is a member of RANZCO’s Practice Management Committee and is also a member of the Australian Association of Practice Management (AAPM), a not-for-profit, national peak association supporting effective practice management in the healthcare profession. Sullivan participated in AAPM peer-support meetings on Zoom during Insight-July2021-HP-Nova Eye Medical-PRINT.pdf

3/6/21

"IDENTIFYING THE RIGHT PARTNER IS VERY IMPORTANT AS YOU HAVE TO BE ABLE TO HAVE BOTH BUSINESS-AS-USUAL AND BUSINESS-CRITICAL DISCUSSIONS." AARON KANGISSER THE OPTICAL COMPANY COVID and reads practice management journals and magazines for important updates on pharmaceutical drugs and Medicare item numbers that need to be reflected in practice management systems. “I try to be in the loop as much as possible and be on the front foot. I like to be informed so I can make the best decisions. I’m always trying to find efficiencies and reduce double-handling. No two days are the same in our clinic, and as practice manager, I need to be across everything,” Sullivan says. “At Bayside, we have a range of subspecialties – glaucoma, cornea, medical and surgical retina, oculoplastics, strabismus and of course, cataract. Each specialty has their different requirements. We work on a four-week roster, in line with The Royal Victorian Eye and Ear Hospital, and our 10 specialists are supported by staff spread across three teams.”

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PRACTICE MANAGEMENT

In addition to five receptionists, seven orthoptists and a theatre-booking team, Sullivan also manages two typists off-site who transcribe letters dictated by the clinic’s ophthalmologists. Each team uses different software, and each software program charges a service fee. Sullivan’s top-line advice for efficient practice management is to ensure practitioners are seeing patients efficiently, and aren’t side-tracked by their other interests. “For example, if your software crashes, practitioners need to be seeing patients, not trying to fix IT.” “Practitioners’ time is best spent seeing patients. It’s really important to get practitioners – be it an ophthalmologist or optometrist – focusing on core competencies. Don’t use their time on tasks not generating income, or not seeing patients,” she says. When Sullivan established the clinic, she researched the available practice management software and concluded Zedmed was the best at the time. “There are a few different software programs on the market including Zedmed, Best Practice, VIP, and some clinics use Genie Solutions, Clinic to Cloud or MedicalDirector. They all have their pros and cons. We use Zedmed because I thought they were the best 15 years ago, and we’ve made it work for us. Most upgrades introduce bugs. I try not to be an early adopter. Once you’ve invested in a software it’s difficult to move, not just because of the financial investment but in doctor and staff training too. It’s essential to have excellent and instant IT support. We are very happy with Vibe. Prior to working with them we spent a huge amount of time chasing a ‘proper’ fix for any issues,” Sullivan says. To communicate electronically with GP’s, Bayside Eye Specialists uses Argus and GoFax, while Oculo helps to communicate with optometrists. “There are other software programs available, such as HealthShare, but each charges a service fee. Most GPs in our catchment area use Argus, so we went with them," Sullivan says. “We are heavily Zeiss oriented with our equipment so we also have Forum, which is helpful when counselling patients. We use Quickbooks for accounting, and KeyPay for rostering and for staff to clock in and out. We also use HotDoc to send SMS reminders to patients, and the patient registration details to be completed by new patients. My end-of-month reports are drawn from a number of softwares,” she says. Before installing and providing training on new equipment or software, Sullivan recommends doing a cost-benefit analysis. “Consider if the investment will be time-saving, how frequently it will be used, and, in the case of equipment, does it correspond with an MBS item number.” Sullivan says all ophthalmology practice management systems integrate with Medicare and health funds, although Bayside staff still must individually call the health fund of every patient to ensure they’re covered for the relevant surgery or procedure. More recently, the clinic has adopted e-prescribing technology as part of its aim to streamline processes and reduce paper. “This technology was fast-tracked in Victoria because of COVID. We’re using eRx Script Exchange. If, for example, a patient requires cataract surgery, our ophthalmologists can generate a theatre booking and simultaneously generate a pre-operative prescription in Zedmed,” she explains. “The software then sends a QR code script directly and immediately to the patient’s phone, which the patient can then take to a pharmacy. It saves the cost of printing scripts, postage costs of stamp and envelope to mail a prescription, and saves time going through Australia Post. It streamlines double-handling and reduces human error.” INTEGRATION OF SYSTEMS Practice manager Ms Kylie Payne met Sullivan last year when Payne was hosting weekly networking meetings for practice managers on Zoom during

INSIGHT July 2021

Experts state it is better to implement practice management systems for success, rather than react to change as this can create uncertainty for staff.

"A PRACTICE MANAGER IS NO DIFFERENT TO THE CEO OR GENERAL MANAGER OF ANY OTHER BUSINESS." KYLIE PAYNE AAPM VICTORIA

COVID in her role as state president of AAPM’s Victorian committee. Payne is business owner of Interconnect Healthcare, a Victorianbased organisation supporting healthcare businesses, owns Kerrie Road Family Medical Centre in Glen Waverley, and manages three other clinical practices. Despite her medical background, Payne believes practice management, regardless of speciality, has the same fundamental principles that managers need to be across. “At a practice management level, you need to have great communication with directors and owners, and clear budgets and targets so everyone is on the same page,” she says. “A practice manager is no different to the CEO or general manager of any other business; you’re responsible for building maintenance, IT and software, payroll, managing clinicians and staff – it’s a balancing act.” Payne shares the same views as Sullivan in terms of software selection. She speaks from experience, having gone through the process of evaluating key products on the market to replace a practice management system which had been in place for 20 years. “Once you’ve got a patient management system, try not to change it if you don’t have to. It’s a big investment in cost and time to re-train staff – accounts, admin, clinicians – it’s really challenging. No software program is perfect. You need to find ways to work around what’s not 100%.” Payne uses Best Practice and HealthLink, a secure messaging service

that exchanges private patient information between different healthcare providers and their software systems. She also utilises HealthShare, a free, up-to-date directory of Australian private practising specialists and allied practitioners, which is also integrated with Best Practice, and HotDoc to manage online bookings, and patient reminders and recalls. “The IT-space is such a huge area of practice management; every area uses a different platform. It’s getting more specific,” she says. Payne is also operating e-prescription technology through the practices she manages, integrated with the practice management software. “Best Practice and eRx Script Exchange are integrated. Although this technology (eRx Script Exchange) was fast-tracked as a result of COVID, it’s not without controversy," Payne says. "Software vendors are planning to introduce a cost to the practice per script. This was going to be introduced early this year but has been pushed back to later in the year. It threatens to be a significant increase in operating costs, especially for smaller clinics, for what was previously a cost-neutral task." As part of Fast Track ePrescribing, there are two options to send eScripts to patients; SMS and email. There is no charge for email messages, however, during Fast Track ePrescribing, the Department of Health is covering the cost of eScript SMS messages. Once full conformance is achieved, the Department of Health will cease funding eScript SMS messages. While optometry practices don’t have a need for e-prescription software to directly send patients QR-code scripts, Kangisser –

"ONCE YOU’VE INVESTED IN A SOFTWARE IT’S DIFFICULT TO MOVE, NOT JUST BECAUSE OF THE FINANCIAL INVESTMENT BUT IN DOCTOR AND STAFF TRAINING TOO." LARA SULLIVAN BAYSIDE EYE SPECIALISTS The Optical Company’s general manager – says changes in practice and patient management are constantly on the horizon. “There are always changes based on the need of customers; efficiency in practice; and expectations based on categories outside optometry for what customers will come to see as standard, regardless of industry,” Kangisser says. “Automation of processes to ease administration and keep a level of consistency have only been aided by the increased digitisation of everyday lives. It’s important to also adapt changes based on your customer and capacity. It’s always better to implement for success than just be reactive to every change as that creates uncertainty for the people utilising the system daily, plus increases risk of a great addition being overpromised and under-delivered to the customer.” n

ANNIVERSARY

From the humble optician's lathe in 1900 (below left), to achieving a breakthrough in extreme ultraviolet lithography for chip production, Zeiss has a rich history across many sectors.

175 YEARS OF ZEISS From pioneering surgical microscopes and slit lamps, to a precision spectacle lens featuring point-focal imagery, Zeiss has an incredibly rich history in optics and ophthalmology. Insight traces its story from a modest workshop in Germany to global tech company.

n 17 November 1846, German entrepreneur Carl Zeiss opened a small workshop in the German city of Jena where he worked on precision mechanics and optics. Through a process of trial and error, he kickstarted an innovative journey towards the global technology company bearing his name today – 175 years on – generating an annual revenue of €6.3 billion (AU$9.8 b).

successful – attempts to challenge the limits of what is physically and technically feasible,” he says.

In the initial years that followed the opening of his workshop, Zeiss designed, built and repaired physical instruments before producing simple microscopes in 1847, leading to compound microscopes 10 years later. However, it was an alliance with physicist and mathematician Ernst Abbe from the mid-1860s that proved pivotal in transforming the small enterprise into a fully-fledged company with a heavy focus on scientific development.

Today, Zeiss is a global leading technology company operating in the optical and optoelectronic industries. It is divided into four segments: semiconductor manufacturing technology (SMT), industrial quality and research (IQR), medical technology (ophthalmic devices and microsurgery) and consumer markets (vision care).

But science never progresses in a linear fashion, and the same can be said for the Zeiss Group. The German firm wasn’t immune to the consequences of two world wars, which split the company until the fall of the Berlin wall. But these troubled times have been offset by achievements such as involvement in the first moon landing, helping scientists win Nobel prizes, and innovations like the surgical microscope, slit lamp and other gold standard ophthalmic equipment such as optical biometry and OCT. Reflecting on the company’s history, current president and CEO Dr Karl Lamprecht says it has been unique and rather turbulent. “Its many technological milestones attest to its repeated – and

INSIGHT July 2021

“This unique innovative spirit has imbued the company with real staying power while helping both us and our customers to be successful.” ZEISS IN AUSTRALIA

The company employs more than 34,000 people in almost 50 countries. As it celebrates 175 years since inception, 2021 also marks the 60th year of operations in Australia. In 1961, the first German Zeiss employee ventured to Australia and set up in Sydney. After successes in its then core businesses of research microscopy, spectacle lenses, surgical microscopes and photogramy, Zeiss expanded to New Zealand in 1978. In 2005, it then acquired SOLA Optical, an international ophthalmic lens manufacturing giant, which had major operations in South Australia. Today, the ANZ Zeiss business is headquartered in Sydney and provides customer support and services through six facilities across Australia and New Zealand.

Around four years ago, the Adelaide laboratory relocated from Lonsdale to a new $6 million premises at Tonsley Innovation District where it has invested in technology like dry-edging with Computerised Numerical Control (CNC). The facility also houses the international headquarters of Zeiss’ customer enablement business. The group provides tailored business and technology solutions to various international markets and supports a global network of prescription laboratories ranging from retail giants to individual eyecare providers. Tonsley is a key site in Zeiss Vision Care’s global technology and innovation department network and busies itself with developing new products and processes for the optical market. “Zeiss employees tend to have a long tenure,” says Mr Joe Redner who is one of only five local managing directors since 1961. “In ANZ, the company has 290 employees and operates in the medical, vision care and industrial quality and research fields. One of our team has been with us for 46 years and is a son of a career-long Zeiss employee from our corporate headquarters in Oberkochen, Germany.” When the company first arrived in Australia, its portfolio consisted of research and surgical microscopes, spectacle lenses and movie projectors. That’s now expanded through products in ophthalmic diagnostics, intraocular lenses and software, among others. “In ANZ, Zeiss has a very strong presence in eyecare,” Redner says. “Approximately 75% of all cataract surgery involves the use of a Zeiss device, whether for diagnosing (slit lamps), planning (biometry, EQ Workplace), visualising (microscopes) or treating (IOLs) the disease. Bringing information together to improve workflows and outcomes is central to our strategy.” He believes Australia is a dynamic market for multinational firms, with its forward-looking approach to research and technology adoption. “It also offers an opportunity in that it’s a good sandbox for companies to try new things and deploy best practices to other markets,” Redner adds. INNOVATION IN THE BLOOD In the 1860s – two decades after establishing his workshop – Carl Zeiss’ collaboration with Abbe was catalyst for setting the company on the path towards becoming a major global firm. He worked with Abbe to produce objective lenses on the basis of mathematical calculations. Abbe was originally a private lecturer at Jena University before becoming Zeiss’ “ingenious” business partner. And in 1873, Abbe developed his eponymous formula to limit the optical resolution in a microscope. Since the 1890s, Abbe’s findings and his style of working have been adopted in other fields of optics, leading to the creation of all-new products, new business areas and rapid growth for the company. Another pivotal character in the company’s development was Jenabased glass chemist Otto Schott – the founder of today’s Schott AG, a manufacturer of high-tech materials for specialty glass that became Zeiss’ sister company. Schott produced glass that offered new optical properties and in 1879 sent a sample to Abbe, which led to a fruitful collaboration. As a result, Glaswerk Schott & Genossen commenced factory operations in September 1884. The quality of the optical glass ultimately made it possible for the benefits of Abbe’s theory to be fully implemented in Zeiss instruments. It proved a pioneering stroke of genius to marry scientific research with entrepreneurial acumen, paving the way for further technological innovations. MORE TECHNOLOGICAL MILESTONES Many years later, in 1969, the Zeiss brand was involved in documenting what remains one of humankind’s greatest feats – the moon landing. An image of a footprint became a symbol of the event, which was

captured by Zeiss camera lenses specially developed for space. The lenses used during the mission formed the nucleus for the lenses that would be developed for optical lithography. Elsewhere, several Nobel Prize winners have worked with Zeiss microscopes, including Robert Koch, the man who discovered tuberculosis, and Christiane NüssleinVolhard, who conducts research into genetic control in embryo development. From 1900 onward, Swedish ophthalmologist Dr Allvar Gullstrand worked with Moritz von Rohr, head of development at Zeiss, which culminated in two milestones that continue to shape ophthalmology today.

Carl Zeiss, circa 1850.

Gullstrand’s research into the optical characteristics of the eye earned him a Nobel Prize in 1911 for his work in dioptrics. Eventually, his eye model and the determining of the eye’s centre of rotation – as well as the jointly developed measuring and examination instruments – combined with von Rohr’s applications of these findings for eyeglass lens calculations, led to the first slit lamp, which Zeiss launched in 1912. Another product of their work was Punktal, the world’s first precision eyeglass lens featuring point-focal imagery delivered razor-sharp vision into the corners and for the moving eye. Meanwhile, Zeiss also manufactures products that contribute to medical progress. The optical system for the very first slit lamp also formed the basis for the development of the OPMI 1, which was launched in 1953 and is considered the progenitor of modern surgical microscopes. To this day, the company is influencing ophthalmology, through innovative technologies and application-oriented solutions, with recent innovations including the Artevo 800 – the first ophthalmic digital microscope – and Forum ophthalmic data management software designed to improve practice workflow. In microsurgery, recently launched products include the Kinevo 900 for spine and neurosurgery. Comprising more than 100 innovations and 180 patents, the system marries robotics, digital visualisation and modern assistance solutions. A FOUNDATION-OWNED COMPANY Following Carl Zeiss’ death, Abbe established the Carl Zeiss Foundation in 1889, which remains one of Germany’s largest and oldest private foundations for the promotion of science. Today, the foundation is the sole shareholder of Carl Zeiss AG and the Schott AG glass company, making for a unique ownership structure. After publishing its statutes in 1896, Abbe defined how both entities would be managed and their profits used, with its main duty to permanently secure the future of the two foundation companies and advance science.

INSIGHT July 2021 37

ANNIVERSARY

Interestingly, the foundation is prohibited from selling its shares in the two companies – this is explicitly stipulated in its statutes. And Zeiss and Schott use the dividends to promote science and teaching in the fields of mathematics, computer science, the natural sciences and technology. Support is given to projects and individuals in the German federal states of Baden-Württemberg, Rhineland-Palatinate and Thuringia, where the foundation and the foundation companies are based. Redner says another key goal of the Carl Zeiss Foundation is to promote charitable interests, which the company does locally through major donations such as an IOLMaster 700 to the Indigenous Diabetes Eyes and Screening (IDEAS) Van, and $1.5 million in new and refurbished equipment to the Northwest Eye Hub in Broome. It also recently funded Papua New Guinea’s first neurosurgeon to travel to Paris for skills training. DIVISION AND REUNIFICATION Zeiss has trod a turbulent path in unison with its German homeland, with the most notable events being both world wars. In the aftermath of the second world war, Germany formally split into two independent nations: West Germany, allied to the Western democracies, and East Germany, allied to the Soviet Union. The company was subsequently divided into what would later become the combined VEB Carl Zeiss Jena and Carl Zeiss West Germany. This all began when American troops took 77 selected employees from the Zeiss plant in Jena to Heidenheim in southern Germany. In 1946, Opton Optische Werke Oberkochen GmbH was founded as a subsidiary of the Carl Zeiss Foundation. The companies in Jena (East Germany) and Oberkochen (West Germany) continued to work closely together until 1953. But starting in spring that year, Carl Zeiss in Oberkochen and VEB Carl Zeiss Jena began to go their separate ways. The companies subsequently operated independently, in a divided Germany, and developed in different ways. That all changed with German reunification in 1989 and 1990, an event which the company believes underscored how important it was for Zeiss in the east and west to once more grow as one. Following a lengthy process, both were then rejoined to form a single entity. GLOBAL GROWTH AND INTERNATIONALISATION The opening of the first subsidiary in London in 1893 paved the way toward internationalisation, triggering a raft of new global locations, including Australia in 1961, entrepreneurial ventures, as well as acquisitions and strategic partnerships.

The Artevo 800 is the first ophthalmic digital microscope.

“That’s in terms of image management and patient data – we are looking at cloud-based apps to improve efficiency and help businesses grow. With our investment in R&D, a lot of that is going into digital, so in the last three years we have hired well over 1,000 people to work in the digital space,” he says. For its 175th anniversary, the company will host various activities and events. Its close links to science are said to be evident in projects such as the ‘Zeiss Beyond Talks’ interview series. In these interviews, pioneers and eminent figures from across the globe, including climate researcher Professor Antje Boetius, speak about their work and the topics that are having a major impact on the world. This anniversary year is also ideally timed for Zeiss to pool its strategic efforts, funding and the commitments it has made for the common good over many years in a bid to encourage children and young people to consider a career in the sciences and conduct open-minded research. An official anniversary celebration is set to be held in November 2021, with employees able to tune into a virtual event, which will also welcome prominent figures from the worlds of science, politics and the economy.

Zeiss is pursuing a global investment strategy that includes a series of international projects aimed at expanding, modernising, and realigning sites in Germany, Europe and Asia. It is also continuing to invest in an optimised infrastructure, state-ofthe-art buildings and production facilities, and with a heavy emphasis on digitalisation and sustainability. The latest investment was the new Zeiss Innovation Center at the site in Dublin, California (US), which opened its doors just a few weeks ago. HELPING TO SHAPE THE FUTURE Looking ahead, Zeiss is aiming to continue its tradition of heavy research and development (R&D) investment. It invests more than 10% of its annual revenue in this area (in fiscal year 2019/20, it invested 13%). Optical technologies are considered vital for progress in the life sciences, medicine, IT, telecommunications, automobile, consumer products and many other fields. Redner says part of its future work will focus on expanding the company’s presence in information management and digital technology.

INSIGHT July 2021

Zeiss’ state-of-the-art site in Tons ley,

Adelaide.

CONTACT LENSES

CONTACT LENS TECHNOLOGIES OF THE FUTURE Insight explores how contact lens innovations are venturing beyond conventional boundaries as a means of vision correction, to another realm where new technological features are being developed for diagnostic and drug-delivery purposes.

arking the 50th anniversary of the soft contact lens this year, the vice president of R&D for vision care at Bausch + Lomb remarked on how this single invention triggered a whole series of other innovations that are ubiquitous in the optical sector today but were completely unknown at the time. As contact lenses evolve over the next five decades, it is worth considering what other advances are on the horizon.

powered contact lenses through advancements in nanotechnology “will enable the commercialisation of lenses that can both detect and treat ocular and, in some cases, systemic disease”. The review also takes into consideration new concepts like biosensing capabilities and antibacterial surfaces to produce safer contact lens cases and materials, reducing the likelihood of sight-threatening microbial keratitis and infiltrative responses.

In April this year, a stand-out academic review provided arguably one of the clearest answers to this question by demonstrating the incredible diversity of new technologies that are set to shape the future contact lens segment.

Willcox and Hui talk with Insight about the CLEAR review, while two optometrists with a special interest in contact lenses discuss advancements from their clinical perspective.

Published in Contact Lens and Anterior Eye, the official journal of the British Contact Lens Association (BCLA), two well-known names in Australia were among the article’s 14 researchers: Professor Mark Willcox and Canadian-born Dr Alex Hui. The study was the latest in BCLA’s Contact Lens Evidence-based Academic Reports (CLEAR).

Since contact lenses were invented in 1887, innovations have included advances in optical design, material, care systems, wear modality, lens size, lens shape and applications, according to CLEAR.

In ‘CLEAR – Contact lens technologies of the future’, Willcox, Hui et al note that rapid growth in novel biomaterials and the development of

UNLIMITED POTENTIAL

In fact, this year marks the 50th anniversary of the soft contact lens, with Bausch + Lomb’s SofLens introduced in 1971. The company says it became the first mass-produced soft contact lens in the US market shortly after the Food and Drug Administration (FDA) granted approval of

INSIGHT July 2021 39

CONTACT LENSES

DR ALEX HUI UNSW "THERE IS A LAUNDRY LIST OF BIOMARKERS THAT CAN BE DETECTED IN THE TEAR FILM."

the novel device. This breakthrough and the many follow-on innovations have led to a US$15 billion (AU$19 b) per annum contact lens market today, according to Vision Monday. More recently, in November 2019 the FDA’s approval for the use of MiSight 1 day (CooperVision) for myopia control in children was an important milestone – and signalled another breakthrough in contact lens design and performance. A medical microbiologist who has worked for many years in infections of medical devices, Willcox is research director at UNSW School of Optometry and Vision Science. He has watched the evolution of contact lenses from the advent of cheap, disposable soft lenses in the 1980s to silicone hydrogel lenses in the late 90s, to a soft toric lens in 2002, to myopia control lenses today. “In the last few years, we’ve witnessed the re-discovery of orthokeratology rigid lenses. Although they’ve been around for a while, they fell out of favour, but have had a comeback, with better materials and better design,” Willcox says. In recent years the success of myopia control contact lenses, and their commercial availability, have virtually elevated them to best practice, he says, but there could be even further advances in this field. But in the CLEAR report, the researchers explain many of these approaches are related to innovations that appear in patent articles and not in the scientific literature and, therefore, may be in planning or preclinical development stages. For example, a PhD student who Willcox is supervising at UNSW is investigating contact lenses as a drug delivery device, by combining a myopia control lens to deliver atropine, which is currently administered as a nightly eye drop. “Delivering atropine through a contact lens could potentially produce a more sustained release over a longer period,” Willcox says. Other forms of therapeutic contact lenses have taken a significant step forward this year. In March, Johnson & Johnson (J&J) Vision’s world-first drug-releasing contact lens for vision correction and allergic eye itch was approved by the Japanese Government. It was the first health authority to clear the novel device, with Canada following in April. The approved combination contact lens – Acuvue Theravision with Ketotifen –contains an H1 histamine receptor antagonist to prevent itch associated with eye allergies, including conjunctivitis and hay fever. Willcox says J&J’s lens – the first commercial drug delivery contact lens

INSIGHT July 2021

MARGARET LAM CCLSA "STEM CELLS HAVE BEEN SHOWN TO RELIABLY TRANSFER FROM THE CL TO THE OCULAR SURFACE."

LACHLAN HOY EYESPACE LENSES "WE’RE ABLE TO TAKE INDIVIDUAL MEASUREMENTS TO CREATE A ONE-OFF PRODUCT."

to reach the market – represents an exciting prospect but it has taken years to come to fruition. “This development has arrived after 10 years of research and design, and numerous clinical trials. Generally speaking, there has been regulatory hesitancy around delivering drugs in contact lenses – a novel idea that has fallen in and out of favour,” Willcox says. Although the industry has metaphorically turned a corner with approval granted in Japan and now Canada, TGA approval in Australia for this lens may be a different proposition, Willcox cautions, because of tighter regulatory controls. He says J&J’s drug-releasing antihistamine contact lens hints at unlimited potential. “We could, in theory, use contact lenses to deliver drugs, such as antibiotics, for ocular conditions from blepharitis to keratoconus. We could use contact lenses to deliver glaucoma drugs, which are currently administered as eye drops. It can be difficult for elderly patients to put eye drops in – not only manually using an eye drop device but also remembering to do it. Contact lenses could maybe even deliver cyclosporin for dry eye,” Willcox ventures. While laboratories are actively designing contact lenses with capabilities beyond mere vision correction, the performance of contact lens packaging and storage is also an area of focus. “Manufacturers are trying to design packaging that eliminates wearers touching the lenses to reduce the risk of bacterial transmission. Menicon’s flat pack technology is leading the way, designed in such a way that wearers don’t handle the lens,” Willcox says. As a one-time-use medical device, daily disposable contact lenses, by design, don’t require disinfection, but monthly contact lenses do, and here a new challenge is being addressed. “When disinfecting lenses overnight, we get bugs colonising in contact lens cases. If you replace contact lens cases regularly, monthly, you are less likely to get infections. Is there a way contact lens cases can discolour to indicate there are too many bugs present, or is there a way contact lens cases can disintegrate if there are too many bugs to be safe?,” Willcox says, noting these are some of the ideas being explored in research labs. In his own lab at UNSW, he is investigating an antimicrobial contact lens’ inherent ability to kill bugs. A Phase 3 trial – a large population study in India – completed two-to-three years ago showed a 50% reduction in inflammation.

Now, Willcox is working on a next-generation antimicrobial contact lens, modifying peptides to be resistant to bacteria for a duration of two weeks of contact lens wear. “We’ve finished designing the contact lens and have now moved into animal studies as part of pre-clinical evaluation. In about a year’s time, we hope to receive Proof of Principle and move into Phase 1 human trials.” Incorporating microelectronics into contact lenses to detect disease is another surging field of research and design. Here, Willcox says, the task of miniaturising power sources is “challenging, but not insurmountable”. “It will take a few years to get right,” he says. One product leading this field is the Sensimed Triggerfish contact lens, a commercially available device with CE marking and FDA approval that permits extended monitoring of IOP. According to the CLEAR review, this flexible silicone-based contact lens measures minute dimensional changes in corneal shape, which correspond to changes in ocular biomechanical properties and volume, as well as IOP. “Triggerfish is likely to be the first in a generation of commercially available contact lens-based devices to monitor ocular biomarkers of disease. However, there are a number of limitations with the current device, principally driven by the bulky microprocessor and strain gauge assembly,” the CLEAR authors state. A second-generation Triggerfish lens is currently in the pipeline. UPTAKE AND RELEASE Willcox’s colleague and fellow author of ‘Contact lens technologies of the future’, Dr Alex Hui completed his PhD at the University of Waterloo

HOME2

and the Centre for Contact Lens Research, where he investigated drugreleasing contact lenses. Now a Senior Lecturer at the School of Optometry and Vision Science at UNSW, his work in this field is ongoing.

"IS THERE A WAY CONTACT LENS CASES CAN DISCOLOUR TO INDICATE THERE ARE TOO MANY BUGS PRESENT?" PROF MARK WILLCOX UNSW

“I’m interested in the ability of contact lenses to tailor therapeutic drugrelease to treat and prevent infection, such as using contact lenses to release antibiotics after laser surgery,” Hui says. “The patient is already wearing a bandage contact lens after some procedures, so that lens could potentially also release antibiotics to help them recover, instead of being required to put in eye drops. But there are marketing issues around delivering drugs this way. We need to overcome this hurdle.”

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CONTACT LENSES

The CLEAR report states that incorporating drug-releasing technology into a soft contact lens may significantly improve treatment compliance over eye drops. Hui says the report also delves into the challenges to contact lens drug delivery including the lens/drug combination to optimise the uptake and release profile. Notably, according to the report, if a drug molecule has an exceptionally high affinity for the lens material, then it could result in an unacceptably prolonged drug-release profile once the lens is placed on the eye. The molecular weight of the drug may also impact the ultimate uptake and release of the drug. “Very few concepts have gone into animal studies,” Hui says. “What can we do to change the release profile? We’re in the early stages of focusing on that.” Hui and his colleagues note in the report that the scope and timing of clinical trials to demonstrate the safety and efficacy of a drug-releasing lens are a substantial hurdle. “Combination devices already exist in other medical fields, but it is a newer field in eyecare. The FDA in the US recognises combination devices, whether they be combinations of drugs, devices or biological products. How a combination product is ultimately evaluated and by whom depends on its primary mode of action, which in some cases may not be readily apparent,” Hui says. Not all new ideas succeed, however. As it has become increasingly apparent that the tear film contains a wide range of biomarkers that may help diagnose systemic diseases, the potential for a contact lens-based diagnostic device has entered the equation. “There is a laundry list of biomarkers that can be detected in the tear film, including glucose levels in the case of diabetes, and changes in combination of specific proteins in cancers,” Hui says. The concept of a contact lens-based glucose sensor to monitor diabetes, in lieu of the gold standard finger-prick method, rose to popularity in 2014 but the hype has waned since a collaboration between Google and Novartis fell by the wayside in 2018 due to technical challenges. “The physiology didn’t work out, because of the delay between changes in blood glucose levels and tear glucose levels, which is potentially fatal if patients were relying on those measures to determine insulin doses,” Hui says. AMNIOTIC MEMBRANE THERAPY PAIRED WITH CONTACT LENSES An amniotic membrane therapy that sits under a bandage contact lens as a delivery device is also gaining traction.

Regenerative amniotic membrane therapy. The new AmnioTek Vision (right) features a hole in the centre to minimise blurred vision. Image: ISP Surgical/Designs For Vision.

bandage following grafting. “Limbal epithelial stem cells have been shown to reliably transfer from the contact lens to the ocular surface and an initial study of three patients with limbal stem cell deficiency reported a 100% success rate at a 12-month follow-up,” the CLEAR report states. Describing amniotic membrane therapy as “an amazing new technology – the application of amniotic membrane therapy via a bandage contact lens is a new therapy with the potential to improve cases of severe corneal damage”, Lam says there are several specific indications when it would be used. “Any potential corneal pathophysiology not healing well is indicated for amniotic membrane application including corneal ulcers, and potentially, peripheral corneal ulcer,” Lam says. “It can also be used for dry eye cases with recalcitrant dense superficial punctate keratitis. Amniotic membrane is certainly a treatment that can be considered for many types of severe dry eye – amniotic membranes won’t necessarily help all patients with dry eye, but it would particularly help those with staining and those with systemic antiinflammatory conditions associated with dry eye.” Another application is for recurrent corneal erosion and epithelial membrane basement dystrophy (EMBD) with a recurrent corneal erosion component. “In the past, to apply the amniotic membrane was a complex surgical intervention, applied as an end-stage procedure when all other options were exhausted,” Lam says.

Known as amniotic membrane therapy, skilled specialty contact lens practitioner Ms Margaret Lam says this is new to Australia and has only been accessible in recent months.

Today, using donor placenta tissue that is wafer thin – as thin as a sheet of cellophane – and dry, which is also screened, sterilised and safe to use under a bandage contact lens, the therapy has entered a different ball game.

Lam is a therapeutically-endorsed optometrist with multiple professional roles, including head of professional services at George and Matilda Eyecare, an Adjunct Senior Lecturer at UNSW School of Optometry and Vision Science, and a director on the national board at Optometry Australia.

“The benefit and difference now is that this amniotic membrane therapy is in a more accessible form, applied under a bandage contact lens. It is no longer a surgical procedure. Instead, it can be administered by an optometrist or ophthalmologist that has been appropriately trained,” Lam says.

She is also National President of the Cornea and Contact Lens Society of Australia (CCLSA), an organisation with a history of introducing new techniques in contact lens technology to the wider profession. In keeping with this reputation, CCLSA is hosting an introductory lecture into the application of amniotic membranes for both ophthalmologists and optometrists in mid-July.

Regenerative amniotic membrane therapy has recently become accessible in Australia and New Zealand through ISP Surgical, a Thailand-based company that has developed custom dehydrated amniotic membrane grafts for many sub-speciality surgical applications.

BCLA’s CLEAR report touches on this emerging technology, noting that the use of contact lenses as a stem cell delivery device has been demonstrated, with the contact lens vehicle doubling as a protective

INSIGHT July 2021

ISP Surgical is also working with I-stem from France on a proposal to trial AMT grafts populated with “Stem Cells” in the future. Designs For Vision is the ISP Surgical/AmnioTek Brand Distributor in Australia and MEDIX21 Surgical in New Zealand. Lam explains that a bandage contact lens comes with the allograft kit.

“This is very new, and practitioners are still deciding which is the most compatible contact lens that works best with this membrane therapy.”

optical wavefront of the eye – is resulting in more eyes being capable of wearing contact lenses, and with greater improvement in vision.

Amniotic membrane therapy is not listed on the Medicare Benefits Schedule (MBS), and each application currently needs to be given special approval by the TGA, making accessibility an issue, Lam says.

“We can now intricately fit soft and rigid contact lenses. From where I sit, we’re able to take individual measurements to create a one-off product, a completely custom-made lens,” Hoy says.

“In order to access amniotic membrane therapy, eyecare practitioners have to apply to the TGA on a case-by-case basis, for each and every patient they wish to treat with this therapy. The problem is, for optometry approval, TGA approval can take between three to five days to come through however, the sooner the membrane can be applied, in acute cases, the better the outcome for the patient.”

Hoy says EyeSpace is working with optometrists from Australia, New Zealand, the US, Latin America and Africa, as well as with ophthalmologists in China and Russia, to produce completely customised contact lenses for a wide range of patients from keratoconus to orthokeratology.

CUSTOMISATION A future that would allow eyecare practitioners to design and fit a completely customised contact lens is now a reality for optometrist and contact lens designer Mr Lachlan Hoy. Hoy is a clinical optometrist at Innovative Eye Care – a business he purchased in 2010 with practices in Adelaide and Woodville – where he predominantly consults with contact lens patients.

“The number of instruments coming on to the market that map and measure the eye is increasing every year; the technology is more sophisticated, it can measure more, which can contribute to better results. By capturing a 3D map of the eye, you can manufacture a contact lens that fits first time, eliminating the need for a trial set,” Hoy says. From his R&D lab in Adelaide, Hoy is closely watching the development of smart contact lenses.

When he is not fitting custom-made contact lenses, he is running the R&D lab as managing director of EyeSpace Lenses, a team dedicated to developing end-to-end software systems for the design, supply and manufacture of bespoke contact lenses.

“Last year Mojo Vision unveiled their smart scleral lens incorporating a microprocessor, image sensor, 70,000 pixel display 480nm in size, with a tiny solid state battery which can be recharged when placed in its case at the end of the day, and then paired to your computer or phone,” he says.

Hoy says radical improvement in instrumentation and technology of the metrology of the eye – measuring the shape, tomography and

“Smart contact lenses seem futuristic, but it is becoming reality, with Sony, Google, and Amazon all working in this space in recent years.” n

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DRY EYE

WITH A

DRY EYE INNOVATOR

SBM Sistemi's IDRA device is considered a gold standard diagnostic tool.

BOC Ophthalmic Instruments forged a new alliance with Italian ophthalmic device manufacturer SBM Sistemi four years ago with a focus on innovative dry eye devices. As TONY COSENTINO explains, the relationship has advanced at a rapid pace and there’s more to come in 2021.

n his 50-year career in ophthalmic equipment sales and distribution, BOC Ophthalmic Instruments managing director Mr Tony Cosentino has had a front row seat to some of the major trends that have shaped and reformed eyecare in Australia. The push for all optometrists to own a slit lamp, and the introduction of non-contact tonometry and OCT are among the major technological milestones he’s witnessed and, subsequently, aligned his company with to bring the best overseas equipment to local eyecare practitioners. One of BOC’s most enduring partnerships has been with the Japanese firm Nidek, which – like Cosentino – is also celebrating a 50-year milestone in 2021. At the other end of the spectrum is one of BOC’s newest agencies, SBM Sistemi, a firm in northwest Italy punching above its weight in terms of ophthalmic innovation. The entrepreneurial spirit of SBM is what initially attracted Cosentino (who is also Italian) when they first met by chance at the MIDO trade show in Milan in 2017. But it’s also the fact its team of 20-odd employees is developing new technology for one of the next major growth areas of eyecare – dry eye. The company entered the ophthalmic arena in 2015 and has since expanded its portfolio to encompass six diagnostic dry eye devices, supported by its own software, and now a new treatment option for meibomian gland dysfunction. “They are a company that innovates by research – not by copying other technology that is out there – that’s why we have introduced them into the portfolio,” Cosentino says. “We always say we want to bring the best factories to our customers, and this is a relationship that has evolved at a rapid pace over the past four years.”

INSIGHT July 2021

SMALL ITALIAN FIRM GOES GLOBAL Headquartered in Turin and commencing operations in 1984, SBM Sistemi initially produced software for optical practices in its region. Within a few years it began opening new distribution facilities across Italy before expanding into other European markets and later developing equipment for the pharmaceutical market. But it was six years ago – in 2015 – when the company took its first step into the ophthalmic market with a focus on dry eye diagnostics. The technology came amid mounting research that helped define dry eye disease, its causes and the various ways in which it could be measured.

Tony Cosentino, managing director, BOC Ophthalmic Instruments.

A tear film screening device called the I.C.P. Tearscope and its meibomian gland evaluator, I.C.P MGD, were among SBM's early instruments. But the company soon went to a new level with the I.C.P OSA (Ocular Surface Analyser), which offered practitioners a full assessment of the ocular surface through a combination of tests, from tear break up time to tear volume production tests, as well as various measurements and classifications according to international grading scales. A later version, the OSA Plus was then developed, with a key feature being auto meibography.

Then in 2019, SBM released IDRA, its most comprehensive ocular surface analyser yet, incorporating all OSA features, plus more. The company says it is a gold standard dry eye diagnostic instrument, with key functions including auto interferometry test, auto 3D meibography, auto non-invasive break-up time (NIBUT), eye blink detection, tear meniscus height (evaluation of the tear film quantity, up to five values), blepharitis examination without additional lenses, break-up time staining test, white to white measurement and pupillometry, among others.

Activa for meibomian gland dysfunction is SBM Sistemi's first dry eye treatment device.

Cosentino says with IDRA comes a tool that takes full control of the dry eye examination, with automated functions supported by upgradable software. For eyecare practitioners it removed the need for manual testing procedures across multiple devices, while also eliminating any grey areas or guess work. “What’s so great about dry eye instrumentation like this is that it can measure and identify the type of dry eye and determine which layers can be treated with a specific treatment, in relation to the type of deficiency," he says. "And it helps inform the diagnosis with a colour coded system from red to green, which provides an indication of someone with severe dry eye or who might be on the verge, for example. Now all you need to do is determine the treatment." The tests and images can also be shown to patients during visits, as well as printed, sent by email, or collected with a smartphone app that the patient can keep and compare over time if they’re undergoing therapy. “I’m always excited about being involved with state-of-the-art technology that comes along like this, which help optometrists and ophthalmologists give better service to their patients and grow their practices as well,” Cosentino adds. In Australia, SBM’s dry eye range has been popular among independent optometrists seeking to differentiate their business, as well as those who have set up dedicated dry eye practices. But time and space are critical in the modern-day eye clinic, which SBM has factored into the design of its equipment. The IRDA and I.C.P OSA, for example, can be mounted to the existing slit lamp tonometer hole, while the Tearscope is fitted to an iPad for examination and data collection. “SBM is also trying to bring down the examination time. They can get tear analysis and whole dry eye examination down to about four minutes with their devices, so that means valuable time isn’t being taken away from the optometrist or ophthalmologist,” Cosentino explains. “For optometrists in Australia, there is no separate Medicare item for these tests so it has been a challenge trying to fit dry eye diagnostics into [billable] examinations because previously it had to be done manually and could take 10-15 minutes. But now with the automation that’s been introduced, it basically does everything for you and gives you results, within minutes.” MULTIPLE NEW RELEASES IN 2021 Reflecting on the beginning of his career in 1971, Cosentino recalls simpler times when manufacturers would release updated equipment and new inventions every two to three years. But times have changed, and this is particularly the case with SBM who have essentially rolled out a new product every six to eight months. This year BOC is introducing two new diagnostic platforms from SBM, as well as the manufacturer’s first foray into dry eye treatment. The first of the diagnostic platforms are two new modules: the DSLC200 which adds digital capabilities to slit lamps; and the Dry Eye Module (DEM 100), a software interface that attaches to the slit lamp and DSLC200 and offers a comprehensive set of dry eye diagnostics. The DSLC200 is said to transform slit lamps into a high-quality digital imaging device and is compatible with various makes and models, including CSO, Zeiss, Haag-Streit, Nidek, Topcon, Takagi, Righton, Keeler, Huvitz, Mediworks, Shin Nippon.

The company manufactures its devices at its headquarters in northern Italy.

The module’s key difference is the use of an optical image splitter, which is fitted between the eyepieces and magnification optics of the slit lamp. This means it is not mounted to the eyepieces like other after-market cameras, allowing the eyecare professional to use the eyepieces normally, while offering superior image quality. The system is also accompanied by software that allows the user to save images and video, with functionalities such as the Efron and CCLRU grading scales, comparison between exams, patient follow-up and reports. The DSLC200 can be combined with the DEM 100 on Haag-Streit devices, which converts slit lamps into a dedicated dry eye platform. It can also perform various tests including lipid layer thickness, meibography, tear meniscus height, automatic detection of blinking motion and quality, and bulbar redness. The software is designed to guide the eyecare professional through the dry eye examination and all software automations are provided to obtain reliable and complete objective results. Soon, Cosentino says BOC will be distributing a new topographer by SBM called the OS 1000, which also includes a module dedicated to the evaluation of the ocular surface. It’s an integrated, true diagnostic workstation, featuring complete dry eye assessment with tear film analysis and 3D meibography. And in the therapy space, SBM recently unveiled Activa for meibomian gland dysfunction, featuring an eye mask with heating and automatic squeezing technology. The device provides heating at 42C, and after a few minutes starts massaging through pads designed to push on the lids, avoiding pressure on the cornea, and with gentle vibrations it squeezes meibum from the glands. This process is also thought to be useful in conjunction with IPL (intense pulsed light) therapy for evaporative dry eye. “Compared with existing treatments like IPL, SBM have found this is a much easier treatment that you can even do at home,” Cosentino explains. “It’s not always easy for patients to go in and have IPL treatment, and then come back again for another treatment, and sometimes it is not even necessary to go down the IPL path, so this has a place in dry eye management.” n

INSIGHT July 2021 45

LOW VISION – READINESS FOR SCHOOL VISION IMPAIRMENT IS A DISABILITY OF ACCESS. DR SUE SILVEIRA EXPLAINS HOW ORTHOPTISTS HELP CHILDREN OVERCOME THESE BARRIERS TO PARTICIPATE WITHIN MOST AREAS OF THE CURRICULUM.

hildren with low vision and blindness are a unique and diverse group of learners. Given the significant impact that vision impairment can have on general childhood development and learning, early detection and management of vision impairment is essential. SUE SILVEIRA

"THE LOW VISION ASSESSMENT ACTS AS A CONDUIT TO THE SIGHTED WORLD TO REVEAL THE NUANCES OF THE CHILD’S PREFERRED USE OF THEIR VISION"

Because Australia has committed to services that provide vision surveillance from birth and early vision screening, most children suspected with vision impairment have access to timely diagnostic services. Early diagnosis of vision impairment segues into essential early intervention and preparation for learning, with the child and their family being central to all planning and decisions. Education of children with low vision and blindness in Australia aims to prepare children for the life challenges they will face, but also the life opportunities they will be offered. As the standard national curriculum doesn’t capture the diverse skills needed by these children, an approach called the Expanded Core Curriculum (ECC) is recommended. The ECC embraces nine essential skill areas including compensatory, sensory efficiency, orientation and mobility, assistive technology, social interaction, selfdetermination, recreation, and leisure and career skills. An understanding of the child’s visual ability and needs informs their participation and success in each ECC skill area. Details of the child’s visual ability can be found in reporting from a low vision assessment. Low vision assessment plays an essential role in translating the child’s lived visual experience, by reporting both visual function – or what a child can see, and functional vision – or how the child prefers to use their vision in their everyday life. Reporting must be available to everyone that has contact with the child including their family, educators, orientation and mobility instructors, access technology consultants, allied health and other professionals. Reporting must also be meaningful for older children so they can

INSIGHT July 2021

build essential self-determination and self-advocacy skills, by understanding their eye condition and speaking up about their access needs. Fundamental differences exist when clinical and low vision assessments are compared. Clinical assessment is generally performed in environments that are optimised for visual performance, to reveal the child’s visual threshold. Low vision assessments often aim to mimic the actual environment where the child uses their vision, where dynamic factors such as changes in lighting, background information and other distractions occur. Importantly, the child’s visual performance in their actual environment Low vision assessments can guide decisions such can reveal the presence and impact of as whether a child becomes a braille user. significant factors such as glare and visual fatigue which will not necessarily be apparent in clinical environments. the low vision assessment is used when setting up classrooms and considered The format of low vision assessments when planning for the child’s general will vary according to the child’s age school participation. For example, and co-morbidities, and the aim of the assessment. Typically, the diagnosis will significant factors that routinely impact on children with vision impairment such be explained, with essential information as glare can be identified in the low such as the stability and fragility of the vision assessment, and then minimised eye and/or vision condition, flagging in the school environment. the likelihood of future changes to the child’s visual function. Visual acuity will The low vision assessment acts as a be included in reporting, with additional conduit to the sighted world to reveal the details such as binocular near and nuances of the child’s preferred use of distance visual acuity, and changes in their vision. By reporting visual function visual acuity when low vision devices and particularly functional vision, the low are used. Other strategies that maximise vision assessment plays an essential role the child’s access to literacy such as in guiding significant decisions made by font type and size, and adaptations to families, educators and professionals, the reading position will be described. and contributes to the child’s readiness When available, information on visual for school. n fields is included, to inform on the child’s peripheral visual ability, particularly for orientation and mobility planning. Vision impairment is a disability of access and when these barriers are overcome, children can participate in most areas within their learning curriculum. Information in the low vision assessment can be used to guide decisions around access such as recommending that a child becomes a braille user, and how access technology and low vision aids can enhance learning. To maximise the child’s educational experience, information from

ABOUT THE AUTHOR: Dr Sue Silveira is the Course Director of the Master of Disability Studies, Macquarie University, and a research fellow with the NextSense Institute (formerly the Renwick Centre, Royal Institute for Deaf and Blind Children). 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

PROTECTING YOUR FUTURE HEALTH PROFESSIONALS DEVOTE THEIR CAREERS TO IMPROVING THEIR PATIENTS’ LIVES, SO WHY DON’T THEY AFFORD AS MUCH ATTENTION TO THEIR OWN FUTURES? KAREN CROUCH EXPLAINS THE BENEFITS OF PLANNING AHEAD.

s COVID-19 management improves and green shoots of confidence emerge, it’s worth considering going ‘back to the future’. I’m referring to a time when you could formulate a serious plan for the longterm when business/environmental conditions were more predictable. KAREN CROUCH

"LEARNING AND UNDERSTANDING PERSONAL FINANCE AND INVESTMENT OPTIONS ARE OFTEN RELEGATED TO THE 'LATER' TRAY"

When practitioners focus on their careers that make a huge difference to peoples’ lives, it is easy to defer financial affairs or retirement plans. After all, isn’t patient care the core objective of many years of training and education? Protecting your future hardly compares to the task of providing someone good health. But inevitably you may want to stop working, or work less, and spend more time pursuing other activities that require accumulated funds. Estate planning, making a will or ensuring dependents are catered for are often deferred in favour of pressing career matters. It’s important to give priority to the development of a comprehensive ‘financial care plan’ for yourself, just as you execute a ‘healthcare plan’ for patients. ISSUES AT HAND The main challenge is invariably paucity of time. Managing a practice must get priority. So finding adequate time after daily paperwork for the practice, patients, suppliers and staff, can be daunting. Learning and understanding personal finance and investment options are often relegated to the “later” tray. Before developing a plan, beware of the following: Now vs future: Assuming that a successful practice will automatically grow personal finances often results in complacency and unwillingness to heed expert advice. A smarter strategy is to invest some practice income to help you become independent of your business and assure a planned retirement lifestyle. Greed: Individuals generally make financial decisions on emotion/impulse. Sure-fire investment tips at BBQs can

SMART PLANNERS

LATE PLANNERS

Set goals, short and long term, enjoy early and mid-career phases while planning retirement.

Focus mainly on saving money for long term (retirement) benefit only.

Establish goals early during career and review regularly.

Wait till just prior to a major event (e.g. retirement).

Progressively accumulate wealth through wise and diversified investment planning.

Assume regular savings will ultimately serve long term needs.

Seek assistance of professional financial planning managers.

Rely on personal knowledge of finance or advice from acquaintances/others.

Ensure assets regularly monitored to optimise investment opportunities.

Assume investments grow without supervision ... and miss opportunities.

Ensure personal aspects of wealth creation (e.g. estate planning) also addressed.

Focus on income generation from careers and increasing savings in (often) sub-optimal returns.

The differences between smart and late planners.

result in negative investments that are not adequately understood. Fear: Alternatively, fear of losing money may result in safer, low return investments that overlook longer term opportunities. Impatience: Some expect quick results and if they do not perform, they sell/ switch. Creating wealth takes time. Of course, some lucky ones made a bundle by selling before the financial crash, but inexperienced investors often pile into trendy investments and hold them too long. Future options: As retirement approaches, you may consider winding down your practice/employment. For example, some specialists may no longer perform surgery, reducing earnings and savings to retire on. By building assets outside your practice, you can enure your retirement plan is on track. SEEING THE LIGHT Acknowledging the importance of a financial strategy for the future is fine, but taking action is where the true challenge lies. But by putting in the hard work now, a strategy will be established so you can focus on healthcare. Then you can rest easy knowing your future is in good shape.

When you realise you are working to satisfy your current lifestyle needs, you will regret not having considered retirement and practice/employment exit plans earlier, so you can ultimately decide when to stop working, or reduce your load. In the table above you can find a comparison of attributes between smart and late planners. Which one are you? Do you think it’s time to start considering your financial future now? Common statements from those who fail to plan include; I don’t have time. I have a practice to run; when I retire, I’ll sort out my finances then; I don’t know how much I’ve saved or my worth, but I think I’m fine. For those considering a more concrete future, the basic elements of a comprehensive plan include seeking help, analysis and objective setting, a savings plan, estate/succession planning, insurance, retirement planning, wealth management and review and oversight. n

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

INSIGHT July 2021 47

DISPENSING

WHAT GOES INTO A FRAME? WITH THE EVERYDAY DEMANDS OF PRACTICE LIFE, IT CAN BE EASY TO LOSE SIGHT OF THE EFFORT PUT INTO EACH FRAME. JED CROTTEY DETAILS THE DESIGN AND MANUFACTURING PROCESSES BEHIND ACETATE FRAMES.

ost of us dispensers don’t tend to think too much about the processes a frame has been through before it lands on our shelves. We tend to think more about the quality, the finishes, the hinges, the materials and so on.

JED CROTTEY

"WHEN YOU START TREATING YOUR STOCK LIKE A PIECE OF JEWELLERY FOR SOMEONE’S FACE THIS RESPECT WILL TRANSLATE TO YOUR CUSTOMER"

As vital as these details are, it is also important to know where the frame started so you can learn to respect the processes which, in turn, will allow you to appreciate your inventory. This respect and knowledge for the product will translate into your sales techniques and allow you to make higher value sales. I could talk about the process of manufacturing and design all day, but for the purpose of keeping within the scope of this article, I will focus on the acetate frame. These are simpler to produce and are, on average, 12 months faster to manufacture than metal or titanium frames, from the initial concept and design, to final product. An acetate frame’s life begins in the acetate itself but before any of the details are even thought about, the acetate needs to be created. The material is naturally derived from cotton which makes it highly hypoallergenic. There is an amazing range of colours, textures and lamination combinations, mixing these with different hardware and finishes means the options are endless. A very generalised list of steps starts with the concept or an innovation which is taken to a team of designers. This process can go back and forth until an initial design is agreed upon. After this a 3D model is drawn on a computeraided design (CAD)-like program and printed using a 3D printer. The model is assessed and goes through a validation process that ensures the model you have built works for the end customer as intended. While all the technical elements of the frame are being ironed out, the acetate has already been ordered or being produced as a custom design. The production of a custom acetate design can take 12 months to design and

INSIGHT July 2021

The polishing process is usually done in three stages, each delivering a different level of shine.

another four months to produce. Once all components are ready, we head to production. The CNC (computerised numerical control) machines are programmed in preparation of production and the acetate sheets are cut into strips. Once the strips are cut, they are then planed to the correct thickness, in some designs small pieces of acetate will be glued where the built-up bridge pieces will sit depending on the design. The acetate block is then sent to the CNC machine to be cut out precisely. The CNC machine can do eight to 15 frame fronts per hour depending on the complexity of the design. The temples are then cut and hinge pieces are sunk into both the frame front and insides of each temple ready to be polished. The polishing process is usually done in three different stages, each one delivering a different stage of shine and takes about a week to finish. The frames are then polished by hand, assembled by hand and ultrasonically cleaned to remove any grease. Finally every single frame undergoes a series of meticulous checks to ensure a high quality finish. If passed by all the quality control

checks, the frame is taken to a dispatch centre and sent out to your distributor who then places them into their sales representatives kits and then sold to you and your practice where they will find their forever home. With the hustle and bustle of the practice, it’s easy to forget that a frame is far more than just a commodity. When you start treating your stock like a piece of jewellery for someone’s face this respect will translate to your customer and make them view it as a beautiful ‘piece’ and not just a frame. Give your customer a brief summary of the frame, for example: “This piece is amazing. Handmade in Berlin – more than 12 months and 20 handmade processes have gone into this frame." It is so special watching a regular patient turn into a loyal repeat customer by showing them how passionate and knowledgeable you are about your industry. n

JED CROTTEY is a business development manager for VS Eyewear and an optical dispenser with 10 years’ industry experience. He has followed his passion for the optical industry and design throughout the east coast of Australia.

2021 CALENDAR JULY NACBO CONNECTED - HYBRID CONFERENCE 2021 Gold Coast, Australia 9 – 11 July acbo.org.au

SYDNEY EYE HOSPITAL ALUMNI MEETING Sydney, Australia 23 July ranzco.edu

OPHTHALMOLOGY UPDATES! Newcastle, Australia 31 July – 1 August ophthalmologyupdates.com

SEPTEMBER O=MEGA21 Melbourne, Australia 2 – 4 September omega21.com.au

EURETINA 2021 VIRTUAL International 9 – 12 September euretina.org

SILMO PARIS Paris, France 24 – 27 September en.silmoparis.com

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OCTOBER

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RANZCO ANNUAL SCIENTIFIC CONGRESS Brisbane, Australia 19 – 23 November ranzco.edu

SUPER SUNDAY 2021

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Brisbane, Australia 20 – 22 November orthoptics.org.au

AUSCRS 2021 Noosa, Australia 20 – 23 October www.auscrs.org.au

Canberra, Australia 30 September – 3 October kathpoon@bigpond.com

DECEMBER 14TH ASIA-PACIFIC VITREO-RETINA SOCIETY (APVRS) CONGRESS Chinese Taipei 10 – 12 December 2021.apvrs.org

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All Specsa ve stores rs no with O w CT

Specsavers has an exciting opportunity for experienced optometrists looking to take the next step in their career. State of the art equipment including OCT, opportunity to mentor graduates and students, supportive and welcoming teams to help you settle in, loyal patient database’s and mixed demographics including pathology. Not sure partnership is right for you? Why not try before you buy? Permanent or fixed term can be discussed. Relocation support also available. Opportunities available in Emerald, Port Pirie and Shepparton. Graduate Opportunities - Australia & New Zealand

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 yet. 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. To take up this limited time opportunity, contact apac.graduateteam@specsavers.com Full-time Opportunity – New Zealand Thinking of a sea change, or want to return to NZ? With 56 stores across New Zealand Specsavers has an abundance of opportunities for experienced optometrists. Whether you enjoy the hustle and bustle of city life or prefer the relaxed outdoor lifestyle, we can offer you the perfect location. At Specsavers you will be working with the latest technology, including an OCT in every Specsavers New Zealand store. Full-time Optometrist Opportunity – Specsavers Mandurah Specsavers Mandurah are looking for a patient focused optometrist. In return you will be surrounded by a supportive and highly experienced team of dispensers and retail staff who will ensure you have a smooth transition to all patients. The store also has a great relationship with a local ophthalmologist. Full-time Optometrist Opportunity – Specsavers Mittagong Our Mittagong team have a vacancy for an optometrist and are looking to talk to a patient focused professional. Specsavers Mittagong is flexible to work around current commitments and able to offer part or full-time options. Work with a store who offers a supportive learning environment with ongoing career development.

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

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

marie.stewart@specsavers.com or 0408 084 134 Australia Employment 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 02 7579 5499 Graduate employment enquiries: apac.graduateteam@specsavers.com

SOAPBOX

ROCKY PATH OF AN EARLY CAREER RESEARCHER also an opportunity to engage with AK patients in research (outcome was ‘No water’ stickers). Then my genetics study that I went to conduct started to unravel. There was an outbreak of AK, I had a lot more gDNA samples than I expected, and we needed to find out why this outbreak was happening so the emphasis on epidemiology became more important. I moved back to Sydney in January 2015, then in October, I was diagnosed with Stage 3c breast cancer (now five years clear, I'm happy to report).

fter spending the first 10 years of my career as a practising optometrist in Australia and the UK, I returned to Australia in 1999 and seized an opportunity at the Cornea and Contact Lens Unit (now BHVI) where I fell in love with research. I liked following protocols, discovering associations, formulating and presenting data. I was fortunate to be trained by Professor Brien Holden, Professor Debbie Sweeney and many other leading lights. We travelled to international conferences and worked in multidisciplinary teams. I had two kids, a good wage, great childcare support but after nine years there was a ceiling, and you couldn’t break through without a PhD. My PhD (2008-2012) was a fantastic experience. I had great supervisors led by Professor Fiona Stapleton, and including Professor Lisa Keay, the previous and current UNSW School of Optometry and Vision Science head. I learnt about epidemiology, genetics and project management. I got numerous awards and thought I was doing pretty well. Then someone said to me, “people might think you have been spending too much time getting awards and not enough time researching”. I thought, what?

INSIGHT July 2021

This is a conundrum of academic life. You constantly must promote your research and profile to secure opportunities and build your CV because your track record is key. You also need to publish (on average four to eight peer-reviewed publications per year) and be awarded grants to generate the data to publish. And this is the crux of the matter. There is not enough money to support research in Australia. Immediately after my PhD, I was awarded an Australian Government NHMRC CJ Martin Early Career Researcher (ECR) grant. These are highly-prized and provided salary and living expenses for my family to move to the UK for two years and work at Moorfields Eye Hospital, and two years to return and work at USyd. There was no research project funding provided with the grant, so I spent the entire first year applying for funds. Exactly 12 months after I arrived, I started my (too) ambitious study on Acanthamoeba keratitis (AK). At this time, other senior researchers saw my potential and invited me to work on additional corneal research projects. I was thinking that next year I would be going back to Sydney, there is not much AK there (I was wrong), I should take up these offers. There was

In 2017 as my CJ Martin Fellowship was ending, I was fortunate to be offered a four-year Scientia Research Fellowship at UNSW. This has given me the space to build a research team and be more strategic about my research as I am not continually stressing about where my salary and project funding is coming from. I published the AK genetics paper this year. The life of an ECR is not easy. In 2018, the NHMRC listened to advice on fellowship schemes and started awarding project grant money to accompany salaries. A lot of the funding, however, is going to the top end of town, and this is not supporting ECRs and building our national research future. Medical funding is being channelled into the Medical Research Future Fund (MRFF), but the big winners are cardiovascular disease and cancer. I can relate, but these diseases have large community funding streams, and we need more than 1% of that pot accessible to sensory diseases, including vision research. Vision 2020 Australia and other peak professional and advocacy groups collectively can move the agenda forward for preventing and preserving good vision for life, by increasing the funding pot but also by supporting ECRs. n Name: Nicole Carnt Qualifications: BOptom, PhD, GradCertOcTher Organisation: School of Optometry and Vision Science, UNSW Position: Scientia Senior Lecturer Location: UNSW, Sydney Years in the profession: 32 years

THIS IS A CONUNDRUM OF ACADEMIC LIFE. YOU CONSTANTLY MUST PROMOTE YOUR RESEARCH AND PROFILE TO SECURE OPPORTUNITIES AND BUILD YOUR CV BECAUSE YOUR TRACK RECORD IS KEY.

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Delivering more – Any way you look at it. Aberration-free optic1 | Predictable outcomes1,2 | Smart design1,3,4 For more information contact your Bausch + Lomb Territory Manager or Customer Service 1800 251 150 References: 1. enVista Directions for Use. 2. Data on File. Bausch+Lomb Inc. enVista IOL Comparison Data. 3. Data on File. Bausch+Lomb Inc. 4. Elachchabi A, Martin P, Goldberg E, Mentak K. Nano indentation studies on hydrophobic acrylic IOLs to evaluate surface mechanical properties. Paper presented at: XXV Congress of the European Society of Cataract and Refractive Surgeons (ESCRS); September 8-12, 2007; Stockholm, Sweden. © 2021 Bausch & Lomb Incorporated. ®/TM denote trademarks of Bausch & Lomb Incorporated and its affiliates. Bausch & Lomb (Australia) Pty Ltd. ABN 88 000 222 408. Level 2, 12 Help Street, Chatswood NSW 2067 Australia. (Ph 1800 251 150) New Zealand Distributor: Toomac Ophthalmic. 32D Poland Road, Glenfield 0627 Auckland New Zealand (Ph 0508 443 5347) AHAI.0017.AU.20