Insight July 2022

JUL

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

OSHOW22 success a taste of what's to come when Australia hosts global optometry event.

PROVIDING SPECIALIST EYECARE – AT SCALE Vision Eye Institute's CEO on running Australia's largest private ophthalmology network.

33

INDUSTRY EVENTS MARK RETURN TO NORMALITY

26

WWW.INSIGHTNEWS.COM.AU

03

COMPATIBLE WITH YOU

OPTOMETRISTS AT DIABETES COALFACE Evidence-based, practical strategies for optometrists caring for patients with diabetes.

Specsavers Clinical Conference is back

20 hours of CPD content all in the one place!

10 – 11 September 2022

0 202

O pt o m etris t s

1 202

O pt o m etris t s

2 202

O pt o m etris t s

After a disruptive two years, Specsavers Clinical Conference is returning with a distinctly 2022 look.

Now in its eleventh year, this year’s two-day SCC will offer live CPD content from an incredible line-up of industry-leading speakers over a state-of-the-art, custom built virtual platform – it’ll be just like being in the room!

Not only that, but there will be a variety of compelling on-demand CPD content for you to access when and where you want, as well as in-person networking experiences in each state, allowing you to enjoy some social time with your peers.

The two-day ophthalmology-led educational event will include a stellar line-up of industry leaders presenting on myopia control, anterior eye therapeutics, ocular lesions, paediatrics, glaucoma, diabetes, age-related macular degeneration, neuroophthalmology and vitreoretinal.

SCC is one of Australia and New Zealand’s best-attended optometry professional development events on the industry calendar and with a jam-packed agenda, this one is not to be missed!

To find out more and to register, go to SCC2022.com.au.

SPEC008 - Specsavers Clinical Conference - Insight - Print 235x297mm_r3.indd 1

3/6/22 10:44 am

JUL

2022

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

KEY EVENT RETURNS AS INDUSTRY PREPARES FOR GLOBAL OPTOMETRY AUDIENCE IN 2023 Almost three years since its last major event, the Optical Distributors and Manufacturers Association (ODMA) is basking in the success of OSHOW22, which could become a permanent biennial fixture for Sydney.

The optical trade fair was held at the Hordern Pavilion Friday 27 May and Saturday 28 May, with around 1,100 industry professionals registering their attendance to view the latest releases from more than 70 suppliers across 130 booths.

The last OSHOW was held in Melbourne in 2018. It alternates with ODMA’s other major event O=MEGA, which it organises with Optometry Victoria/South Australia in Melbourne.

COVID forced the postponement or cancellation of these events in recent years, with O=MEGA being ODMA’s

last event in 2019. So the return of OSHOW – a key industry trading platform as well as a revenue stream for ODMA – was met with equal measures of relief and excitement.

attendees were from New South Wales. Last time OSHOW was held in Melbourne, around 80% were from the home state, indicating Sydney’s accessibility as a host city.

ODMA acting CEO Ms Amanda Trotman told Insight this year’s OSHOW was almost double the floor size of the last show in Melbourne that featured 700-800 attendees and 47 exhibitors. This was a deliberate move, considering how few events there had been across the Australian optical industry and was achieved despite placing a limit on the number of booths exhibitors could purchase.

This year, Victorians and Queenslanders made up around 12% of attendees each, and around 4% came from South Australia and 2% from Western Australia and another 2% from New Zealand. While COVID-19 is still impacting the desire of some to travel, attendees came from as far afield as Canada, France, Japan and Hong Kong.

“When I’ve been walking the aisles and getting a chance to talk to exhibitors, firstly I’ve been hearing that everyone is loving having an event for Sydney – that’s not happened for a

The Eyes Right Optical stand was a hive of activity at the recent OSHOW22.

long time,” she said.

“Secondly, they’re really enjoying that face-to-face interaction and the opportunity to be back out building business in a vibrant event setting.

I’ve also heard it’s a good mix of not only customers they know, but they're actually seeing many new faces.”

Trotman said around 65% of

In terms of the types of attendees, approximately 30% classified themselves as owners/directors/ continued page 8

OPHTHALMIC SECTOR REACTS TO NEW LABOR GOV The Australian ophthalmic sector is upbeat about the transition of power to a Labor government and will now seek to advocate for eyecare reforms that peak bodies say are well overdue.

Labor ended its nine-year term in opposition on 21 May, convincingly beating the Coalition that tended to lose seats to Labor in suburban areas, and to independents in wealthier areas of capital cities.

New Prime Minister Mr Anthony Albanese – Australia’s 31st leader – unveiled his full line-up of Labor ministers shortly after, handing Mr Mark Butler the health and aged care portfolio.

Asked how she expected the incoming Labor government to impact eyecare in Australia, Optometry Australia (OA) CEO

Ms Lyn Brodie told Insight several significant health announcements were made in the pre-election period, but none signalled significant systemlevel reform or changes to improve community eyecare access.

“We will be reaching out to the government to continue conversations, begun during their period in opposition, about changes needed to ensure all Australians can get timely, affordable access to the eyecare they need. We have good relationships with key people within the incoming government,” she said.

Optometry Medicare indexation – recently increased by 1.6% but lagging significantly behind Consumer Price Index (CPI) which rose 5.1% in the past 12 months – is a high priority for OA. The

organisation said it would press to discuss “fairer Medicare indexation” with Butler.

“A freeze in indexation for optometry between 2013 and 2019, plus a 5% cut to MBS rebates introduced by the government in 2015, has resulted in Medicare rebates in real terms in 2022 being a decade behind where they should be today,” Brodie said.

“Optometrists will have no choice but to charge patients more and more out-of-pocket costs. There are already too many Australians who are unable to access the timely care they need and we believe lagging Medicare indexation will contribute to a national eye health crisis."

According to OA, long-term eye continued page 8

HOW PREMIUM LENSES ELEVATE A PRACTICE Eye Trend director Helen Lee (right), and her daughter and marketing manager Charlotte Ng, discuss their decision to introduce ZEISS lenses into their five-practice optometry business in Melbourne.

page 42

Maximise your glaucoma workflow with ZEISS SLT.

Carl Zeiss Pty Ltd, NSW 2113 AUSTRALIA.

NE W

Introducing ZEISS VISULAS green with SLT Discover an efficient glaucoma treatment experience with the integrated SLT option on your VISULAS® green laser from ZEISS. • Workflow integration and digital documentation • Safe and effective primary open-angle glaucoma therapy • Comfortable and intuitive operation zeiss.com/visulasgreen © Carl Zeiss Meditec AG, 2022. All rights reserved.

ZEISS AU: 1300 365 470 med.au@zeiss.com

IN THIS ISSUE JULY 2022

EDITORIAL

FEATURES

A MUCH-NEEDED BOOST There’s nothing like a trade fair to breath new life into an industry that has been starved of face-toface interaction during the past three years.

OSHOW 2022 can be considered a resounding success for organisers ODMA and the broader optical industry, helping bridge the important divide between suppliers and key decision makers within optical practices.

22

UNBRIDLED FREEDOM Two early career optometrists have just opened an independent boutique in Sydney's inner west.

26

LEVERAGING SCALE Key opportunities and challenges facing Vision Eye Institute's network of clinics and day surgeries.

Many eyecare professionals use such events to short-circuit purchasing decisions for big ticket items, frames ranges and services by comparing like-for-like products on the exhibit floor. After being limited to one-on-one meetings and demonstrations, many practice owners I spoke to relished the chance to see what the industry had to offer under one roof, without the distraction of their daily business responsibilities.

Having the opportunity to do so helps push the industry forward in terms of innovation, fashion and practice efficiency – key elements to the sustainability of independent optometry.

Carl Zeiss Pty Ltd, NSW 2113 AUSTRALIA.

There’s also the intangible benefits of trade events – networking strengthens the fabric of the independent optical community where practice owners can share their ideas, struggles and triumphs. It’s also a chance to celebrate innovation that continues to astound me in this industry.

30

PIVOTAL MOMENT A behind-the-scenes look at Cylite’s expanding production facility in suburban Melbourne.

44

LOCUM LIFE Locum optometrists offer a glimpse into their life on the road across Australia.

EVERY ISSUE 07 UPFRONT

55 MANAGEMENT

09 NEWS THIS MONTH

56 PEOPLE ON THE MOVE

53 OPTICAL DISPENSING

57 CLASSIFIEDS/CALENDAR

54 ORTHOPTICS AUSTRALIA

58 SOAPBOX

ODMA is yet to decide the location of the 2024 event, but has signalled an interest to keep it in Sydney (page 3). NSW comprises the largest proportion of optometry practices at 32% and Victoria the second-most at 26%. That way, Melbourne (O=MEGA) and Sydney (OSHOW) – two fantastic and accessible event destinations – could host alternating events, maximising the opportunity.

Organisers are also considering whether the event keeps its Friday-Saturday program – both business days for many optometry practices – or whether they should opt for a Saturday-Sunday schedule in 2024.

Either way, it’s a delight to see the return of an event that has re-energised the industry. COVID has certainly taught us that nothing can galvanise an industry like in-person events.

MYLES HUME Editor

INSIGHT July 2022 5

Alcon Toric IOLs lead the way in astigmatic correction ®

†1

Alcon® Toric IOLs allows you to correct even the smallest amount of astigmatism‡2-5 Most cataract surgery patients present with some level of corneal astigmatism.§6 The Alcon® Toric IOL portfolio, with cylinder powers from T2–T9, accommodate a wide range of astigmatic correction needs, from high to low.2-5 Built on the heritage of the proven AcrySof ® platform, Alcon® Toric IOLs offer exceptional performance with outstanding refractive predictability7-10 and rotational stability7-10 for you and your patients.

Based on market size and unit share from Q2 2021 compared to AMO, Zeiss, and Bausch & Lomb/Dorc in select markets. ≥0.65D of corneal astigmatism. § Refractive and keratometric data from 4540 eyes of 2415 patients.6 † ‡

References: 1. Market Scope Data. Q2 2021 in Australia and New Zealand. 2. AcrySof® IQ Toric Directions for Use. 3. Clareon® AutonoMe® Toric Directions for Use. 4. AcrySof ® IQ PanOptix® Toric Directions for Use. 5. AcrySof ® IQ Vivity ® Toric Directions for Use. 6. Ferrer-Blasco T et al. J Cataract Refract Surg 2009;35:70–75. 7. Lee BS and Chang DF. Ophthalmology 2018;125(9):1325–31.

8. Levitz L et al. Asia Pac J Ophthalmol (Phila) 2015;4(5):245–9. 9. Oshika T et al. Eur J Ophthalmol 2020;30(4):680–84. 10. Lane S et al. J Cataract Refract Surg 2019;45:501–506. ©2021 Alcon Inc. Alcon Laboratories (Australia) Pty. Ltd. ABN 88 000 740 830. Phone: 1800 224 153. New Zealand NZBN 942904703 0480 Phone: 0800 809 189. ALC1430b 09/21 ANZ-ACO-2100002

UPFRONT Just as Insight went to print, RANZCO published a new position statement entitled: ‘Progressive Myopia in Childhood’. Launched during Myopia Awareness Week (23-28 May), it suggested a more nuanced public policy that aims to optimise UV exposure to reduce skin malignancy – but not to the level that results in vitamin D deficiency – and, importantly, maintains exposure to sufficient high-intensity sunlight to minimise myopia progression. “By increasing the exposure of the paediatric eye to an increased lux of visible light and limiting a child’s exposure

to UV radiation, it should be possible to limit both UV-related eye diseases and myopia.”

IN OTHER NEWS, National Institutes of Health researchers showed the AREDS2 formula, using the antioxidants lutein and zeaxanthin instead of beta-carotene, not only reduces risk of lung cancer, but is more effective at reducing risk of AMD progression. The study, published in JAMA Ophthalmology, followed up 3,883 of the original 4,203 AREDS2 participants to analyse 10 years of data. After a decade, the group originally assigned lutein/ zeaxanthin had an additional 20% reduced risk of progression to late AMD compared to those originally assigned beta-carotene.

“These results confirmed that switching our formula from beta-carotene to lutein and zeaxanthin was the right choice,” the authors said. FINALLY, pharmacists have been called upon to help the millions of Australians suffering dry eye disease following new research showing that 77% have experienced symptoms yet many do not have a clear understanding of the signs, symptoms or causes. To raise awareness about undiagnosed dry eye, Alcon's consumer study suggesting that despite the prevalence of dry eye discomfort, only 11% of people would see an optometrist and 3% would speak to a pharmacist for advice in response to their eyes bothering them.

insightnews.com.au Published by:

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

n

WEIRD

US scientists revived photoreceptors in dead people's eyes and restored communication between them, raising questions about the irreversible nature of death. According to the team from John A. Moran Eye Center at the University of Utah and Scripps Research: "In eyes obtained up to five hours after an organ donor's death, these cells responded to bright light, coloured lights, and even very dim flashes of light." n

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

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

Client Success Manager Justine Nardone

WONDERFUL

A UK man who lost his sight during the pandemic has launched a TikTok account with his brother dedicated to supporting those with blindness. Yahya Pandor, 27, lost his sight due to macular degeneration and has now amassed more than 10,000 followers. He told the BBC he wants to show others that people with visual impairments are not "a burden on society". n

christine.clancy@primecreative.com.au

STAT

WACKY

A Perth pupil who lost sight in one eye after being struck by a computer stand thrown by another student has been awarded $360,000 in damages.

According to Perth Now, the district court ruled his teacher was negligent by leaving the classroom before the incident happened.

justine.nardone@primecreative.com.au

Design Production Manager Michelle Weston

OPHTHALMOLOGY TRAINING

michelle.weston@primecreative.com.au

The latest Medical Training Survey revealed 94% of RANZCO trainees would recommend their position to other doctors versus the 80% national average. Page 24.

WHAT’S ON THIS MONTH

Complete calendar page 57.

NEXT MONTH

Art Director Blake Storey Graphic Design Michelle Weston, Kerry Pert, Aisling McComiskey Subscriptions T: 03 9690 8766 subscriptions@primecreative.com.au

NQV CONFERENCE

AUSCRS

9 – 10 JULY

3 – 6 AUGUST

omit any article or advertisement submitted

Optometry Queensland/Northern Territory’s annual North Queensland Vision conference will be held at the Hilton, Cairns.

The Australasian Society of Cataract and Refractive Surgeons’ yearly meeting is returning to its ‘home-away-from-home’ – Peppers, Noosa.

and contributors against damages or

infoqld@optometryqldnt.org.au

julie@outstandingdisplays.com.au

The Publisher reserves the right to alter or and requires indemnity from the advertisers liabilities that arise from material published. © Copyright – No part of this publication be reproduced, stored in a retrieval system or transmitted in any means electronic, mechanical, photocopying, recording or otherwise without the permission of the publisher.

INSIGHT July 2022 7

NEWS

FIRST INTERNATIONAL GATHERING IN FOUR YEARS continued from page 3

managers, 30% were optometrists, 25% were optical dispensers and 12% worked in customer service.

While the majority of attendees were from independent practices, exhibitors told Insight they had spoken to several corporate employees scoping out equipment and products to make the jump to independent practice.

Equipment distributors such as Device Technologies, Designs For Vision and OptiMed, and frames suppliers like Sunglass Collective, Eyes Right Optical and Frames Etcetera appeared to enjoy high activity on their booths, alongside lens suppliers Hoya and Zeiss.

Trotman said the industry had been calling for a Sydney event for some time, and would now canvas attendees and exhibitors in a survey to decide whether OSHOW would be again held in Australia’s most populous city in 2024.

“The plan would be to try and keep this in Sydney based on its success. The survey for both attendees and exhibitors will also ask for feedback on other aspects such as opening hours and days of the week – and whether it should stay on Friday and Saturday, or be run Saturday and Sunday,” she said.

Device Technologies ophthalmic diagnostic business manager Mr Ryan Heggie said the event “was a great success”.

“It was fantastic to reconnect with customers, friends, and industry once again,” he said.

O=MEGA23 BIGGER THAN EVER

“There was a steady flow of traffic and a real buzz around the Device Technologies booth. We had particular interest in our range of myopia management instruments, as well as OCT and our new automated refraction system.”

Hoya Lens Australia national training and development manager Mr Ulli Hentschel said he was impressed with the strong turn out across both days, with there tending to be more interstate visitors on Friday, and more Sydneysiders on Saturday.

He said there was a particular interest in Hoya’s myopia activities, and the fair created an environment to break the ice with many new potential customers.

“It’s been difficult to get into practices and we have had to pivot with online meetings etc, but as a lens company this platform allows you to have quick informal discussions that aren’t as imposing as a structured sales meeting. Having a casual discussion allows practice owners to test the waters to see whether they're interested in partnering with you,” Hentschel said.

Meanwhile, details have been released for ODMA’s next event, O=MEGA23, at the Melbourne Convention and Exhibition Centre from 8-10 September 2023.

“THE WCO IS EXCITED BY OUR CONGRESS PARTNERSHIP WITH OV/SA AND ODMA, AND THE VALUE THE CONGRESS WILL BRING TO OPTOMETRY WORLDWIDE” PETER HENDICOTT, WORLD COUNCIL OF OPTOMETRY

This year’s event also included Masterclasses and Workshops for the first time, focusing on topics related to optical dispensing, skills for front of house staff and starting independent practices.

The three-day event will be bigger than usual, combining with the 4th World Congress of Optometry. The three-way partnership between ODMA, OV/SA and the World Council of Optometry (WCO) will see the largest eye health conference and trade show for optometry in the southern hemisphere, showcasing Australian optometry to a world stage.

The two events are expected to attract more than 2,000 global professionals including optometrists, optical dispensers, ophthalmologists, orthoptists, ophthalmic nurses, practice staff, optical retailers and service providers, technicians and students to Australia over three days.

Originally scheduled for 2021, the 4th World Congress of Optometry and O=MEGA21 were postponed due to COVID-19. The 2023 event will mark the first major international gathering of eye health professionals in four years.

“Importantly, [it] allows optometry to highlight its role in the international agenda of securing improved vision and eye health outcomes across the world. The WCO is excited by our congress partnership with OV/SA and ODMA, and the value the congress will bring to optometry worldwide,” WCO president Professor Peter Hendicott, former head of the Queensland University of Technology optometry school, said. n

It also featured Spotlight Sessions on the exhibit floor, focusing on issues such as the patient experience in a digital world, 3D printed customised eyewear, choosing frames for patients’ face types, and building rapport with customers for increased sales.

CALL TO PLACE EYE HEALTH AT TOP OF AGENDA continued from page 3

conditions place a $16.6 billion economic burden on the Australian economy annually.

“Any increase in fees a patient is asked to pay can result in them delaying, or ignoring, the need for regular eye examinations and this will put the eye health of many at risk," Brodie added.

Australian Society of Ophthalmologists vice president Dr Peter Sumich said Australia was now left with a new mosaic of a parliament that will need to be adapted to.

“I can only see a benefit for health because we finally have a new, keen

8

INSIGHT July 2022

government which has not been exhausted by the COVID effort,” he said.

According to Vision 2020, vision loss costs the Australian economy $27.6 billion annually. Recent estimates indicate that by 2050, half of Australians will require eyecare services and the economic costs are about to compound.

“We feel confident that eye health will continue to receive good support.”

Vision 2020 Australia CEO Ms Patricia Sparrow said the new parliament presented opportunities for positive change.

“In Australia, 90% of blindness and vision loss is preventable or treatable if detected early enough," she said.

"The time to enact policies that ensure prevention and timely treatment are available for all Australians and that people who are blind or have low vision can get the services they need has well and truly arrived.”

Prime Minister Anthony Albanese.

“Additionally, Aboriginal and Torres Strait Islander communities are disproportionately impacted and experience vision loss at three times the rate of other Australians, accounting for 11% of the health gap,” Sparrow said.

“We urge the Albanese government to put eye health and support for people who are blind or have low vision on the top of its first term agenda.” n

NEWS

EYEQ-NOC ACQUIRES THE SPECTACLE SITE OPTOMETRY GROUP Victorian optometry business The Spectacle Site has been acquired by EyeQ Optometrists-National Optical Care (NOC), with the deal comprising five Melbourne and Victorian practices and a Canberra location trading as Specialeyes.

an optical group with extensive optical experience and support.”

She said the acquisitions were settled in mid-April and were already operating under EyeQ-NOC ownership.

“The latest acquisitions take the total of practices in the EyeQ-NOC network to 46 with another practice to join soon, making the total 47,” Wegrzynowski said.

The purchase now sees EyeQ-NOC gain a stronger foothold in Victoria, while expanding its practice network to 46 locations, with another expected to join shortly after.

The Spectacle Site acquisition comprises practices in Croydon North, Croydon Central, Rowville, Healesville, and Seymour – all in Victoria – as well as Specialeyes in Canberra to complement EyeQ-NOC’s existing ACT practices.

The Spectacle Site’s Boronia location was not included in the deal due to a different ownership structure and will continue to operate as an independent site.

EyeQ-NOC general manager of eyecare and professional services Ms Lily Wegrzynowski told Insight the practices had been acquired under a full ownership

The Spectacle Site in Croydon Central is one of six practices involved in the acquisition.

model, with all teams, including more than 20 staff, retained across the practices.

“The Spectacle Site group of practices had most recently been under private ownership with the owners having had no prior experience in the optical industry,” she said.

“The transition to EyeQ-NOC ownership will help deliver more resources to these practices as a result of being part of

“To date the network has been strongly represented in NSW and Queensland, however the network is growing in Victoria, particularly given that Victoria is a state well-resourced with optometry practices.

Our growth has also been concentrated on the eastern seaboard to enable the best support and resources for the newly acquired practices.”

On its website, The Spectacle Site prided itself on being eyecare-led and 100% Australian-owned and operated. Most of its practices are equipped to cut and fit lenses in-store, and offer other services like contact lens fitting and intense pulsed light (IPL) therapy. n

NEWS

STRONG EARLY SIGNS OF NEW SPECSAVERS-MDFA AMD PILOT

IN BRIEF n

CARE FAILURE

New Zealand’s Deputy Health and Disability Commissioner Dr Vanessa Caldwell found a district health board (DHB) in breach of its duties after a 6-year-old boy with reduced vision waited six months for an appointment before seeking private care. He was subsequently diagnosed with a brain tumour.

Two referrals were sent to the DHB by two different GPs requesting an appointment for worsening eye symptoms. Despite initially being triaged to be seen within 12 weeks, and then re-prioritised following the second referral to be seen within four weeks, the boy didn’t receive an appointment. His mother took him to a private ophthalmologist who arranged for him to have an urgent CT head scan that revealed a solid mass lesion in the back of his brain. This was removed and found to be benign.

n

CLIMATE CHANGE

RANZCO is among five medical colleges, with more than 56,000 members, that have written to Australian policymakers and energy companies calling for a plan to phase out coal by 2030. The colleges have advocated for protection of Australians from the impacts of air pollution and climate change by adopting orderly plans to replace coal with renewable energy. “RANZCO joins our medical colleagues calling for leadership from the Federal Government on decarbonising our society and building resilience to drought, fire, floods and heat stress, as a coordinated national response can effect meaningful change for healthier livelihoods in Australia,” RANZCO president Professor Nitin Verma said.

n

CLINIC ACQUISITION

Presmed Australia (PMA) has taken a minority shareholding in Devonport Eye Hospital (DEH) and the practices of North West Eye Surgeons (NWES). DEH is a one theatre ophthalmic specialty day surgery that opened in 2014 with co-located consulting rooms of NWES, and additional consulting rooms in Burnie, Tasmania. NWES has been servicing Tasmania’s North West coast community for more than 50 years and has three ophthalmologists, supported by other ophthalmic experts. Over the next few years, PMA will aim to further increase its shareholding until it becomes the majority owner of both businesses.

10

INSIGHT July 2022

Specsavers and Macular Disease Foundation Australia (MDFA) are reporting early positive signs from a pilot tackling preventable blindness in patients with neovascular age-related macular degeneration (nAMD).

The pilot is expected to show true prevalence of national nAMD rates.

Image: Specsavers.

In May, the organisations launched a strategic scoping partnership which they say represents an Australian-first move to overcome preventable vision loss from nAMD. Specifically, they will support nAMD suspects to attend their first ophthalmology appointment and help with treatment adherence.

It is also an opportunity to gain a true understanding of incidence and prevalence rates of nAMD across Australia for the first time.

“As a part of our Transforming Eye Health strategy, we’ve been focussed on making progress toward better health outcomes for patients with the major forms of avoidable blindness – in terms of glaucoma and diabetes, we are making a demonstrable difference,” Dr Ben Ashby, director of optometry for Specsavers Australia and New Zealand, said.

“We’ve yet to really start making a big impact in AMD and the project that our pilot stores are working on will lay out the pathway for how we can work together with the MDFA to protect these people’s sight. All optometrists know the scale of the problem that we’re trying to solve for the 150,000-plus Australians currently with the neovascular form of this disease.

There is incredibly effective treatment out there that to some degree restores people’s sight, and protects their vision for as long as they are on the treatment.

“The challenge is that as many as one in five people stop adhering to this treatment and, as a result, permanently lose their vision.”

The project has begun in pilot phase with 16 Specsavers practices from around the country.

Consenting patients with suspected nAMD who have had an eye test at these practices are being referred to MDFA via Oculo at the same time as their ophthalmologist referral.

MDFA then contacts the patient within three business days to check how they are feeling and to answer questions from the referral. Here, the organisation encourages them to attend the ophthalmology appointment and invites them to join the

MDFA specialised treatment support program called ‘My Eyes’.

Once the appointment has occurred, MDFA contacts the patient again to find out the diagnosis and prescribed treatment, and seeks to answer questions or concerns.

‘My Eyes’ then commences which sees periodic check-ins with the patient, aligned with their treatment intervals. All ‘My Eyes’ patients also receive tailored information and resources every two months and are connected to other services.

Through this methodology, MDFA can report on patient consent/participation rates, anonymised patient diagnoses, false positive ophthalmology referral rates and patient sentiment.

This is shared with participating Specsavers optometrists who can also feedback on the process in monthly project meetings.

While the initiative is still in infancy, Specsavers has reported that early trends are encouraging, with 75% of participating patients joining ‘My Eyes’ and early figures showing the first patients adhering to treatment.

Ashby said that the project may take several years to test and slowly grow as key trends and data emerges from the pilot phase.

“Eliminating loss to follow up and increasing treatment adherence rates within our patient base would significantly reduce the unfortunately high amount of Australians who lose vision to nAMD every year,” he said.

“As always, we’re committed to sharing the blueprints to any success in patient health outcomes as we work closely with MDFA to formulate a strategy that could eventually impact all Specsavers patients with AMD nationwide. As we receive key learnings and data, we’ll be sharing it on HealthHub.” MDFA CEO Ms Dee Hopkins added: “For this project, we are thrilled to position ourselves alongside the nation’s largest optometry provider to determine how we can collaboratively improve the visual outcomes of our patients. Our shared vision is that the successful measures determined through the partnership will be shared with the entire industry to further impact the nation’s eye health.” n

The power of 1,008

Traditional OCT with a single scanning spot

Hyperparallel OCT with 1,008 simultaneous scanning spots

Hyperparallel OCT technology is redefining anterior segment imaging by: • Simultaneously scanning a snapshot grid of 1,008 beamlets, instead of just one.

• Each snapshot covering the entire region of interest, enabling true volume images.

• Scanning at over 300,000 scans per second, minimising motion artefacts.

Want to learn more?

Scan the QR code or visit cyliteoptics.com

NEWS

NEW ANTI-VEGF THERAPIES SEEKING AUSSIE APPROVAL The suppliers of two new anti-VEGF therapies recently cleared in the US and that work to reduce macular disease treatment burdens are seeking approval to list the therapies on the Australian Pharmaceutical Benefits Scheme (PBS).

(DME). It is said to be the first and only FDA-approved injectable eye medicine for nAMD and DME that improves and maintains vision with treatments from one to four months apart in the first year following four initial monthly doses.

One of the therapies – a port delivery system with ranibizumab to treat neovascular age-related macular degeneration (nAMD) called Susvimo – is also seeking a new Medicare item number with the Medicare Services Advisory Committee (MSAC).

Both therapies are now being considered by the Pharmaceutical Benefits Advisory Committee (PBAC) in Australia.

If approved, the therapies would significantly expand the number of available and PBS-listed anti-VEGF treatments in Australia, which currently include Eylea (aflibercept) Lucentis (ranibizumab) and, more recently, Beovu (brolucizumab).

In October 2021, the US Food and Drug Administration (FDA) cleared Genentech’s Susvimo therapy for nAMD in patients who have previously responded to at least two anti-VEGF injections. The implant has been described as the first and only FDAapproved treatment for nAMD offering as few as two treatments per year.

Then, in January 2022, the US regulator approved Vabysmo (faricimab-svoa) for nAMD and diabetic macular edema

received supplemental ranibizumab treatment before their first refill, and more than 98% could go six months before their first refill.

Treatment cost is considered a major barrier for patients.

At PBAC’s March 2022 meeting, drug company Roche sought PBS listing of Susvimo for nAMD for patients who are responsive to prior anti-VEGF treatment.

The outcome cannot be made public until the TGA outcome is known. The therapy is also before MSAC for a new Medicare item number, which also hasn’t been decided at the time of writing.

Vabysmo’s supplier is seeking PBS listing for DMO at PBAC’s meeting in May. Genentech said Susvimo was shown to be non-inferior and equivalent to monthly ranibizumab injections.

The therapy’s FDA approval was based on positive results from the Phase 3 Archway study, which showed nAMD patients treated with Susvimo achieved and maintained vision gains equivalent to monthly ranibizumab injections at weeks 36 and 40 of treatment.

In addition, only 1.6% of Susvimo patients

However, the implant has been associated with a three-fold higher rate of endophthalmitis than monthly intravitreal injections of ranibizumab; 2% of patients receiving an implant experienced at least one episode of endophthalmitis.

Meanwhile, Vabysmo’s manufacturer Roche said the therapy offered a new medicine that could improve patients’ vision, potentially lowering treatment burden with fewer injections over time.

The FDA approval was based on positive results across four Phase 3 studies in nAMD and DME. They consistently showed that patients treated with Vabysmo given at intervals of up to four months achieved non-inferior vision gains versus aflibercept given every two months in the first year.

Vabysmo was generally well tolerated in all four studies, with a favourable benefitrisk profile, Roche reported.

The most common adverse reaction (≥5%) reported in patients receiving Vabysmo was conjunctival hemorrhage (7%). n

GEORGE & MATILDA CONTINUES TO GROW AS NETWORK CELEBRATES SIX YEARS IN BUSINESS independent is still there,” he said.

An established practice in Queensland is the latest to join George & Matilda Eyecare (G&M) with more in the pipeline to be announced shortly, as the company celebrates its six-year anniversary.

Stephens and practice manager Ms Kerryn Watkins said they valued the support G&M provided during the transition to the network, including an onboarding team member who came into the practice for the first few weeks to help streamline the transition process.

Aspley Optical House in the Brisbane suburb of Aspley joined the growing G&M network in April. Optometrist Mr Hugh Stephens was the original owner in 1978 and continued working there after selling the practice in 2017.

“Going from being an independent practice of 40 years to being part of a larger group was daunting, but we have found that George & Matilda Eyecare have the same goals and ideals as us in delivering the best in professional optical care, and enabling us to still maintain what had always made our practice unique,” Stephens said.

“The difference now is, we have a large network to rely on bringing in

12

“Also beneficial is being part of a G&M that's bringing in fresh new brands and having access to marketing and promotional resources, enabling us to reach a broader market and implement professional campaigns,” Watkins said.

Aspley Optical House team (from left) Jackie Dickinson (optical dispenser), Andrew Rice (optical dispenser), Hugh Stephens (optometrist), Anna Reaburn (optometrist), and Kerryn Watkins (practice manager).

She said G&M’s training and reference guides had been helpful and easy to access.

fresh ideas, the latest in technology and really feeling part of a bigger family all invested in improving patient care in the best possible way. It is very community minded and that feeling of being

“There are professional departments to answer our questions, and the team are always friendly and on hand, listening to any concerns and coming up with solutions,” she said. n

INSIGHT July 2022

OP0621-46 HR

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

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

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

LEARN MORE OPSM.COM.AU/CAREERS VISIT US ON LINKEDIN

OP0621-46 HR GeneRic Ad 235x297mm

Arvin Optometrist

NEWS

FLINDERS UNIVERSITY ANALYSIS FIRST TO QUANTIFY AUSTRALIA’S OCULAR TOXOPLASMOSIS RATE One in 150 Australians have retinal scars caused by the Toxoplasma parasite, according a new Flinders University analysis that has prompted calls for increased awareness about the risks of eating raw and undercooked meat.

Closely associated with cats, Toxoplasma is a parasite that causes the infectious disease known as toxoplasmosis. Many animals around the world are infected, generally contracting the disease in environments soiled by infected cats or by consuming other infected animals.

According to Flinders experts, while domestic cat faeces can be a carrier for humans, the most common route of infection is by eating undercooked or raw meat sourced from infected livestock.

A Toxoplasma parasite infection can put people at risk of attacks of toxoplasmosis that can progressively damage the retina and lead to vision loss.

“Considering Australia’s substantial population of feral cats that are known to be infected, alongside high levels of farming and diets rich in meat, it’s imperative we understand the prevalence

of the disease across the country,” study senior author Professor Justine Smith, Strategic Professor in Eye & Vision Health at Flinders University, said.

“While there is no cure or vaccine, the symptoms of toxoplasmosis vary depending on the age, health and genetics Eye scan showing of the infected individual. Many people ocular toxoplasmosis. are asymptomatic, but the most common Image: João M. Furtado. disease that we see in the clinic is retinal inflammation and scarring known as ocular toxoplasmosis.

“Studies around the world show that 30% to 50% of the global population is infected with Toxoplasma, but despite knowing that, what we didn’t know was how common the related eye disease was.”

In the study, published in the journal Ophthalmology Retina, Smith and her team analysed retina photographs of over 5,000 people living in the Busselton area in Western Australia, previously collected to evaluate the prevalence of glaucoma and age-related macular degeneration for a long-term healthy ageing study.

Three specialised ophthalmologists, including Smith, assessed the scans for

toxoplasmic retinochoroiditis, with positive cases confirmed with antibody blood tests.

“Among the 5,000 people, we found eight participants with blood test-confirmed toxoplasmic retinal scars. Add to that that about three-quarters of the retinal lesions would be in a position not visible in these particular photographs, we were able to estimate the prevalence of ocular toxoplasmosis to be one per 149 persons,” Smith said.

According to a press release, the work represents the first effort to quantify the rate of ocular toxoplasmosis in Australia, with the findings indicating the condition can be considered common.

With previous research showing the infection can lead to reduced vision in more than 50% of eyes and even blindness, the authors say it is important for people understand the risk factors of toxoplasmosis and ways to avoid it.

“While people are often familiar with pregnant women needing to avoid cat litter trays, we also need everyone to know that preparation of meat is an important risk factor,” Smith said. n

POOR EYESIGHT COULD UNFAIRLY SKEW COGNITIVE TEST RESULTS Researchers at the University of South Australia have ascertained that millions of older people with poor vision are at risk of being misdiagnosed with mild cognitive impairments.

of 50 – unfairly affect cognitive scores when tests involve visual abilities.

“A mistaken score in cognitive tests could have devastating ramifications, leading to unnecessary changes to a person’s living, working, financial or social circumstances,” she said.

Their study – published in Scientific Reports – found cognitive tests that rely on vision-dependent tasks could be skewing results in up to a quarter of people aged over 50 who have undiagnosed visual problems such as cataracts or age-related macular degeneration (AMD).

The research team recruited 24 participants with normal vision to complete two cognitive tests – one involving visiondependent reactive tasks and the other based on verbal fluency.

Using a set of goggles to simulate AMD, the participants scored far lower on the cognitive test involving reaction time tasks than without the goggles. There was no statistical difference with verbal fluency tests when using the goggles.

University of South Australia researchers involved in the study included PhD

14

“For example, if a mistaken score contributed to a diagnosis of mild cognitive impairment, it could trigger psychological problems including depression and anxiety.

Undiagnosed visual problems can unfairly affect cognitive scores when tests involve visual abilities.

candidate Ms Anne Macnamara, Dr Scott Cousens and Associate Professor Tobias Loetscher. Researchers from Bond University, Flinders Medical Centre and Singapore also took part.

Macnamara, who led the study, said the results are a stark reminder that visual impairments – which affect approximately 200 million people worldwide over the age

“People with AMD are already experiencing multiple issues due to vision loss and an inaccurate cognitive assessment is an additional burden they don’t need.”

Visual impairments are often overlooked in research and clinical settings, the researchers said, with reduced vision underestimated in up to 50% of older adults. With this figure expected to increase in line with an ageing population, it is critical that neuro-degenerative researchers control for vision when assessing people’s cognition. n

INSIGHT July 2022

1634_T

FROM SCREENS TO SUN. FACE THE LIGHT. NEW TRANSITIONS® POINT OF SALE AVAILABLE NOW To order visit www.Transitions-Plus.com First time visitors use registration code TransFSTS For campaign details email: info@transitions.com.au Transitions is a registered trademark, the Transitions logo and Transitions Light Intelligent Lenses are trademarks of Transitions Optical, Inc. used under licence by Transitions Optical Limited. ©2022 Transitions Optical Limited. Photochromic performance is influenced by temperature, UV exposure and lens material.

1634_Transitions_From Screen to Sun Trade Ad_Insight_v3.indd 1

30/5/22 12:46 pm

NEWS

CODE OF CONDUCT UPDATE FOR OPTOMETRISTS

LOCAL STUDY COMPARING CONTACT LENSES FOR MYOPIA PROGRESSION Researchers at UNSW Sydney’s School of Optometry and Vision Science are conducting a study comparing two multifocal contact lenses for their impact on myopia progression.

The Multifocal Contact Lenses for Myopia (MALCOLM) study is seeking children between 6-12 years of age with -0.50 to -5.00 DS of myopia and -1.00 DC of astigmatism or less, without strabismus.

Optometry is one of 12 health professions that will be bound by the national regulator’s revised shared code of conduct which came into effect 29 June.

Martin Fletcher, Ahpra.

The new code – which applies to a range of professions including chiropractic, dental, occupational therapy, osteopathy, pharmacy, physiotherapy, and podiatry – replaces the existing codes of conduct for the 12 professions.

It sets out National Boards’ expectations of professional behaviour and conduct for practitioners registered, which promotes safe and effective care and helps to keep the public safe.

Participants will be followed for 12 months, during which contact lenses will be provided at no cost.

The National Boards have published an advance copy of their revised shared code of conduct and are encouraging practitioners to familiarise themselves with it.

The child will be required to insert a new lens into each eye daily and dispose of the lenses at night. They will then be asked to return after one week and one, three, six and 12 months when ocular and medical history and wear time with the lenses will be discussed and similar measurements as the baseline visit performed.

The main changes include: • p rinciples to guide behaviour including when an issue is not specifically addressed in the code; • a new section on Aboriginal and Torres Strait Islander health and cultural safety that includes the National Scheme’s definition of cultural safety;

They will also be given a $150 ColesMyers gift voucher as compensation for their time. Participants will still be required to wear spectacles during the study when not wearing the contact lenses and be asked to obtain these from their usual practitioner and not from UNSW.

• i nformation about practitioners’ responsibilities in relation to bullying and

New six-year data on Hoya Vision Care’s defocus myopia spectacle lens presented at ARVO 2022 has answered key questions over rebounding effects and the lens’ ability to sustain its myopia controlling effect over time.

MiYOMART was launched in Australia in October 2020.

The findings of the longest study on a myopia management spectacle lens were shared by Professor Carly Lam from the Centre for Myopia Research at The Hong Kong Polytechnic University who conducted the research.

The results of the six-year clinical study conducted on 90 children in Asia looked at the progression of myopia in children who wore the Hoya’s MiYOSMART spectacle lens with with Defocus Incorporated Multiple Segments (D.I.M.S.) Technology.

16

INSIGHT July 2022

ontent about the importance of clinical • c governance particularly for practitioners in leadership positions; • m ore information about vexatious complaints (notifications); • g uidance for employers about ensuring performance targets and other business practices are consistent with the code, and; • r eorganised content to reduce duplication and make sequencing more logical and minor changes to wording to improve clarity.

Ahpra CEO Mr Martin Fletcher said: “The revised code is contemporary, more useful and more accessible to both practitioners and the public because of these contributions. We strongly encourage practitioners to familiarise themselves with the code before it comes into effect.”

Ahpra said the code does not apply to the Medical Board of Australia, Nursing and Midwifery Board of Australia or the Psychology Board of Australia, as these boards have profession-specific codes of conduct or code of ethics in place. n

FRESH SIX-YEAR MIYOSMART DATA UNVEILED AT ARVO

If practitioners have patients who are interested or have any questions, contact Ms Rebecca Dang (r.dang@unsw.edu. au) or Dr Alex Hui (alex.hui@unsw.edu. au) for more information. n

The MALCOLM study is seeking children between 6-12 years of age.

harassment, including the importance of addressing the issue in the workplace and the role of National Boards/Ahpra;

The results build on an original two-year, double-blind randomised trial, published in the British Journal of Ophthalmology,

that concluded children aged 8-13 years wearing MiYOSMART had 60% less myopia progression compared with single-vision wearers as measured by the axial elongation, and a 59% reduction in spherical equivalent refraction.

Subsequent three-year data showed the lens continued to slow myopia progression, while patients who switched from singlevision to MiYOSMART had a significant slowdown in their condition.

According to Hoya, the findings of the six-year follow-up study proved the MiYOSMART spectacle lens myopia control effect is sustained over time for children wearing the lens. It also confirmed that patients who stop wearing the MiYOSMART spectacle lens show no rebound effects when compared to the initial myopia rates of progression during the two-year randomised control trial or with the general population. n

COMPANY

SIGHTGLASS VISION POSTS TWO-YEAR MYOPIA DATA

COOPERVISION STEPS UP ANZ SUSTAINABILITY COMMITMENT

Spectacles that use SightGlass Vision’s trademarked Diffusion Optics Technology have demonstrated efficacy in slowing the progression of myopia in children, based on 24-month interim data from its pivotal multisite clinical study.

All CooperVision’s one-day contact lenses distributed in Australia and New Zealand are now plastic neutral, the company has announced.

The initiative is made possible through a global partnership with Plastic Bank, a social enterprise that builds ethical recycling ecosystems in coastal communities.

The data from the CYPRESS trial, now in its third year, was presented at the Association for Research in Vision and Ophthalmology (ARVO) conference in Denver.

For every box of CooperVision one-day contact lenses distributed in Australia and New Zealand, the company purchases credits that fund the collection and recycling of ocean-bound plastic into the global supply chain, that is equal to the weight of the plastic used in its one-day contact lenses, the blister and the outer carton packaging.

An analysis of full-time wearers – children aged six to 10 at initiation whose parents reported that they did not remove the study spectacles for near vision activities – showed statistically significant improvements between groups using Diffusion Optics Technology lenses and the control cohort.

Plastic Bank collectors in the coastal communities receive a premium for the materials they collect, which helps them provide basic family necessities such as groceries, cooking fuel, school fees, and health insurance.

Axial length exhibited a 0.21 mm difference, and the spherical equivalent refraction difference was 0.52 dioptres (D).

Study investigators enrolled, randomised, and dispensed the lenses to 256 eligible children across 14 clinical trial sites in the United States and Canada – a geographical distinction compared to most other myopia-related spectacle lens studies.

Ms Michelle North, general manager of ANZ at CooperVision, said the company is on a sustainability journey.

“Over the past several years, we have built a strong track record of sustainable manufacturing and operations, focused on areas in which we can make the greatest impact,” she said.

At the time of enrolment, subjects were six to 10 years old having myopia between -0.75 D and -4.50 D.

“Plastic plays a critical role in the hygienic delivery and sterile protection of our contact lenses, and how that plastic is managed is important to us. The commitment to making all of our one-day lenses in Australia and New Zealand plastic neutral is an innovative addition in CooperVision’s holistic approach to sustainability, with the opportunity to make a positive impact – for our oceans, and for everyone.”

Neary all (99%) of contact lens wearers agree that if their optometrist recommended a plastic neutral daily disposable contact lens, it would have a positive impact on trying that lens. n

Plastic Bank’s collection station in Rio de Janeiro, Brazil.

18

With a mean age of 8.1 years at

The trial enrolled 256 children.

screening, the CYPRESS cohort is reportedly younger than children in other well-known myopia management studies.

According to SightGlass Vision, given the higher likelihood of spectaclesbased interventions for younger children, this study parameter should help build confidence in prescribers and families alike.

CEO Mr Andrew Sedgwick said Diffusion Optics Technology spectacle lenses, with their mechanism of action, represented a promising new approach.

“We’re enthusiastic about sharing more detail from the two-year interim results, which will further support our development efforts and ongoing commercialisation activities in select markets,” he said. n

RODENSTOCK ACQUIRES LEADING SPANISH LENS MANUFACTURER The Rodenstock Group is acquiring Spanish corrective lens maker Indo Optical.

Anders Hedegaard, Rodenstock.

A market leader in the manufacturing of ophthalmic lenses as well as the commercialisation of diagnostic equipment and optical instruments for opticians and ophthalmologists, Indo Optical has 440 employees in Spain, Portugal, Morocco and France, with two main manufacturing sites in Barcelona and Tangier.

Rodenstock believes the acquisition will allow it to increase its global footprint and reach new customers outside the premium segment, with the potential to cross-sell products.

“Indo Optical’s product offering is an ideal fit to our new brand architecture and will allow us to lift synergies for the benefit of our customers,” Mr Anders Hedegaard, CEO Rodenstock, said.

It comes as Rodenstock reported 23% revenue growth to 494 million euros in the 2021 financial year.

“Significant investments in research and development are paying off: the increase in net sales was clearly driven by the ongoing successful execution of the B.I.G. VISION strategy. The patented DNEye Pro technology sits at the very core of the business strategy,” the company stated. n

INSIGHT July 2022

VEI2983

DRY EYE

VEI29837_INSIGHT_FULL-PG_AD_235x297_MAY22_FA2_OL.indd 1

31/5/22 4:53 pm

INTERNATIONAL

DRUG TREATMENT COULD REPLACE SURGERY FOR SPECIFIC CATARACTS

NOVA EYE MEDICAL PURSUES US APPROVAL OF 2RT LASER THERAPY Adelaide-based Nova Eye Medical says it has navigated time-consuming and complex discussions with the US Food and Drug Administration Professor Robyn (FDA) to pave a clear Guymer, CERA. approval pathway for its pioneering 2RT laser system for selected intermediate age-related macular degeneration (iAMD) patients.

Melbourne’s Professor Robyn Guymer will now lead an important study to build on findings in the seminal LEAD trial, which she described as encouraging, but not conclusive.

The ASX-listed company announced in May the clinical study plan and the commercial rights would be pursued by its subsidiary AlphaRET. 2RT is described as a world first nanosecond laser therapy to treat iAMD. Based on the FDA feedback, AlphaRET will begin a confirmatory pivotal clinical study outside of the US at sites in Australia, Canada and Europe. The principal investigator will be Guymer, with early data then to be submitted to the FDA. Importantly, the FDA has agreed patients with reticular pseudodrusen (RPD) will be excluded.

The company expects this will enable the expansion of investigator sites into the US and the progression of the pivotal clinical study for US marketing clearance.

Dr Philip Rosenfeld, Professor of Ophthalmology at the Bascom Palmer Eye Institute of the University of Miami Miller School of Medicine, pioneered anti-VEGF therapy Avastin in nAMD. He is also an advisor to AlphaRET. “The LEAD Study completed by Professor Guymer was a well-controlled clinical trial that showed the immense potential of 2RT,” he said. “However, a second study is required. If the second study is successful, AlphaRET will have the data needed to harness that potential and significantly change the landscape in AMD therapy in the US and around the world. It is not unusual that the FDA is taking such a cautious approach.” n

20

INSIGHT July 2022

A revolutionary new therapy for cataract has shown positive results in laboratory tests in Britain, giving hope that the condition could soon be treated with drugs.

Oxysterol improved refractive index profiles.

A team of international scientists, led by Professor Barbara Pierscionek, deputy dean (research and innovation) in the faculty of health, education, medicine and social care at Anglia Ruskin University (ARU) in Cambridge, UK, has been carrying out advanced optical tests on an oxysterol compound that had been proposed as an anti-cataract drug.

Drug treatments for cataracts have been tested but the results remain inconclusive.

An oxysterol called lanosterol has been shown to increase transparency in dissected rabbit cataractous lenses in vitro and cataract severity in vivo in dogs.

But a separate analysis highlighted three studies that failed to provide evidence that lanosterol or 25-hydroxycholesterol have either anti-cataractogenic activity or bind aggregated lens protein to dissolve cataracts.

The new ARU results have been published in the peer-reviewed journal Investigative Ophthalmology and Visual Science.

In laboratory trials on mice, treatment with the oxysterol compound VP1-001 showed an improvement in refractive index profiles – a key optical parameter that is needed to maintain high focusing capacity – in 61% of lenses.

According to the published results, the protein organisation of the lens is being restored, resulting in the lens being better able to focus. This was supported by a reduction in lens opacity in 46% of cases.

Pierscionek said the study was the first research of this kind in the world.

“This study has shown the positive effects of a compound that had been proposed as an anti-cataract drug but never before tested on the optics of the lens.

“It has shown that there is a remarkable difference and improvement in optics between eyes with the same type of cataract that were treated with the compound compared to those that were not.”

Pierscionek continued: “Improvements occurred in some types of cataract but not in all, indicating that this may be a treatment for specific cataracts.” n

ESSILORLUXOTTICA TEASES SMART GLASSES WITH NEURAL INTERFACE Facebook founder Mr Mark Zuckerberg travelled to Milan to meet with EssilorLuxottica chairman Mr Leonardo Del Vecchio where he hinted at a new smart glasses project featuring a neural interface wristband.

“Great to be back in Milan to discuss plans for new smart glasses with Leonardo Del Vecchio and the EssilorLuxottica team,” he posted on 4 May. “Here Leonardo is using a prototype of our neural interface EMG [electromyography] wristband that will eventually let you control your glasses and other devices.”

EMG measures muscle response or electrical activity in response to a nerve’s stimulation of the muscle.

Facebook – which now comes under the parent company Meta to also include What’s App and Instagram – changed its name to align with its plan to create a ‘metaverse’, which it describes as the next

Mark Zuckerberg showing EssilorLuxottica chairman Leonardo Del Vecchio a prototype in Milan. Image: Facebook.

evolution of social connection.

It believes wearable technology like smart glasses will become gateways into the metaverse, allowing wearers to interact in a virtual world.

The first step in this journey was the launch of Ray-Ban Stories last year, with EssilorLuxottica, which allow users to record audio and video with one touch. n

Stand out with stock that is not standard.

ZEISS ClearView FSV Lenses Stock that is anything but standard: • Freeform technology in FSV lenses • Very thin and very flat without optical compromise • On average 3× larger area of excellent vision clarity 1 zeiss.com/vision 1| Based on a visual clarity simulation on a 50 mm diameter lens area for 1.60 index ZEISS ClearView FSV lenses compared to 1.60 ZEISS AS FSV lenses. Average of +5D, +3D, +1D, -1D, -3D, -5D, and -7D with and without a cylinder of -2D. Quantitative analyses by Technology & Innovation, Carl Zeiss Vision GmbH, 2020.

PRACTICE PROFILE

Theia Optical opened in Five Dock, Sydney, in January.

EARLY CAREER OPTOMETRISTS RELISH INDEPENDENT FREEDOM A shared work ethic and a desire to make their own mark has led university friends DR ANNA TANG and DR KATHERINE DUONG to open an independent optometry boutique in the Sydney suburb of Five Dock.

D

r Anna Tang and Dr Katherine Duong met in the optometry and vision science lab at UNSW in 2014 midway through their optometry Masters degree, spawning a friendship that has evolved into a business partnership.

Tang graduated in 2017 and joined the Specsavers graduate program, working at its Liverpool store for two years. Duong graduated in 2018 and worked in an independent practice for one year.

“Both of us decided we wanted to experience working at different practices, and both went locum full-time,” Duong says.

“Between us, we worked at several independent practices and corporates, including Specsavers, OPSM, and Oscar Wylee. Both of us had the same idea in terms of work ethic – we were both working six or seven days a week.”

through their whole journey – the best way for me to achieve that is to create my own practice so I can practise the way I want,” Tang says.

Her motivation to guide and educate patients about their eye health stems from personal experience.

“I’ve been short-sighted since a young age, and my myopic prescription kept changing every year I was growing up. I had a lot of questions about my eyes but never had any answers,” Tang adds.

BUILDING FROM THE GROUND UP While both women gained optical dispensing experience before graduating, business was not among their skill set.

Their shared drive and exposure to various optometry business models shaped their views on how they wanted to practice.

“Because we both worked so hard, we definitely wanted to work on something that was our own, though we were realistic about it as it would take time to make back that margin and build up our patient base,” Duong says.

Tang and Duong, in their fifth and fourth year out of university respectively, opened a greenfield practice, Theia Optical, in Five Dock in January this year, with the support of ProVision. ‘Theia’ is derived from the Ancient Greek Goddess of sight and all things shining. With youth and time on their side career-wise – and both equally determined to build something for themselves – the duo considered joining a corporate franchise, but ultimately decided to stride out on their own.

“Working at other practices made me realise what I really wanted to do. In order to appease that – to build a rapport with patients and look after them

22 INSIGHT July 2022

The practice fit out was a challenge for the pair who were inexperienced in this area.

“It was extremely daunting. We’re all afraid of failure. That was one of the biggest things that held us back. It took us a while before we set things up,” Tang says.

Although they didn’t initially plan to open a greenfield practice, buying an existing business didn’t meet their requirements.

“We had a strong vision but there wasn’t any store that aligned with that.

We knew we wanted our practice to be modern, welcoming, and catering to all ages, but have a strong clinical background,” Duong says.

“We wanted the best of both worlds, to cater to fashion needs but never compromise on the health of eyes. We couldn’t find somewhere opportunitywise during the time when we were looking (during COVID); there weren’t many practices that were selling.”

For the ambitious pair, the construction process at their chosen Five Dock location was the most daunting. They’re trained in optometry, not project management.

“When you don’t know what you’re doing, everything is hard,” Tang says.

“When you’re looking for services when you’ve never used that kind of service you don’t know who to ask.”

Duong adds: “We didn’t have much idea about business or the construction side of things, setting up accounts, meeting with suppliers, marketing, accounting … there’s more to business than just being an optometrist.”

The self-described perfectionists concede that the idea of starting a greenfield practice was unnerving, but the challenges didn’t end once the fit out was complete and their doors opened.

“There is so much to learn everyday as a new business owner,” Tang says, noting that building a patient base with a limited marketing budget has been a major learning.

“We’ve been trying to post a lot and be consistent on social media. To some degree it has worked, people have reached out,” Duong says.

“Apart from social media, we’re speaking to local businesses. Before we opened, we introduced ourselves to surrounding health clinics and pharmacists, as we’re located next to a medical practice, and in our street there’s quite a few medical practices.”

Tang adds: “We have a lot to learn, even the networking process and reaching out to businesses is still a challenge for us.”

SELECTING EQUIPMENT AND STOCK Tang and Duong are both therapeutically endorsed optometrists and agreed on going “all in” when it came to fitting out their practice with the latest equipment, purchased mainly through Designs For Vision.

“We wanted a beautiful practice, but we didn’t want to compromise on the eye health of the patient, so we’ve purchased an OCT, visual field, fundus camera, and we offer myopia management so we have a biometer and stock Hoya MiYOSMART and CooperVision MiSight contact lenses,” Duong explains.

“The one thing we are missing right now to call ourselves a full scope practice is a topographer. It’s on the list but we’re taking it one step at a time as we splurged a lot because we wanted to make sure we had everything that we needed,” Tang says.

Choosing the frames range was a time-consuming but rewarding part of starting the new business for Duong, who enjoys the fashion retail side of business. They’ve opted for a range that caters from the affordable price point, through to luxury, with brands such as Gucci, Prada, Ray-Ban, Oakley, Tiffany&Co, Carrera and Oroton, to name a few.

“I reached out to suppliers in December in the lead up to the practice opening, during the busy peak period. I met up with every frame rep to see their range, while also still working full time, so it was a packed schedule,” Duong says.

“Based on my prior experience in dispensing and in independent practice, I had a general idea of what was popular and what sold well, and I ordered what I thought would be a good range.”

Prior experience also came into play when Tang and Duong considered

Dr Katherine Duong (left) Dr Anna Tang at their practice opening.

lens suppliers. “We primarily use Hoya but we do use a lot of Essilor as well.

I hadn’t used Hoya prior to us opening but Anna had a good experience with them at an independent practice,” Duong says.

“We occasionally use CR Surfacing and JP Optical because not one lens supplier is going to have all the lenses that you want. It depends on what the patient needs, but being an independent, we’re able to open accounts with any lens supplier we want.”

COMPETITION AND BILLING As if it isn’t difficult enough establishing a greenfield practice, Theia Optical also had to contend with another independent practice opening two doors down around the same time.

Duong and Tang made a point of differentiating through offering different brands and lenses, but say that at the end of the day, they’re focusing on their own business.

“I’m really enjoying the process. Day-to-day, I’m excited for work, and feel the difference between working for someone and having our own store. It’s a different kind of stress, but a good kind of stress,” Duong says.

Tang adds: “I love what we’re doing, and I’m glad I took the leap to start something new, although I’m always striving for more.”

Aligning with ProVision has also helped them remain competitive. NSW then-business coach Ms Joanne Scott-Dostine, who has since left ProVision, was influential in their start up.

“We didn’t know much about the business side of things. ProVision have been helpful finding suppliers, providing advice through the process of securing the rent, a lot of business advice,” Duong says. “They have their own team of people behind the scenes. If the business coach can’t answer your question, they’ll refer it to someone in ProVision that’s their specialty.”

“It’s been nice to have a business coach and support from an organisation that knows what they’re doing. We’d be lost without their help,” Tang adds.

As with all new businesses, Tang and Duong have weighed up whether to bulk or privately bill patients.

“It’s daunting thinking about private billing. We’re a new practice, still building our patient base. We thought if we private bill from the start it might be a little difficult. We also had to consider the demographic in Five Dock,” Tang says.

“The reason why we decided to bulk-bill – at the moment anyway – is because all the GPs around us do it. And Katherine and I both come from practices that have always bulk-billed.”

Finally, when it comes to the future of independent practices, Tang and Duong are optimistic.

“At university, we often heard that it is not profitable to open your own clinic anymore,” Duong says. “In my opinion, there’s always going to be a place for independents, because even at the other independent practices where I’ve worked, we would often get patients from elsewhere who were unhappy with the customer service or quality of frames or lenses they had received.” n

INSIGHT July 2022 23

MEDICAL TRAINING SURVEY

SURVEY OFFERS GLIMPSE INTO LIFE OF A

RANZCO trainee

The Medical Board of Australia has released its third annual Medical Training Survey, creating greater transparency to elevate the training experience for aspiring doctors. Insight analyses ophthalmology’s performance.

F

resh findings from the 2021 Medical Training Survey (MTS) show one in five ophthalmology trainees have experienced bullying, harassment and discrimination, with 92% opting not to report it. Long work hours also remain an issue, with the average RANZCO trainee working 49.7 hours.

The latest survey also reveals that trainees in states and territories worst hit by the pandemic were more likely to report COVID-19 had adversely impacted on their medical training. However, RANZCO has made a priority to mitigate such disruption, noting the implications for future trainees, as well as future workforce and service delivery.

The 2021 MTS is the Medical Board of Australia’s third nationwide survey of all doctors in training and is a confidential way to obtain national, comparative, profession-wide data to strengthen training. More than 21,000 trainees participated in the 2021 survey at a 55% response rate.

Seventy-five trainee ophthalmologists responded, similar to the 2020 survey response rate.

The latest snapshot reveals ophthalmology ranks highly in terms of trainees recommending their position to other doctors – 94% of RANZCO trainees versus the 80% national average.

However, bullying, harassment, discrimination and long work hours are areas that may require further work.

While 82% of RANZCO trainees (versus 78% national average) say bullying, harassment and discrimination (including racism) is not tolerated at their workplace, 22% (22% national average) experienced it and 30% (31% national average) witnessed it.

In ophthalmology, the person responsible was most likely senior medical staff (46%), nurse (46%) or patient and/or patient family/carer (31%).

Concerningly, 92% of ophthalmology trainees who experienced bullying, harassment or discrimination did not report it, considerably higher than the 67% national average, while 89% who witnessed the behaviour did not report it (76% national average).

In terms of hours worked, on average, RANZCO trainee doctors worked 49.7 hours per week compared with 45.5 hours on average across all medical specialties. For RANZCO trainees, 89% were working 40 hours a week or more, compared to the national response of 67%.

In total, 31% of ophthalmology trainees rated their workload as ‘heavy’, while 11% said it was ‘very heavy’. Nationally, these numbers were 39% and 9%, respectively. But when working unrostered overtime, 72% of RANZCO trainees got paid at least most of the time, markedly higher than the 55% national average. But 31% (versus 16% nationally) valued the extra training opportunities this provided.

Unsurprisingly, trainees from places hit hardest by the pandemic reported that their medical training overall had been impacted negatively, while trainees in states and territories less COVID-affected reported the pandemic

24

INSIGHT July 2022

had a mixture of positive and negative impacts on training overall. Broadly, 41% of respondents indicated COVID-19 had negatively impacted their medical training in 2021.

In ophthalmology, 58% said COVID-19 had impacted their training opportunities negatively versus 45% nationally. However, the figures were more encouraging for RANZCO trainees in terms of how the pandemic influenced their exam preparation, research opportunities, career progression and medical training overall.

HOW RANZCO IS RESPONDING RANZCO censor-in-chief Dr Justin Mora told Insight the college carries out its own surveys of both trainees and supervisors multiple times each year.

“Our surveys have been central to understanding the impact of COVID. We have been determined not to let COVID affect our trainees’ progression, which would result in a lot of stress for trainees and has implications for future trainees, workforce and service delivery,” he said.

Mora said a key group that been expanding in size and remit is the college’s Trainee Representative Group (TRG). The college works closely with the body to workshop improvements and improve the flow of communication to all trainees.

Some changes that have come online or continue to roll out include: • Increased access to surgical simulators • Online access for all trainees to tutorial programs run by the NZ and NSW training networks • Determination of RANZCO tutors to use lighter clinics and lists due to social distancing requirements to focus teaching on patients who could attend • Creation of a refraction Entrustable Professional Activity (EPA) to assess a skill that could no longer be assessed in a live exam • C ontinuing to run online written exams and virtual OBCK and RACE OSCE exams • Moving training post accreditations from face-to-face to virtual, which has had the benefit of allowing trainees to provide more candid feedback • Working to educate supervisors and trainers on educative theory and best practice, and the importance of understanding, and providing, useful feedback. This includes newly developed supervisor modules, which include unconscious bias training • Reviewing the education governance structures at the college to ensure each committee is running as effectively and efficiently as possible, in a future-proofed and sustainable manner.

“A positive outcome of all these efforts is that ophthalmology trainees are recommending their position to other doctors at a rate of 94%,

versus the 80% national average,” Mora said.

“This is testament not only to specific initiatives and changes, but groups like the TRG, all our trainers, tutors, mentors, supervisors, Directors of Training and the staff at training posts and, of course, at RANZCO.” Mora said much of the work the college has been doing, and that was mentioned in an interview with Insight last year, is still progressing. This includes a stringent accreditation system for training posts that has confidential avenues for trainees to report issues such as bullying, harassment and discrimination they experience or witness. Training posts are not provided reaccreditation until all issues are satisfactorily addressed.

RANZCO has also been asking questions about trainees’ employment conditions during accreditation inspections, which it hopes will bring down excessive working hours.

“Cultural change does not occur overnight, and we’re working hard to move the needle,” Mora added.

“The wellbeing of our trainees and trainers is critical to them, to their patients and to the overall health system. As well as our own initiatives, we work closely with groups like the Council of Presidents of Medical Colleges (CPMC) where collective power can yield faster outcomes.”

‘TURNING A BLIND EYE’ UNHELPFUL Australian Medical Association (AMA) president Dr Omar Khorshid said the wider survey demonstrated the need to act now to tackle systemic issues impacting the training and wellbeing of doctors in training (DiTs).

“The 2021 survey again finds doctors in training reporting unacceptable levels of bullying, discrimination and harassment and a reluctance to report it. Seven out of 10 DiTs experienced bullying, discrimination and harassment saying it had adversely affected their medical training,” he said.

“It’s time for state and territory health departments to get serious about valuing the time doctors in training spend learning and providing excellent patient care by reviewing and providing appropriate staffing and adopting better rostering practices.

“They also need to take concrete steps to guarantee a safe working environment for doctors and other staff in public hospitals.”

According to the AMA, 45% of trainee doctors Dr Justin Mora, RANZCO. (28% RANZCO trainees) said they never/sometimes got paid for unrostered overtime and 49% rated their workload as heavy/very heavy (42% ophthalmology).

“Turning a blind eye to practices that allow doctors to work excessive unpaid, unrostered overtime is not only inefficient and unproductive, but it puts patient care and doctor wellbeing at risk,” Khorshid said.

“Very disturbingly, Aboriginal and Torres Strait Islander doctors in training reported higher levels of bullying, discrimination and harassment, including racism, compared to non-Indigenous colleagues.”

Khorshid said the AMA wants legislative changes in all states and territories to improve health service leadership, governance and accountability to provide a culturally and psychologically safe work environment for all employees.

Dr Hash Abdeen, chair of the AMA Council of Doctors in Training, said the survey found despite interruptions to training because of COVID-19, many trainees rated their training experience highly in the 2021 survey.

“This is a testament to the high quality of training in Australia and commitment from supervisors, colleges and senior medical staff to supporting trainee during this challenging time,” Abdeen added. n

Perform Premium Capsulotomy with Ultra Q ReflexTM by Ellex® Posterior Capsular Opacification (PCO) is a common consequence following cataract surgery. With newer generation of IOLs, higher precision is required to perform posterior capsulotomy.

The Ultra Q ReflexTM offers leading-edge YAG laser technology, delivering a four nanosecond Ultra Gaussian pulse at high peak power - achieving the industry’s lowest optical breakdown energy at 1.5 mJ. Performing capsulotomy at lower more efficient energy levels, the Ultra Q ReflexTM enables a perfectly, centered, and precise capsulotomy - a safe and highly effective treatment option for all types of IOL’s whilst achieving successful patient outcomes.

Contact: salesadmin@ellex.com Call +61 8 7074 8200 | ellex.com

Images courtesy of Karl Brasse, MD, MRCOphth

Capsulotomy, Ellex – Step 1: multifocal lens

Capsulotomy, Ellex – Step 2: multifocal lens

OPHTHALMOLOGY

VISION EYE INSTITUTE

A vision realised

CEO JAMES THIEDEMAN discusses how Vision Eye Institute leverages its scale to provide industry-leading eyecare. He also delves into how the organisation is tackling challenges on several fronts with health funds, workforce shortages, wage escalation and other increasing operational costs.

Vision Eye Institute’s Panch Day Surgery Centre in Preston, Victoria.

T

he genesis of Vision Eye Institute (VEI) – known as Vision Group when it launched in 2001 – involved a handful of established Australian ophthalmologists who figured private specialist eyecare could be better delivered and sustained at scale.

Capital to access leading-edge technology, a comprehensive clinical support staff workforce and an emphasis on real world ophthalmic research and collaboration have been hallmarks of the organisation – and remain so in 2022. But, most importantly, it features a complementary treatment network comprising some of the country’s best sub-specialist ophthalmologists, aiming to provide tertiary eyecare to any patient, regardless of their eye condition.

VEI’s roots are in the Victorian suburbs of Camberwell, Blackburn and Coburg where it set up its inaugural clinics, operating as the world’s first publicly listed ophthalmic company and one of the earliest publicly listed group medical practices.

Now privately owned by China's Jangho Group (acquired for AU$200 million in 2015), it has progressively expanded along the eastern seaboard, and more recently South Australia, with 21 VEI clinics and 10 day hospitals operating under the Vision Hospital Group banner. A laser eye service will be established in its existing North Adelaide clinic, and last year VEI opened its first overseas clinic west of Shanghai. In November 2021, the organisation also launched its not-for-profit Future Vision Foundation to support research initiatives.

While VEI was officially established 20 years ago, many of its eye clinics and day surgeries that have joined the group have been operating for far longer – some for more than 60 years. The organisation now employs

26 INSIGHT July 2022

ophthalmologists, optometrists, orthoptists, nurses and support staff, comprising 130 doctors and nearly 500 ancillary staff treating over 100,000 patients annually.

As the country’s largest private provider of specialist eyecare, CEO and managing director Mr James Thiedeman says access to technology and a longstanding culture of collaboration and innovation are VEI’s key differentiators.

James Thiedeman, VEI CEO. VEI ophthalmologists have been responsible for many ‘firsts’ in Australian eyecare, including LASIK surgery with the intralase femtosecond laser (2005), corneal transplant (2006) and cataract surgery (2011) with the femtosecond laser, and an Australian trial of an intraoperative OCT scanner (2016).

For ophthalmologists who join the network, one of VEI’s major functions is allowing its “doctors to doctor”, taking care of the important administrative tasks such as marketing, procurement, accounting, legal and logistics that often lead to fatigue for smaller practices and detract from time with patients.

“If you think about pathology, diagnostic imaging, cancer care, fertility and other medical fields, that coalescence around scale and putting more organisational rigour around those private specialties has really started to play itself through,” Thiedeman, who has led VEI for almost five years, says.

“It’s rare nowadays to go to an independently-owned pathology provider or diagnostic imaging provider because it makes more sense to have an organisation that runs those services at scale. Then they can afford to put the capital into new technology, they can afford to have risk and quality managers and big procurement teams who can buy equipment and consumables cheaper, so you can keep the service affordable to patients.

“We're doing the same in ophthalmology and are unique to the extent there isn't another ophthalmology provider out there at such scale, who looks after the whole care continuum. From the first time the patient sees an ophthalmologist all the way through to an operation, and then having a post-operative review. It works extremely well because you, therefore, provide continuity of care for the patient.”

When VEI acquires a practice, it typically involves the ophthalmology practice operating under the VEI banner. The partner ophthalmologist works as an independent contractor and clinical support staff are employed by VEI. The clinic bills the patient, with a portion going to VEI for each patient, or some clinics have adopted a profit-share model.

Due to the nature of medical care, Thiedeman says VEI is careful about who it brings into the network, which boasts internationally renowned ophthalmologists such as Professor Gerard Sutton, Associate Professor Michael Lawless, Professor Rasik Vajpayee and Dr Joe Reich.

“We've got a reputation we've crafted over 20 years, so we are very selective about who we invite into the organisation – we make decisions based on professional reputation and whether that particular doctor is a good subspecialty fit into the ecosystem. It's about succession planning as well, finding the next person to take over when an ophthalmologist starts thinking about transitioning to retirement,” he says.

“Within that there are certain expectations we reinforce and codify. Our doctors have a number of expectations and protections in those contracts, as well as service standards around how we will behave as an organisation.”

OPERATIONAL CHALLENGES AND OPPORTUNITIES Despite its success to date, Thiedeman is under no illusions of the challenges VEI faces as the COVID-19 pandemic slowly moves out of the spotlight.

Financial challenges, additional PPE and hygiene costs, insurance premiums and supply chain cost appreciation aren’t showing signs of abating. Coupled with funding compression from Medicare and private health insurers, he says operators like VEI are challenged to deliver more with less.

More recently, the organisation has been hit with workforce constraints due to COVID, with 10-15% of its workforce unavailable at any given time.

It comes amid a cost-of-living squeeze that has VEI’s single biggest cost (staff) seeking wage increases – and understandably so. There’s also a considerable patient backlog still to work through due to service restrictions imposed by state governments during lockdowns.

“A significant portion of what we do is funded by private health insurers and there’s no doubt there is tension between what we are seeing as the rising cost of delivering good quality care versus what the private health insurers are paying in terms of increases in funding. We are happy to work with them to ensure they understand we are doing everything to minimise our costs and drive efficiencies through our facilities, but it does feel like that tension is just going to continue to rise,” Thiedeman explains.

“With our scale and innovation culture, we’re working hard to implement new cost saving methods while maintaining exemplary care and outcomes.”

Digitalisation of certain components within the patient journey has been an important part of this. Clear patient communications have been vital to ensure patients turn up prepared at their allotted time, while avoiding breaches of density limits in waiting rooms.

“We’ve had to moderate the pace of how some of our doctors work because on occasions, we haven’t had the full complement of staff. We’ve also had to use more agency staff, which is not ideal, because they won't be as familiar with our facilities or our protocols. These are the types of things we've been contending with. How have we been tackling it? Well,

The Chatswood clinic comprises 14 consulting rooms and a treatment room for minor procedures.

the available staff have been fantastic in terms of working over and above their typical hours – and we've tried to get smarter with the way we interact with patients,” Thiedeman explains.

“We’re now doing as much as we can with patients digitally before they arrive at our facilities, rather than sitting for 20 minutes filling an admission form in the waiting room, all the way through to sending them information ahead of their visit that prepares them for what to expect when they see the doctor. That way the interaction with the doctor and the support staff is a much richer interaction, rather than repetitive questioning about your age, your family history of diabetes, heart disease, glaucoma etc.”

The roll out of a digital platform in VEI clinics also allows patients to provide anonymous real-time feedback to monitor delivery of patient expectations.

NURTURING A CULTURE OF INNOVATION VEI prides itself on giving patients access to the latest clinical technologies.

Recent examples include A/Prof Lawless performing Australia’s first SMILE Pro laser surgery this year with one of the Southern Hemisphere’s first installed VISUMAX 800 femtosecond lasers. Its ophthalmologists are also involved in trials of new intraocular lens (IOL) technology providing patients with enhanced depth of vision with a monofocal-like visual disturbance profile.

This emphasis on ophthalmic research to improve patient care was the reason for VEI to establish its Future Vision Foundation in November 2021, which is a passion project of Thiedeman’s.

It aims to support the research endeavours of Australian eyecare professionals, including those with little-to-no formal research experience, through funding, clinical resources and mentoring. It has secured highpowered board members such as Professor Fiona Stapleton (UNSW), Ms Fiona Davies (CEO of Australian Medical Association, NSW), Mr Joe Redner (former head of Zeiss ANZ), and Associate Professor Tim Roberts (former national medical director, VEI).

VEI received almost 20 applications, with the bulk of those being clinicallyrelated projects for research into developing synthetic corneal tissue supplements through to better engagement with educating children with eye conditions. Some applicants are seeking ways to remove pain points when patients walk into the clinic, addressing issues such as anxiety about their condition and treatment cost transparency.

“Not only do we hope this will help VEI improve, but the industry as a whole.

That’s why we have effectively opened it up to whole industry; all we ask is at least one VEI co-researcher is involved in the work,” Thiedeman says. “We want to keep promoting and nurturing that culture of innovation and looking at new ways of doing things – and we want anyone who has a good idea to put their hand up say ‘let’s test this and see if it makes sense’.” n

INSIGHT July 2022 27

OPTOMETRY

MUTUAL BENEFIT:

WHY THE GEORGE & MATILDA MODEL WORKS George & Matilda Eyecare’s inaugural partner optometrists have served their first five years as part of their original agreement terms. Insight talks to some of them about the journey so far, while the company hints at adding further allied health streams. practice Sydney business that joined G&M seeking a step change – echoes Evian’s sentiments. She wanted to ensure optometrists still had clinical independence and a voice in how the practice continued to be run.

“What I've experienced in G&M, is we balance listening to our practitioners and team 'on the coalface', as well as bringing impressive insights from big data analytics that independent practitioners wouldn’t normally have access to. This balance helps to improve the care and product offering we offer patients and improve the care journey,” she says.

“I’ve been impressed by [founder and CEO] Chris Beer’s big picture thinking to integrate analytics and big data into all aspects of growing our optometry businesses. I wouldn't hesitate to recommend someone consider joining G&M as the right step to developing their practice or improve their business, and allow them to take out their hard-earned equity.”

GEORGE & MATILDA IN 2022 Beer – an optical industry stalwart of 37 years, including 11 years as CEO of Luxottica’s Asia Pacific operations – says high quality service is a major reason why the best independents flourish, so it makes sense to preserve this.

Eye Site by George & Matilda in Rouse Hill, NSW.

A

sk a George & Matilda (G&M) Eyecare partner optometrist their chief concern when negotiating their entry into the network, most will say it was the unfounded fear of losing their clinical independence.

When the company launched in 2016, it vowed to become the independent pillar and third major player in the Australian optical market, providing fuel to the engine of some of Australia’s most reputable independent optometrists.

Six years – and around 90 practices – later, technology and the advantages of buying, marketing and administrative power remain the major components of G&M’s value proposition. In the majority of cases, it purchases the assets of the business and co-brands, building on the existing brand equity. The optometrist becomes a remunerated employee, and still shares in the profits.

For optometrists that have built their businesses over many years, letting go of many daily business functions may evoke a sense of liberation.

But there may also be some anxiety around the integrity of their clinical independence.

“For many years I worried about selling my practice one day, who would want to buy it and how it would lead to comfortable retirement one day,” says Mr David Evian, of Evian Optometrists by G&M Eyecare, a practice in the NSW community of St Leonards that was among the first to join G&M. “My initial concerns were: are they a reputable company and how would it affect me practising high quality optometry? What has surprised and delighted me over the years is how little they interfered with the professional part of my practice, enabling me to practise all levels of my definition of quality optometry.”

Dr Margaret Lam – an optometrist partner at theeyecarecompany, a three-

28 INSIGHT July 2022

“Many optometrist partners that join G&M are surprised that we actually don’t interfere at all with the clinical independence and that this is maintained after joining a community like G&M,” he explains.

“They all say ‘you do what you say’. They don’t see this level of independence in corporate optometry and in many cases independent where the owner will heavily influence the practice of one of their team.”

Over its short lifespan, Beer says G&M has learned a lot about itself, but importantly its partners, their patients and local communities.

“This allows us to customise each practice offering to enhance the community offer for eyecare and related services,” he says.

“Like any start-up, there has been many challenges along the way, and then to be impacted by COVID over the last three years and still to be in the strong condition we are in reflects the hardworking and strong team that we have. The efforts of the whole community have put us in a position where we are now well placed to accelerate our growth plans in the coming year.”

Previously, Beer has spoken of his concern for independent Australian optometrists to keep pace with large corporates in terms of technology. He also believes the local independent environment will remain challenged by the ability to provide a competitive service without the buying power that larger businesses have.

He says G&M’s scale has allowed it to invest in technology and place it at the centre of its decision-making. Head office-based data scientists analyse sales data, correlations and trends across the network that are then fed back for continuous improvement. It can also leverage artificial intelligence offering hundreds of personalised patient communications.

“The continual transition to a digital world is going to accelerate the gap between corporate and independent practice as small independents and

David Evian, of Evian Optometrists

by G&M Eyecare (NSW).

Dr Margaret Lam, theeyecarecompany (NSW).

Gary Scheckter, Eyes On Michael Angelos, G&M Eyecare for Glen Barker (pictured) OptomOptometrists by G&M Eyecare (WA). Karisma Optometrist (NSW). etrists by G&M Eyecare (NSW).

buying groups simply don’t have the resources or structure to make the investments required,” Beer predicts in the next five years.

“The gap is accelerating rapidly and COVID has exacerbated this. The customer expectations are changing at a speed that will see those not participating fall of a cliff rapidly over the next two to three years.”

Beer says it’s fair to say in G&M’s early days, its systems and technology stack based off AI learning “were a little clunky”.

“Now we have developed into a very data and insight driven organisation that can cut through opinions to facts that provide insights to continuously improve our offering to partners and patients,” he explains.

“The result of this is we can materially add value to all our incoming partners in a way most have not experienced before. My team often hear me say I’m interested in what the data and AI tells us, not the opinions and personal bias that exist in the industry.”

OPTOMETRY’S MASS RETIREMENT G&M has made no secret of its selectivity when weighing up acquisitions.

As Beer has previously stated, it’s more about building a high-quality community than a drag race for size and scale.

“We are excited to see G&M’s growth, being able to render our professional and high-quality services and products to all parts of Australia and serve and extend our reach to further local communities. In addition, we will start to add allied heath streams to our community where they are aligned with our values and service creation,” Beer says.

“It goes without saying that we are looking for practices that are well established in the local community and practitioners with great reputations.

But on top of that, we have a strong set of characteristics and standards we would like our partners to resonate with as we are a values-driven organisation and go to a lot of effort to ensure incoming partners align with them before proceeding.”

Mr Michael Angelos, of G&M Eyecare for Karisma Optometrist in McMahons Point, NSW, says the ability to lighten his workload has been an attraction of G&M: “I have no plans to retire. But working part time as an optometrist has given me the freedom to pursue other business and social interests."

Mr Glen Barker successfully transitioned his patients on to his successors at his namesake practice. He’s now retired and after six months helping out for a couple of days, he’s taking an extended trip to South Africa to see relatives and friends.

“In future you may see me work from time-to-time as it’s my choice to stay connected to my community. This was the right choice and have no hesitation to recommending Chris and the team.”

According to newly appointed general manager of partnerships Ms Cassie Gersbach, over the next five years the industry will be impacted by very experienced optometrists moving into retirement of their choice. Equally, the sector will have the largest number of new grads entering the industry – “a perfect storm really”.

“G&M plays a pivotal role in this transitional stage by ensuring we connect the two to share learnings and secrets of success while paying homage to the legacy built,” she explains.

“This is complemented by the new ideas and energy to continue servicing and caring for our growing patients in each community. Our existing partners and I propose not to wait till you’re ready to retire. It’s best to work into retirement supported by those who do care for the best outcomes for all involved.” n G&M co-brands with practice partners, building on the existing brand equity.

That means not all negotiations end with a signed contract. But when it does, partner optometrists say they have been impressed by the value created, allowing them to focus more on patient care, work/life balance and a smooth path to retirement.

For Mr Gary Scheckter, of Eyes On Optometrists by G&M Eyecare in Duncraig, WA, the main reason for joining G&M was a willingness to retire or semi-retire.

“I was interested in finding less stressful ways of selling my practice.

G&M offered a fair price and I also liked the idea of not having to deal with landlords and it would be good to have experts deal with marketing, payroll and HR issues,” he says.

“I wouldn't hesitate to recommend G&M, whether you want to retire, need support from experts in their field or just want to make some money from all your hard work. I fully intend to stay with G&M on reduced hours, until I retire in probably five to seven years’ time. That way I can still look after my patients that have been loyal to me and G&M for so long.”

INSIGHT July 2022 29

OCULAR IMAGING

Cylite

EMBARKS ON CRUCIAL SCALE-UP

Cylite HP-OCT base units prior to the assembly stage.

The transition into production and sales is proving a pivotal moment for Australian OCT manufacturer Cylite, as the company outgrows its start-up status to bring its technology to the world.

M

elbourne medical device company Cylite is at an important juncture, according to newly appointed CEO Ms Kylee Hall, transforming from an R&D-heavy business into a firm focused on how it will locally produce and deliver its unique Hyperparallel (HP-OCT) system for real world clinical use.

Hall’s promotion from vice-president of sales and marketing to CEO in April is perhaps indicative of the current stage in Cylite’s evolution, which began in 2013 followed by many years fine-tuning the hardware, microoptics and software that make it unique.

“There is a heavy focus now on how we scale our business from production to sales, to support this pivotal point,” Hall says, noting that former CEO and founder Dr Steve Frisken will remain involved with the engineering and optics team daily while also maintaining Cylite Board director duties.

“My main priority as CEO in the next 12 months is managing the change as we scale up our business to meet the planned demand. It is a transition time from designing a novel piece of technology to turning it

into a highly scalable product.” Taking Cylite from start-up to a fully-fledged company is a monumental task on numerous fronts.

For example, the company’s production capacity is set to triple at a new facility in Melbourne. There, it will need to transport and up-scale its rigorous production process and then obtain all new accreditation under standard ISO:13485, demonstrating it can consistently produce the incredibly complex HP-OCT as designed.

Next there’s recruitment to consider. Because this is precision engineering, Cylite requires additional high-powered candidates for technician roles, often with PhDs and Masters qualifications in their respective fields. And then there’s software development and the need for a salesforce to get the device into clinics to begin generating revenue.

While Cylite can control much of this, it’s also at the mercy of a lagging international supply chain. Managing this is a full-time job for many staff.

Hall believes her experience will put the company in good stead during this transformational period. A combination of her prior roles at Zeiss and Device Technologies exposed her to skills that will be essential to successfully launch the HP-OCT locally and globally shortly after.

“I’ve built and managed sales teams and launched many products over my time in the optometry, ophthalmology, and wider medical space,” she says.

“Years of first-hand experience from the distributor side of the business model has taught me what is needed from a manufacturer if your product is to be successful within a distributor’s portfolio. I also gained intense education during my Global EMBA on all aspects of start-ups. My study notes from this post-grad study have been accessed regularly over these past two-plus years.”

Few would probably realise that Cylite’s headquarters are based in a nondescript building, tucked away in the back corner of a business park in Notting Hill, suburban Melbourne.

A true volumetric anterior image of Insight editor Myles Hume’s eye, taken with the HP-OCT.

30 INSIGHT July 2022

The company outgrew this site a while ago but still runs the bulk of its business from there. However, it has taken possession of another building around the corner, still within the Monash Technology precinct. It plans

to move all operations to the new site once the refurb is complete. An important part of this will be the clean room that will more than triple its production capability. This is where Cylite assembles the OCT and performs the crucial optical alignment process.

“We have already moved some of our engineering team over to the new site, whilst downstairs is currently undergoing the fit-out of the new production facility with the aim for ISO:13485 accreditation before the end of this year,” Hall says.

“Each area of the business is growing, most notably would be our production and engineering team – we have more than 70 full time staff.

We have also expanded our clinical and customer facing team as we start more large clinical trials and look to build a local sales force later this year.

We will also look to replace the leadership role I transitioned from in the next few months.”

NEXT-GEN TECH ‘THE INDUSTRY HAS BEEN LOOKING FOR’ While it’s unusual for an Australian firm to design and develop an OCT in this country, what truly makes Cylite unique is its ability to obtain true volumetric, or 3D, images of anterior segment structures in a series of snapshot captures.

Users can then take a B-scan slice of the eye in any direction, X, Y or Z (enface) axis while obtaining precise measurements of the various ocular surfaces. Industry-leading rates of more than 300,000 A-scans per second allow it to capture a full biometry scan in seconds for motion artefact-free scans.

Hall says many eyecare professionals immediately assume the HP-OCT is another retinal OCT coming to market.

“It is actually quite the opposite; we are an anterior OCT that can measure axial length and also image the retina,” she explains.

“The idea for this technology was borne out of the problem: ‘Why when OCT technology is micron level accurate, is no one using this technology for critical measurements at the front of the eye? Why is technology that is greatly impacted by tear film still the standard of care when measuring the eye for custom contact lenses, or assessing the eye prior to cataract or refractive surgery?”

Locally, Hall says Cylite has a great following among practitioners, many wanting to support an Australian-made product.

“Eyecare professionals working in the myopia management space and those who are fitting scleral lenses are areas where we feel the HP-OCT will make a positive impact to their daily workflow,” she says.

“We have many devices already in use at some impressive global research institutions. The feedback these sites are sharing, now they are back from COVID lockdowns, is inspirational. In the next one to two years, we will start to see some fundamental research be published on what Hyperparallel technology is now enabling. I believe this technology really is that next generation OCT imaging the industry has been looking for.”

In terms of other areas where Cylite may further develop the HP-OCT, Hall adds: “You’ll need to watch this space, we have some very exciting developments from our R&D team that will continue to improve the functionality of Focus, our user interface software. The team are also working on some next level hardware that I can’t say too much about right now.”

‘THIS IS GROUND-UP DEVELOPMENT’ When visiting Cylite’s current headquarters in Melbourne, it’s phenomenal to see what’s required to produce the HP-OCT from scratch. And the fact this occurs in a modest, two storey tilt slab building makes it even more remarkable.

The person overseeing activities in this building is Mr Simon Davis, appointed vice-president of operations in November 2020. Between 2012-2019 he worked with Cylite directors Dr Steven Frisken and Dr Simon Poole at Finisar manufacturing opto-mechanical fibre optic switches, and

The optical alignment is a complex and vital step in producing the HP-OCT, performed inhouse by highly qualified technicians.

previously set up two manufacturing sites in China for a company he founded.

As Cylite matured, requiring more emphasis on manufacturing, he was appointed to build more operational rigor, creating water-tight production processes, better stock and inventory control and hiring of operations staff (25 of those since February 2021).

“What’s so unique about the founders is that they have incredible theoretical knowledge that underpins the HP-OCT, but can then translate that into practical application, which they’ve accumulated from previous businesses,” Davis explains.

Davis is keen to stress everything about Cylite is from the ground up – and the significance of that. People often only consider the end product, but the company has devised its own equipment to manufacture the HP-OCT. All parts and components that go into the system are designed and assembled in-house. The company has also formulated its own intricate production processes, systems and manuals; it can’t simply source critical processes like the optical alignment.

Cylite sources its components from suppliers in Australia and abroad, which often requires working with selected factories due to the bespoke nature of many parts.

The HP-OCT contains more than 500 unique part numbers, and over 1,300 components. When each part arrives at the factory, quality control inspectors check them against the purchase order before they are measured and tested against the original mechanical, electrical and optical drawings.

Approved parts are then grouped together in kits to be sub-assembled, removing the need for people to seek parts in a store-room, while ensuring traceability.

“Hundreds of components need to go together in a certain series of events and we need to ensure we maintain quality and traceability. There are serial numbers and every part that goes into the final device can be traced all the way back through to the purchase order and the supplier who provided it,” Davis says.

INSIGHT July 2022 31

OCULAR IMAGING

The HP-OCT’s design means it must be assembled in a clean room.

That means every component goes through an intense cleaning process, including ultrasonic cleaning for some parts, to remove potential contamination or oils. Surface treatment and curing processes are also performed, before the sub assembled parts enter the clean room.

“While many industries work at the millimetre level, we are working at the micron level. A piece of paper is 100 microns, or 0.1mm, so we are going down to a magnitude thinner than a piece of paper,” Davis explains.

“Contamination for us is a spot of dust in the path of the optics, it is not like some people might think.”

The clean room performs the most important function in the production process. To enter the room, one must wear shoe covers, a hair net, gown and protective glasses. The room’s sophisticated ventilation system circulates the air 24 times an hour, and each of the workstations have laminar flow hoods to ensure no dust settles.

Why this is so important relates to the HP-OCT’s free space optical system, comprising a complex network of lenses, mirrors and other mirco optics that precisely manipulate light in various ways. While other OCTs use a fibre optic system, Cylite’s free space optics design allows it to project a grid of 1,008 beamlets on the eye for its simultaneous A-scans to be captured within one millisecond per frame.

To achieve all of this, engineers need to perform the optical alignment process that involves high precision manufacturing processes and validation. Once complete, calibration is performed assessing various targets, and installing the fixation (crosshairs) target the patient looks at.

“We have numerous main optics stations in this clean room and there are a couple of extra calibration stations – and then we have several sub assembly feeders. This is what we refer to as one production line, but in

The clean room at Cylite’s new, under-construction facility in Melbourne will allow it to more than triple its current production capacity.

the new building the immediate capacity will be tripled, with more room for expansion in the next phase,” Davis explains.

“The process of scaling up our production is both in additional equipment and operators, but also through machine learning and automation of processes that shortens the alignment time. These combined will allow us to meet our delivery target.

“The term ‘continuous improvement’ is very important in a manufacturing team and it’s something we talk about regularly. It's cross functional in that you have core engineering designers working with process owners, technicians and automation staff working to identify opportunities, then people who can validate whether it is going to yield the benefit and enable us to grow.” n

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

Including: • I mplement their own clinical approach to taking a case history of patients with diabetes or prediabetes • Develop clinical strategies to ensure accurate grading of DR and DME • Know the expected content of diabetes eye exam reports to be shared with fellow members of the diabetes care team • Develop procedures to establish and reinforce the collaborative relationships among the various specialties in the diabetes care team • Review key messages for educating patients with diabetes and/or diabetic retinal disease

DIABETES – CPD

OPTOMETRY ON THE FRONT LINES OF THE DIABETES CARE TEAM In Part 1 of its National Diabetes Week (10-16 July) coverage, Insight invites renowned US optometrist and diabetes educator DR A. PAUL CHOUS to share his evidence-based, practical strategies for optometric care of patients with diabetes.

E

very healthcare provider is seeing more patients with diabetes as the global diabetes pandemic rages on.

The International Diabetes Federation (IDF) estimates 537 million people between 20 and 79 years old had diabetes in 2021 – a number that is expected to grow to 783 million by 2045.1

The IDF estimates 1.5 million Australians were affected, with another three million having prediabetes, which significantly elevates risk for development of type 2 diabetes (T2D) and carries similar cardiovascular risk.2 Global data suggest 34% of patients have some degree of diabetic retinopathy (DR), and 10% have sight-threatening diabetic retinopathy (STDR).3 Of note, up to 14.9% of patients with prediabetes also have retinal findings consistent with DR.4

to diabetes, and each arguably is or may be part of any comprehensive eye examination of any patient.

I think the following four elements distinguish the diabetes eye examination: 1. Case history designed to ascertain metabolic control, the systemic treatment plan, medication adherence and other risk factors for vision loss 2. C onsistent and meticulous examination for ocular pathologies associated with diabetes, particularly those known to cause severe vision loss 3. Focused patient education designed to attenuate risk of vision loss and stress the importance of ongoing, defined-interval surveillance.

All this begs the question: What is the role of optometrists in identifying, counselling and managing patients with diagnosed and undiagnosed diabetes? And how do they best collaborate with the rest of the diabetes care team?

4. C onsistent communication with other members of the diabetes care team, with particular emphasis on dilated examination, the presence/absence/severity and stability of any DR or diabetic macular oedema (DME) detected and need for any ophthalmologic referral, the recommended date for the next eye exam and any other recommendations for specific patients.

DEFINING THE DIABETES EYE EXAM

1. CASE HISTORY

Is an eye examination of patients with diabetes distinct from that performed on patients without diabetes? Clinical practice guidelines from Optometry Australia and the American Optometric Association both recommend a battery of diagnostic tests as part of a comprehensive eye examination for people with diagnosed diabetes (visual acuity, refraction, ocular motility, pupil reflexes, tonometry, slit lamp examination, dilated steroscopic fundoscopy, confrontation visual field). Also, ancillary testing ‘as needed’ (fundus photography – including widefield, optical coherence tomography (OCT), gonioscopy, colour vision and contrast sensitivity assessment, automated perimetry).5,6

Case history is paramount for gauging the likelihood of finding diabetic eye disease and for reducing risk through patient education.

On a percentage basis, type 1 diabetes (T1D) confers higher risk of retinopathy after five years duration than does T2D of any duration, and this risk-spread increases with time.3

However, no group of these tests is unique

ABOUT THE AUTHOR: A. Paul Chous, MA OD FAAO Specialist in Diabetes Eye Care and Education Tacoma WA USA

in the Joslin ‘Gold Medalist’ Study [50+ years living with T1D] had no or minimal DR, which suggests – somewhat paradoxically – that very long disease duration without significant DR implies protective genetics in these long-lived patients).8 IS HbA1c ACTUALLY THE 'GOLD STANDARD?'

Nonetheless, recent analysis shows that nearly 2% of T2D patients have proliferative disease (PDR) after five years, with 3.5 times higher risk in T2D patients who use insulin.7

After diabetes duration, blood glucose control has long been considered the second-most important risk factor for DR. Indeed, randomised trials and observational studies alike consistently show that elevated glycosylated haemoglobin (HbA1c) predicts incident and worsening DR.

It’s important to remember that insulin use doesn’t mean a patient with T2D has developed type 1 diabetes. Rather, patients with T2D become increasingly insulin-deficient over time. That said, disease duration is a definite risk factor for developing and worsening DR. (Half of the patients with T1D

However, analysis from the vaunted Diabetes Control and Complications Trial (DCCT) has shown that HbA1c accounted for a mere 6-11% of the total risk for developing DR during the trial.9 Moreover, identical HbA1c values from different patients are associated with significantly different mean blood glucose

INSIGHT July 2022 33

DIABETES – CPD

1. CONTINUOUS GLUCOSE MONITORING (CGM) AND GLUCOSE TIME-IN-RANGE (TIR) ‘TIR’ refers to the percentage of any time interval a patient’s blood glucose levels fall within a specified, relatively ‘normal’ range – typically 70-180 mg/dL (3.9-10.0 mmol/L) and is ideally assessed by continuous glucose monitoring devices (available from Medtronic, DexCom and Abbott).

In both T1 and T2 diabetes, TIR has been shown to predict incidence and significant worsening of DR independently of HbA1c.

A 10% decrease in TIR (for example from 16 to 14.4 hours/day) increases DR risk approximately 60%, whereas a 10%TIR increase reduces DR risk roughly 40%).[A,B] In contrast with HbA1c, CGM and TIR give patients immediate biofeedback about their diabetes self-care practices and assist with reducing glycaemic variability associated with DR.

1A

1B

Figures 1A and 1B: Macula- and disk-centred 45-degree colour fundus photos, left eye for AI interpretation and showing definite venous beading in two quadrants. Source: A. Paul Chous, MA, OD, FAAO.

1C

A. Beck RW, Bergenstal RM, Riddlesworth TD, et al. Validation of Time in Range as an Outcome Measure for Diabetes Clinical Trials. Diabetes Care. 2019; 42 (3): 400-405. doi:10.2337/dc18-1444 B. L u J, Ma X, Zhou J, Zhang L, Mo Y, Ying L, Lu W, Zhu W, Bao Y, Vigersky RA, Jia W. Association of Time in Range, as Assessed by Continuous Glucose Monitoring, With Diabetic Retinopathy in Type 2 Diabetes. Diabetes Care. 2018; 41 (11): 2370-2376.

1D

levels as measured by gold standard continuous glucose monitoring (CGM) devices. This means that a patient with an HbA1c of 9% might actually have better mean glucose than a patient with an HbA1c of 7%.10 This discrepancy and other deficiencies of HbA1c (for example: its value is weighted to the last two weeks’ glucose levels before sample collection; and it does not reflect blood glucose variability linked to microvascular complications, including DR) have led to the adoption of additional glucose metrics best accessed through use of CGM, including glucose time-in-range (TIR) that predicts DR independently of HbA1c (see Box 1 above on CGM and TIR).

This is not to say that HbA1c is of no value, only that it isn’t the gold standard metric of good diabetes control it has long been assumed to be.

From a practical standpoint in the eye exam, a patient’s current HbA1c is of little value to clinicians except insofar as it ‘suggests’ level of control or that it has precipitously decreased within the year

34

INSIGHT July 2022

Figure 1C and 1D: Macular OCT of the left eye showing residual hard exudate and slight centre-involved DME (central sub-field thickness = 300 microns), demonstrating the value of using different imaging techniques to arrive at the correct diagnosis, particularly when best-corrected visual acuity is reduced, as in this patient [note: the right eye also had severe NPDR and was correctly identified by AI has having DME]. Source: A. Paul Chous, MA, OD, FAAO.

(the latter is associated with heightened risk of diabetic ‘re-entry retinopathy’; that is, DR develops or worsens with rapid improvement of blood glucose that re-enters a more normal range – typically a 2+ point drop in HbA1c).11 Far more useful is to ask patients about their HbA1c history since diagnosis to assess for ‘metabolic memory’ demonstrated in every

single major prospective diabetes study.12 This refers to the long-term protective/detrimental effects of good/poor glucose control the first five-to-10 years after diabetes diagnosis that confers decreased/increased risk of DR over time, despite worsening/improving glycaemic control over time.

If a patient has an HbA1c of 6% now but

had lousy metabolic control the first 15 years after diagnosis (for example: HbA1c ranging from 8-12%), we should not be surprised to discover severe DR. In fact, recent prospective trials of anti-VEGF (vascular endothelial growth factor) therapy in severe non-proliferative diabetic retinopathy (NPDR) found that ‘good’ current glycaemic control at study entrance was not at all protective against development of sight-threatening diabetic retinopathy (STDR) – the horse is already out of the barn.13 By contrast, severe hypoglycaemia itself was linked to higher risk for vision loss in the Freemantle Diabetes Study Phase II,14 possibly a reflection of glycaemic variability (that is: patients hospitalised for severe low blood glucose are more likely to have a history of severe high blood glucose levels) or the fact that hypoglycaemia is linked to apoptosis of retinal cells.15 In addition to glucose control, control of blood pressure and lipids, treatment of obstructive sleep apnoea, and absence of non-ocular vascular diabetes complications are linked to lower risk of DR, whereas their opposites are associated with higher risk.16,17

Certain medications commonly used in diabetes are also linked to lower risk, including

metformin, ACE inhibitors/ARBs, statins and fenofibrate18-21 – and might be recommended to patients and other HCPs treating them.

Patients should be asked if they consistently take prescribed medications. The case history also is a great opportunity to ask about prior adherence to annual or biannual dilated eye examinations. This also puts optometrists in a good position to recommend the frequency of future exams pending diagnostic findings.

Patients with a history of depression, renal disease, lower extremity amputation, lower educational and socioeconomic status are at a significantly increased risk for becoming lost-to-follow up (LTFU)22 and should be assiduously pre-appointed, counselled and reminded about the importance of ongoing eyecare despite the absence of visual symptoms.

2. CONSISTENT AND METICULOUS EXAMINATION Eye examination of patients with diabetes should focus on common pathologies (cataract, glaucoma, ocular surface disease, cranial neuropathy and diabetic retinopathy) with particular attention to detection and staging of any DR or DME. I have found a multi-modal approach

"IN MY VIEW, OCT SHOULD BE ROUTINELY USED IN PATIENTS WITH ANY LEVEL OF DIABETIC RETINOPATHY." A. PAUL CHOUS, MA OD FAAO EXPERT OPTOMETRIST IN DIABETES EYECARE AND EDUCATION

combining clinical examination and retinal imaging to be most useful for diagnosing/ staging of retinal disease. In addition to a steroscopic exam of the disk and macula, fundus photography is invaluable for documenting DR severity, serial comparison for progression and patient education.

Use of red-free filters highlights microaneurysm and haemorrhage, as does fundus autofluorescence.24 OCT is the most sensitive tool for detecting DME, including subclinical DME that portends increased risk of worsening macular fluid.25 In my view, OCT should be routinely used in patients with any level of DR. Evaluation of the retinal periphery increases

Keep your on July

This July, look out for the vision of people with diabetes.

Sign them up for handy diabetes eye check reminders at your practice at keepsight.org.au National Diabetes Week | 10-16 July

DIABETES – CPD

2A

2B

Figures 2A, 2B: Eyes with subclinical DME are at significantly higher risk for the development of worsening oedema and must be followed carefully.25 This patient was placed on a xanthophyll-based retinal supplement and the blue colour vision defect improved over 18 months. Source: A. Paul Chous, MA, OD, FAAO.

3

2. A RATIONAL APPROACH TO TAKING A CASE HISTORY OF PATIENTS WITH DIABETES OR PREDIABETES • A sk about disease duration – remember the mean lag between T2D diagnosis and disease onset is 6+ years23 • A sk about current HbA1c and, more importantly, A1c values and glucose control the first decade of living with DM. If patient is using CGM, ask about glucose TIR with a goal >70% • Ask about current medications and adherence, as well as side effects • Ask patients on insulin or sulfonylurea therapy if they experience severe hypoglycaemia and how often • Ask about sleep apnoea and symptoms (snoring, observed breath cessation, daytime sleepiness) linked to higher risk of sight-threatening DR • Ask about depression • Ask about smoking and desire to quit • Ask about dental health. Periodontal disease is linked to severe DR • Ask if patients have had their feet and lower extremity circulation assessed – foot ulceration is highly linked to PDR • Ask for the name and location of the treating diabetes physician and any other healthcare providers.

DM = diabetes mellitus CGM = continuous glucose monitoring Source: Paul Chous, MA, OD, FAAO

36

INSIGHT July 2022

Figure 3: Ultra-widefield image of a patient with predominantly peripheral diabetic retinopathy lesions (PPL) that increases risk of progression to PDR nearly five-fold over four years.27 Source: A. Paul Chous, MA, OD, FAAO

DR severity grading in 10% of eyes and predominantly peripheral DR lesions (PPL) significantly increased risk of retinal nonperfusion, significant worsening of NPDR and PDR over four years,26,27 making wide-field and ultrawide-field retinal imaging systems quite valuable in diabetes.

Finally, AI systems will likely not supplant practising eyecare professionals for a number of reasons. Rather, they will likely make both optometrists and ophthalmologists better at staging DR severity, referring when treatment is most beneficial and reducing vision loss.28 Figures 1A – 1D page 34 show the value of multimodal imaging in patients with DR and DME. They are multi-modal images of a 29-year-old male with T1DM x 20 years and severe NPDR with early CI-DME, OS and 20/30 visual acuity who will likely benefit from antiVEGF therapy. Forty-five-degree imaging with AI analysis and spectral domain OCT were also used to assist with correct diagnosis/staging and persuade the patient to see a retina specialist.

Figures 2A-2C above show the value of multimodal imaging in patients with DR and DME. They show retinal and SD-OCT imaging of a patient with 20/20 bestcorrected visual acuity and no symptoms

demonstrating mild NPDR without clinically apparent DME, but subclinical DME using OCT and S-cone dysfunction with colour contrast sensitivity testing.

It should be noted that ODs, ophthalmologists and even retina specialists frequently under-grade DR severity13 (several prominent retinologists have remarked to me that they are rarely certain about NPDR severity until performing ultrawide-field fluorescein angiography and OCT!), so referral of patients with moderate or worse NPDR makes absolute sense.

4. CONSISTENT COMMUNICATION WITH OTHER MEMBERS OF THE DIABETES CARE TEAM Ideally, eyecare providers, primary care providers and other members of the diabetes care team will openly share diagnoses and recommendations with each other, and with the patient. Communication of eye exam findings should be timely and consistent.

In a meeting with multiple endocrinologists at the American Diabetes Association Scientific Meeting, whom I asked about their expectations from a diabetes eye exam report, they asked for the following: 1. Confirmation the patient was dilated

2. Presence or absence of DR and stability compared to previous eye examination without abbreviations denoting disease state or laterality

3. CLINICAL PEARLS FOR ACCURATELY GRADING DR/DME 1.

Always dilate the pupils at appropriate intervals

3. Notice of any referral to a retina specialist

2.

se imaging and red-free or FAF filters to highlight vascular changes U

specific surveillance interval for the next 4. A dilated exam

3.

se serial imaging to help detect DR progression U

4.

U se fundus lenses giving views of the mid-peripheral retina, and wide-field imaging, with filters as above, if available

5.

V ein beading in any single quadrant and/or significant intra-retinal haemorrhage in 2+ quadrants is an excellent marker of hypoxia, and warrants consideration for referral

6.

emember the 4-2-1 quadrant rule (extensive heme/microaneurysm, vein beading, IRMA) R to accurately detect severe NPDR – IRMA can be impossible to detect without FA

7.

A lthough not a determinative part of ETDRS grading, cotton wool spot formation = ischemia and in the absence of poorly controlled hypertension or anaemia usually signals severe NPDR

8.

P DR can be subtle (see Figure 3), so use filters, magnification and, if available, OCT-A to evaluate the vitreo-retinal interface of any suspicious areas

9.

weep an optic section through your fundus condensing lens to detect macular thickening S (to assess for CSME per ETDRS criteria) – better yet – use an OCT to assess for centreinvolved DME (central subfield thickness = CST = the central 1 mm)

5. A ny educational recommendations pertinent to patient care.

Ideally, communications between ECPs and other members of the diabetes care team would be reciprocal, as evidence suggests better adherence to eye examinations when PCPs send reports to ECPs than vice versa.29 Patients ought to be referred to retina specialists for DR/DME if and when the diagnosis is uncertain, with unexplained vision loss, or when patients have or are anticipated to soon develop treatable disease severity (moderately severe to severe NPDR, PDR, DME or evidence of anterior segment neovascularisation).

Communication to the retina specialist should include patient diabetes history, current medications, best-corrected visual acuity, intraocular pressure and a specific reason for referral. Imaging results are often useful, especially if serial imaging

10. M any patients with long-term diabetes develop retinal neurodegeneration that thins the inner retina on OCT, so look at the raw images for pockets of fluid, not just the colourcoded thickness maps, and compare the two eyes for asymmetric CST. Source: A. Paul Chous, MA, OD, FAAO

JOIN G&M Partnerships Proven Model More flexible & competitive options than ever before

Proudly servicing over 100 communities Australia wide

Exit Strategy, Growth &/or Support We care about your patients, team, goals, succession, and legacy Experience The Difference Meeting our team & partners will help you make the right decision Partnership We guide every step of the way, for smooth transition & onboarding with a dedicated team Confidentially Values driven every day, it’s who we are

Let’s Chat…

Contact Cassie Gersbach P: 0401 577 542 cassie.gersbach@georgeandmatilda.com.au

DIABETES – CPD

4A

4. PATIENT EDUCATION KEY MESSAGES FOR EDUCATING PATIENTS WITH DIABETES AND/OR DIABETIC RETINAL DISEASE

4B

1.

U se imaging to teach patients what normal and abnormal look like

2.

U se the same to motivate patients who are stable or are improving with treatment (e.g., anti-VEGF therapy)

3.

E xplain that DR causes no visual symptoms whatsoever at its earliest, most treatable stages; like a heart attack, everything can seem fine up until the day it isn’t

4.

P re-appoint patients for their next eye exam depending on their retinal status; reschedule patients with you after making a retinal referral to assure the appointment was kept, answer questions and bolster your relationship

5.

T ell patients the worst part of an intravitreal injection, by far, is hearing that you may need one

6.

Empathise with the fear of hypoglycaemia in patients using insulin or sulfonylureas – always recommend CGM for these patients, especially if they live alone

Figures 4A and 4B: A patient with subtle neovascularisation within 1 disk diameter of the optic nerve (NVD – arrows). Note that red-free imaging (Figure 4B) highlights both intra-retinal haemorrhage and microaneurysm formation, but also the PDR. Images courtesy of Diana Shechtman, O.D.

demonstrates disease progression. Ideally, retina specialists will not only send reports back to referring optometrists for ongoing care, but also copy the PCP/endocrinologist to establish and reinforce the importance of collaborative relationships between various specialties. If not, ask them to do so.

Optometrists play an important role on the diabetes care team and can improve patient outcomes significantly. By focusing on the elements described in this article, we can all help maximise patients’ ocular and systemic health and be well-respected within the diabetes care community. n NOTE: A full list of references can be found in the online version of this article.

7.

Not every patient should attempt tight glucose control – older age, cognitive dysfunction & multiple comorbidities are legitimate reasons for higher individualised glycaemic targets – ask the PCP so you can give complementary recommendations

8.

Encourage patients to ask about ACEIs or ARBs for hypertension – these drugs protect both kidney and retinal function independently of their antihypertensive effects

9.

Encourage T2DM patients with NPDR to discuss fenofibrate therapy with PCPs – statin therapy has also shown efficacy against DR progression

10. E ncourage patients with pre-existing cardiovascular disease to ask the PCP about SGLT2 inhibitors and/or GLP-1 drugs to reduce risk. SGLT2 drugs are specifically beneficial for congestive heart failure and mild-moderate renal disease. Both drug classes assist with weight loss sk permission to talk about patients’ weight status by explaining it affects eye health and 11. A risk of eye disease; recommend overweight patients be assessed for obstructive sleep apnoea ncourage regular aerobic and anaerobic exercise to prevent T2D and improve metabolic 12. E control in all patients with diabetes; recommend a pedometer and help patients set a daily goal based on their current level of activity – 7,000 steps daily was recently shown to reduce mortality by up to 50% in adults > 60 years [A] ncourage a predominantly plant-based Mediterranean or Palaeolithic-type diet 14. E 13. M ultiple studies suggest higher macular pigment is associated with lower risk of DR – recommend a lutein/zeaxanthin-rich foods or supplements [B] 14. C reate and use educational handouts on minimising the risk of vision loss from diabetes; create the same for reducing the risk of developing T2D in patients at risk 15. U tilise a sight-threatening diabetic retinopathy risk calculator available at www.retinarisk.com – only accurate for patients with no or mild NPDR, but a great tool for patient education edouble all educational efforts for patients at high-risk of being LTFU, as discussed 15. R above.

SGLT2 inhibitors = sodium glucose transporter type 2 GLP-1 analogs = glucagon-like peptide-1 A. Paluch AE, Bajpai S, Bassett DR, et al. Steps for Health Collaborative. Daily steps and allcause mortality: a meta-analysis of 15 international cohorts. Lancet Public Health. 2022;7 (3): e219-e228.

NOTE: Optometry Australia members can scan the QR code or visit the online version of this article at insightnews.com.au/cpd/ to enter their details to have their CPD hours automatically updated to their Learning Plan. Event ID: 90004285, Session ID: 10806.

38

INSIGHT July 2022

B. Chous AP, Richer SP, Gerson JD, Kowluru RA. The Diabetes Visual Function Supplement Study (DiVFuSS). Br J Ophthalmol. 2016; 100 (2): 227-34 Source: A. Paul Chous, MA, OD, FAAO

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

Insight Dry Eye Directory returning in 2022

The October 2022 issue will feature the Insight Dry Eye Directory, Australia’s most comprehensive source for dry eye care.

Back by popular demand, this all-in-one resource is a valuable purchasing guide for practices, showcasing available Therapies and Diagnostics in Australia. It will also feature a comprehensive list of dedicated Dry Eye Clinics.

It’s FREE and EASY for you to list your products or services.

If you operate a dry eye clinic, or are a supplier of dry eye products, scan the QR code to organise you listing, or visit insightnews.com.au/dry-eye-directory-2022

Scan HERE to arrange your listing.

To amplify your product via advertising, contact Insight Business Development Manager Alex Mackelden: 0413 282 030 or alex.mackelden@primecreative.com.au

www.insightnews.com.au

DIABETES

OPTOMETRISTS HOLD THE KEY TO

KeepSight success

It’s now three years since the launch of KeepSight, Australia’s diabetes eye screening initiative shifting the dial on diabetes-related vision loss. In Part 2 of its diabetic eye disease series, Insight checks in with some of the program’s key stakeholders.

TARYN BLACK, DIABETES AUSTRALIA – NATIONAL PROGRAMS AND POLICY DIRECTOR The daily burden of living with diabetes can be significant. It is estimated that people with diabetes face up to 180 diabetes-related decisions every day – that’s more than 65,000 extra decisions a year.

Combined with busy personal and professional lives, remembering and scheduling regular eye checks can be overlooked or put ‘down the list’ of priorities.

Add in a global pandemic and significant interruptions to routine health care for the past two years, and it is no surprise that people’s routine eye checks may have fallen by the wayside.

With around 1.5 million Australians living with diabetes, and an estimated 50% of those Australians not receiving regular eye checks, compounded by the stress and interruption of COVID-19, there is a significant number of Australians at risk of preventable vision loss just because they are not seeing an eyecare provider routinely. As we know, diabetic retinopathy is often asymptomatic until it reaches an advanced

40 INSIGHT July 2022

stage and outcomes of late treatment are usually inferior to early intervention.

This means KeepSight has become more important than ever in its role to ensure people with diabetes don’t fall through the cracks when it comes to routine eye checks. At the end of March there were 240,000 people with diabetes enrolled with the program.

That’s a fantastic inroad, but we still have a way to go to make sure everyone who is at risk is getting regular checks. Presently around 60% of the optometry sector has KeepSight integrated into their patientmanagement systems, making registration to the program quick and easy. Diabetes Australia is committed to work with other providers to increase that number.

This integration with the eyecare sector is key – it keeps the process simple for patients, efficient for practitioners, and keeps people with diabetes coming back to their provider, building trust and rapport.

Continuity of care is associated with optimal outcomes for diabetes complications, including diabetic retinopathy and KeepSight aims to facilitate this.

This is a unique public-private partnership that is making a real impact on the burden of diabetes related eye disease to our health system and to the wellbeing of Australians with diabetes.

PETER VAN WIJNGAARDEN, KEEPSIGHT CLINICAL DIRECTOR & ASSOCIATE PROFESSOR OF OPHTHALMOLOGY, CENTRE FOR EYE RESEARCH AUSTRALIA (CERA) CERA has been involved in the advocacy for KeepSight from the very beginning because we were convinced that the scheme could make a real difference to the eye health of people with diabetes and prevent avoidable blindness.

I know, from first-hand experience in the United Kingdom, that a national screening program for diabetic retinopathy can be highly effective in preventing avoidable blindness. I also know that late-stage diabetic retinopathy treatment is more often difficult and prolonged, and often has poorer outcomes than treatment at an earlier stage. I am certain that we can do better for Australians with diabetes by providing support to ensure that diabetic eye check appointments are not forgotten. That is the core aim of KeepSight.

DR BENJAMIN ASHBY, SPECSAVERS – DIRECTOR OF OPTOMETRY AUSTRALIA & NEW ZEALAND The burden of avoidable vision loss and blindness due to diabetes primarily affects the 50% of people with the disease who do not get regular eye checks. The fact that more than 90% of vision loss from diabetes is avoidable through regular eye checks is the reason why Specsavers has been a committed supporter of KeepSight since its beginning.

Committed to funding $1 million per year for the program’s first five years, Specsavers has also invested in developing and adopting a range of systems and processes across our network of practices. These have assisted our Specsavers optometrists to register around 400,000 appointments (initial and follow up), making us the largest referrer to date.

Looking to the years ahead, Specsavers’ commitment remains unwavering and will be focussed on: • Continuing to connect all consenting patients and appointments seamlessly to the program; • Supporting Diabetes Australia to enhance KeepSight’s recall strategy, ensuring that the program is coordinated with other recall messages and as effective as possible at engaging with patients, resulting in an increase in patients attending follow up optometric care in a timely manner; • Supporting the development of a digital system that measures the progress of KeepSight against key program goals. While reporting on changes in eye health outcomes isn’t yet practical given it’s still early days, Specsavers shares its deidentified data to aid in the reporting of the program’s take up amongst people with diabetes. Specsavers’ progress with KeepSight and our other Transforming Eye Health strategies, is periodically updated on our optometric data website (www.healthhub-anz.com).

KeepSight is an example of public and private organisations collaborating to address a major public health problem. The success of KeepSight to date shows the potential of such public-private collaboration and similar solutions could benefit countless Australians, addressing other public health problems in the future.

CERA researchers are committed to making a real-life impact for patients and developing innovative new ways to deliver eye health services – so supporting KeepSight is a natural extension of our work.

To date our energies have been devoted to the design, integration and promotion of KeepSight, but we are now focusing on measuring the impact of the program. We are also exploring ways of integrating KeepSight into ophthalmology workflows and will do so in a pilot program supported by Bayer.

Key impact indicators will include the proportion of reminders that result in return visits to eyecare providers; numbers of registrants; the impact of health messaging (both targeted, via the NDSS, and mass market messaging) on diabetes eye check activity.

Having established a digital infrastructure to mobilise people with diabetes and to monitor diabetes eye check activity at a national level, we will be well placed to understand the burden of the disease in near-real time. In addition, we will have the opportunity to target health messages to those people who are not currently having regular diabetes eye checks.

This will be a very powerful means of providing targeted support to Australians with diabetes who are at risk of vision loss from the disease.

PETER MURPHY, LUXOTTICA (OPSM, LAUBMAN & PANK) – DIRECTOR OF EYE CARE AND COMMUNITY For Luxottica, integrating KeepSight registration into its clinical workflow nearly 12 months ago was simply the ‘right thing to do’. Optometry has a very important role to play in addressing this serious public health issue, by providing the very best in eyecare for people with diabetes.

The number of people with diabetes, or at risk of developing diabetes, in Australia is at epidemic proportions and we know the risk of some of these people, up to 100,000 a year, developing a serious eye problem is very real. But a large proportion of these can be avoided just by ensuring people are being checked regularly.

Given the number of patients we see, we recognised we had a responsibility to become involved in addressing this national health issue.

And our patients with diabetes appreciate that we are being proactive in supporting them to manage their condition.

We know that these patients have many health appointments to keep on top of and that more acute issues can sometimes take a front seat.

Vision, however, may deteriorate over time and appointments can get put on the back burner. It’s our role to make sure that doesn’t happen, and that any changes, however small, are picked up in time so that any vision deterioration can be addressed quickly and effectively, before it’s too late. We all take our vision for granted. But vision loss has such an impact on quality of life.

Integrating the KeepSight registration into our workflow means the process is seamless for our practitioners and a ‘no brainer’ for our patients. We’ve received great feedback from both our practitioners and their patients that KeepSight is making a difference. n

KeepSight is led by Diabetes Australia and Vision 2020 Australia and funded through a public-private partnership with matching funding from the Australian Government, Specsavers, Bayer, Novartis and Mylan.

INSIGHT July 2022 41

Eye Trend director Helen Lee (right) with her daughter and the company’s marketing manager Charlotte Ng.

LENSES

THE BENEFITS OF A

g in r e f f o s n le m iu m Pre

Five-practice optometry business Eye Trend, based in Melbourne’s east, discusses the transformative impact of introducing ZEISS lenses as it sought a premium lens offering to elevate its portfolio.

W

hen Ms Helen Lee, a migrant from Hong Kong, took full ownership of Melbourne’s Eye Trend in 2007, she set out to make innovation a cornerstone of the multi-site optometry business.

Established in 1989 by her optometrist brother, Lee always had an interest in Eye Trend, but became more seriously involved in 1996 when she returned to Australia from Hong Kong armed with business experience in fashion and real estate. Eleven years later she took the reins of the business and sought to learn everything she could about the true meaning of providing primary eyecare, visiting trade shows around the globe, as well as researching various optometry models here and abroad.

Lee’s determination to innovate led to her to develop a business model that placed equal importance on full-scope optometry and excellent optical dispensing, believing “one cannot survive without the other”. In 2009, her philosophy for the business led to an in-house ophthalmic lens portfolio, E-Lentes, which Lee built through her Chinese-Hong Kong business networks. Then, in 2013, the business introduced Blue Ray Control lenses at a time when blue-light filter technology was only just emerging and travelled to Taiwan to learn about incorporating orthokeratology into Eye Trend practices.

Today, Eye Trend comprises five full-scope Melbourne practices – three in the eastern suburb of Box Hill, one in Burwood East and another out west in Maribyrnong. It employs six optometrists, seven optical dispensers, as well as Lee’s daughter Ms Charlotte Ng as marketing manager.

With a predominantly Asian patient-base, Eye Trend’s optometrists care for many patients with extreme prescriptions, especially myopes (stable and progressing). When the company went through a transformative period in 2018, which involved refurbishing its flagship store at the corner

42 INSIGHT July 2022

of Whitehorse Rd and Station St in Box Hill, it sought an additional lens supplier to complement and elevate its existing portfolio.

“We were after a lens brand that could provide that level of premium quality, but that was reputable and focused on innovation with similar values to our own business – and that’s why we decided to partner with ZEISS,” Ng says.

Lee adds: “I was invited by the ophthalmology departments in two local district hospitals in China to open an eyecare clinic within their hospitals.

Here, I gained working experience and understanding of the optical industry in China and I saw that ZEISS offered a premium standard. They invented freeform lenses and their commitment to invest in R&D suited our philosophy.”

As a result, Eye Trend has incorporated ZEISS’ most advanced lens offering ZEISS SmartLife – freeform lenses available in single vision, digital and progressive – along with ZEISS BluePro, a new technology incorporating blue light blocking properties into the lens substrate. It also offers the standard ZEISS lens portfolio including grind lenses in single vision, digital and progressive lens designs, and ZEISS PhotoFusion is popular among its customers.

ELEVATED PATIENT EXPERIENCE Mr Stephen Tong started his optometry career with Eye Trend 11 years ago, and today is a joint venture partner of Eye Trend Burwood Brickworks.

Still a practising optometrist, he says the company’s roots are in the Asian community, but as Australian-born generations emerge, it’s broadened to serve the local communities where Eye Trend is located.

“It means we see some very high prescriptions and short-sighted patients,

so we are adept with those challenging patients and that's where ZEISS has particularly helped us with its premium lens products,” he explains.

“We regularly see -7.0 D and above, even up to -12.0 D and -15.0 D, so offering really thin, light lenses with the good optical performance had been difficult previously, especially in progressives, but with the ZEISS SmartLife portfolio we’ve seen these progressives perform really well and patients easily adapt to them. And in single vision patients have been impressed by the lens coatings; they’re easier to keep clean, harder to scratch and look better overall.”

Eye Trend managing optometrist Sze Chin performing visual fields.

When faced with a complex prescription, Tong has been impressed with ZEISS’ level of technical troubleshooting.

to the survival of independent businesses like Eye Trend, allowing it to differentiate, and build customer acquisition and retention.

“It feels like they are trying to improve their product and ensure it’s successful in our practice. They're hands on and send trainers to help educate our dispensers and optometrists on new products,” he says.

“By providing these high-end lens technologies, patients know where to go for their eyecare needs. They also tell their friends and family that this is the practice they’ve been going to for 10 years – so they come along too,” Chin says.

“We’ve also been using their software called ZEISS VISUSTORE for lens ordering, but we’ve also used it to simulate the thicknesses of the lens depending on the frame shape, measurements and prescription – it tells you exactly where the thinnest and thickest part of the lens will be. You can also model the progressives to show how the corridor is going to appear in the lens, so that's been great for patient experience.”

Tong says Eye Trend practices already use ZEISS autorefractors and visual field devices, but intends to expand its suite, starting with the iTerminal mobile. It’s a mobile digital centration solution with easy image capturing via an iPad designed to bring flexibility and efficiency to the practice.

“You only need to take two photos of the patient, and it measures all their frame data and uploads it into their profile. So that's going to further enhance our workflow and patient experience,” he adds.

Eye Trend managing optometrist Ms Sze Chin has worked for the firm since 2009 and has admired Lee’s quest for continual improvement. She says it was the right time to bring ZEISS lenses into the business, with patients often seeking out the brand due to its rich history and international reputation.

“While the lens portfolio is extensive, it’s easy to understand, especially for our staff who are often translating the lens benefits in Mandarin or Cantonese,” she says.

“The feedback has been positive, patients are adapting much faster than our non-premium in-house lenses, and they’ve commented on the overall lens function, clarity and coatings as outstanding features.”

With spectacles being a major source of revenue for optometry practices, Chin says access to leading ophthalmic lens technology is vital

“We can't compete in the fast pace, high volume optical category, so it’s very important to ensure our existing customers have faith in us to continue providing the best lens options so they can have an optimal visual outcome and comfort.”

Ng agrees, adding that when Eye Trend practitioners discuss the benefits of the ZEISS lens designs, coatings or features it isn’t an “out of reach” proposition.

“Patients are finding it’s of real of value to them – they're a premium brand but at the same time they are quite attainable.”

NEW STOCK LENSES WITH FREEFORM TECH With a prevalent Asian patient base, single vision lenses account for a significant proportion of Eye Trend’s spectacle sales. Global statistics confirm as many as 83% of spectacle lens wearers purchase single vision lenses, with that number 75% in Asia. The vast majority are sold as stock/ finished single vision (FSV) lenses.

At present, Eye Trend is providing premium single vision freeform lenses as part of the SmartLife portfolio, but Lee’s business is set to benefit from a new single vision product launching this month.

The lens is called ZEISS ClearView Finished Single Vision, which the company expects to disrupt the FSV category. ZEISS says it has identified a new way to get many attributes of complex single vision freeform lens designs into what is essentially a stock lens.

It says this is possible through a specially created freeform lens design for FSV and a new ClearForm manufacturing process that incorporates this design into the finished lens. The lens design includes point-by-point optimisation with the use of 700 free parameters across the lens. This ClearForm process adopts the latest computer numerically controlled (CNC) generators that use special diamond cutting and polishing tools to surface the complex shaped moulds for ZEISS ClearView FSV lenses.

The final lens is said to deliver, on average, a three times larger zone of excellent clear vision with more clarity from the lens centre to the periphery.

In addition, the complex lens shapes allow wearers to experience this vision clarity in a flatter and thinner lens than conventional FSV lens designs.

In numbers, the company says this means ZEISS ClearView lenses will be on average 34% flatter across all prescriptions and up to 16% thinner compared to typical spherical single vision lenses.

Ng says she is excited about the prospect of premium quality optics in FSV lenses, while still offering the fast and affordable benefits of FSV lenses.

“We're excited because we do sell a lot of single vision stock and grind lenses,” she says.

Optometrist and Eye Trend Burwood Brickworks joint venture partner Stephen Tong (left) and optical dispenser Moon Mun assess the ZEISS lens portfolio.

“But hearing ZEISS has developed what appears to be a freeform lens design in a single vision stock lens is interesting. I'm not sure if anyone else is doing that and to provide that to our patients is exciting. I think it's going to elevate our ZEISS product offering even further. We're looking forward to knowing more.” n

INSIGHT July 2022 43

FEATURE

LIFE AS A LOCUM What is it like as a locum optometrist in Australia? Moving from town to town, organising placements, and collaborating with unfamiliar GPs and ophthalmologists? Insight speaks to those on the road.

P

re-2010, before the optometry profession in Australia moved to a national registration system, anyone wanting to work interstate as a locum had to be registered with the relevant authority in each state they worked. Consequently, they paid multiple registration fees, with the employer usually picking up the bill.

additional professional indemnity insurance.

In the years since 2010, locum-specific services have grown, while communication between practices requiring a locum and optometrists seeking short-term positions has blossomed.

When national registration with the Optometry Board of Australia was established – and state-registration abolished – locums had greater freedom to work across the country under one registration.

One such service was established in 2002 has more than 2,000 locum candidates registered across Australia and New Zealand. Corporates like Specsavers and OPSM also facilitate locum placements for their own stores.

And with the Trans-Tasman mutual recognition in place between Australia and New Zealand, optometrists can locum abroad too. But it is still a costly exercise to register across both country, as well as acquire

Over the next three pages, Insight sits down with a new generation of locums, discussing what drew them to experience the highs and lows of a nomadic career.

Emma Ingram locum Oscar ing at Wylee in Ben digo.

a after ing a cupp ogers hav st 2021.

-R gu u am A th land, Alinta Sou Fraser Is on p m p ca setting u

Hala Al-Gelan at Ulu ru,

44 INSIGHT July 2022

Northern Territory.

ARRIVE AS A STRANGER, LEAVE AS A LOCAL ALINTA SOUTHAM-ROGERS, an early career optometrist who began working as a locum last year, is splitting her time between work and travel while on a road trip around Australia.

"I

’m locuming only 50% of the time – the rest of my time is devoted to travelling,” Ms Alinta SouthamRogers explains as lives out of a 4WD in tropical North Queensland.

The now-locum optometrist graduated from University of New South Wales in 2015 and held a full-time position at EyeQ Optometrists in Ulladulla for five years and EyeQ Vincentia for one year until she and her partner decided on travelling around Australia.

“I started locuming in January 2021. My partner and I always planned to do this trip and we went ahead, despite COVID, because when I make a plan, I stick to it. The ability to combine work and travel was one of the reasons why I chose this profession in the first place,” SouthamRogers says.

Throughout the year, they travelled and worked up and down the East Coast, in Queensland and New South Wales, managing to dodge the numerous lockdowns and subsequent border closures. She spent one lockdown beachfront on North Stradbroke Island.

Southam-Rogers liaises with several locum services to secure work while on the road, preferring to line-up placements to match her physical location.

“Friends who have locumed have gone through Eyecare Recruitment, they’ve got a great reputation and can link you up with independents and corporates.

They are very responsive and diligent when booking placements. I’m also registered on Specsavers locum app and OPSM’s national relief team. I probably did 20 placements last year – I’m open to everything,” she says.

“I was grateful to receive several permanent offers in several great regional practices, some of whom have been without a full-time optometrist for many months.”

Southam-Rogers recalls one instance where she travelled specifically to work in a mining town she’d only heard about from a friend. She was curious about working there due to its isolation.

“I caught two flights to work in Kalgoorlie in Western Australia. I locumed at OPSM Kalgoorlie for two weeks.

The practice doesn’t have a regular optometrist on staff – they rely on locums all-year-round,” Southam-Rogers says.

Alinta Southam-Rogers began locuming in January 2021.

Alinta Southam-Rogers, pictured at Beak Lookout, Airlie Beach, says her early experience in a fulltime job helped prepare her for locuming.

“The patients and support staff appreciated having me there. I was the only optometrist there for those two weeks, but I work on my own all the time, so I’m accustomed to it and not daunted by it.”

Southam-Rogers says she is wellversed in managing complex cases independently, having spent five years working in Ulladulla.

“I made a calculated decision to begin my career in a regional practice, and I had an excellent mentor in Tony Ireland at EyeQ Optometrists Ulladulla,” she says.

“As a graduate, I was really fortunate to secure a full-time job in a regional practice where I was exposed to a lot of pathology and diagnostic challenges in my first five years in the profession.

That has given me confidence and skills in managing complexities and co-morbidities, so I was well prepared to take on the position of sole optometrist in Kalgoorlie,” she says.

One of the more challenging cases Southam-Rogers recalls during her short stint in Kalgoorlie involved managing a patient with a retinal detachment.

“Diagnosis was relatively easy but being 12 hours from Perth, managing what happened next was more challenging,” she says. "Kalgoorlie only has a visiting ophthalmologist every three months, with the Lions Eye Institute van.”

Southam-Rogers had to liaise with Royal Perth Hospital to arrange the patient’s transport, giving them the option to fly or drive the 597km. The patient opted to drive.

Another experience she enjoyed during her first year of locuming involved testing children’s vision at a school in Northern Rivers in NSW. It was organised by self-employed optometrist Ms Andrea Eliastam, owner of Mobileyes Optometry Australia, providing mobile optometry services to schools, aged care and corporates.

“Andrea and I tested almost 900 kids at the school, which took four weeks. I really valued the fact you test a broad spectrum of children when you go to them, rather than only testing the ones who present to you in a practice setting.

I found it really rewarding, identifying those who needed further treatment, and it honed my binocular skills,” she says.

Southam-Rogers says one of the things she values most about locuming is experiencing new locations around Australia.

“When you arrive for a new placement, you’re a stranger to the practice and the town but you always leave with new friends and a better understanding of that particular town and its community.” n

AS A GRADUATE, I WAS REALLY FORTUNATE TO SECURE A FULL-TIME JOB IN A REGIONAL PRACTICE WHERE I WAS EXPOSED TO A LOT OF PATHOLOGY AND DIAGNOSTIC CHALLENGES.

INSIGHT July 2022 45

FEATURE

‘I LEARNT A LOT ABOUT MYSELF WHILE WORKING AS A LOCUM’ After successfully locuming in Australia for several years, Aucklander HALA AL-GELAN has now returned to New Zealand where she is once again seeking this style of optometric work.

Ms Hala Al-Gelan, pictured here in Esperance, Western Australia.

Hala Al-Gela, pictured in Sydney, locumed for three years in Australia.

N

ew Zealand native Ms Hala Al-Gelan graduated from The University of Auckland in 2012 and moved to Australia the following year, first working at George Nasser Optometrist in Greenacre, NSW, before joining Bupa Optical as a mobile optometrist in NSW and ACT. “I worked with Bupa for a year and then decided to do something different,” Al-Gelan says, gravitating towards locuming for the travel opportunities.

She locumed for three years, and says it was like being employed fulltime – there was never a shortage of placements available.

“I loved it. It required a little bit of paperwork to get set up at the beginning, to register for GST and look for an agency. They organise everything – travel, accommodation, clinics. They take care of both sides, liaising with the practices and the locums. All I needed to do was give them my availabilities,” Al-Gelan says.

“I travelled everywhere, from small, one-street towns to big cities. I found everyone soon knows you in small towns, small communities. But there are drawbacks to working as a locum,"

46 INSIGHT July 2022

A locum optometry career has also taken her to Western Australia.

she says. "One of those is the lack of job stability and rarely do you see the same patient for follow-up. It’s also difficult to build a professional relationship with doctors and ophthalmologists because you’re only there for the short term."

Al-Gelan says some places don’t have a resident ophthalmologist, and as the attending practitioner, she would be required to make clinical and patient co-management decisions, usually in consultation with an ophthalmologist over the phone.

“You learn to be independent, and strengthen your decision-making skills.

It’s a good learning curve, and I learnt a lot about myself while working as a locum.”

Al-Gelan recalls treating a patient she would ordinarily refer.

“I was locuming in Charters Towers in Queensland, about an-hour-anda-half drive from Townsville. A male patient walked in with a foreign body in the centre of his eye which had been there for a few days – I would usually refer a case like that to the local ophthalmologist,” she recalls.

“But there wasn’t one. The patient lived alone and couldn’t drive. I called

an ophthalmologist, who consented for me to remove the foreign body.

The patient also gave me permission to go ahead and do it. So with their permission, I removed the foreign body, and it healed beautifully. I locumed there for a month, so I was able to see the patient for a follow-up. It was a great outcome, I was very happy, and that particular case has always stuck in my mind.”

After three nomadic years, she decided to stop locuming, opting for more certainty.

“I needed stability, so I moved to Cairns where I was offered a full-time job with Bupa Optical Queensland.

Then I moved back to New Zealand in early March last year for family reasons,” she says.

Al-Gelan started locuming again, this time in New Zealand, in June 2021, using the same agency to find work.

“I was locuming in Auckland but then it went into lockdown, so I was soon travelling again, working in the South Island while Auckland was in lockdown.

"Options have been limited with travel restrictions. In recent times, working as a locum is not as easy as it used to be," she says. n

YOU LEARN TO BE INDEPENDENT AND STRENGTHEN YOUR DECISIONMAKING SKILLS. IT’S A GOOD LEARNING CURVE, AND I LEARNT A LOT ABOUT MYSELF WHILE WORKING AS A LOCUM.

SEEKING A TREE AND SEA CHANGE Recent graduate-turned-locum optometrist EMMA INGRAM traded a full-time position to pursue travel and test her clinical skills in a variety of settings. launched in March 2021, to simplify the way impacted some positions she had in the pipeline. locums share their availability and accept “I had two months of work lined up in vacancies in real time.

Tasmania, but two to three days after “One option was to remain with the COVID outbreak in August 2021, it Specsavers, on a full-time locum salary, fell through. I’ve had a few other jobs and locum within Specsavers network of like that. Government restrictions and stores as vacancies arose. Another option lockdown means locums are the first to was to manage my own placements. I had friends and colleagues who managed their go,” she says.

“It’s really hard and makes me nervous. own locum work, and that appealed to me, It has made me wonder, is this what as I wanted to experience variety in the locuming is going to be like? Will it be types of places I worked – geographically this volatile forever? But now I’ve had a and clinically,” Ingram says.

Through word-of-mouth, she reached out good run of being able to see through to an industry specific locum service which jobs, which gives me confidence.”

Although limited in how far she’s has successfully facilitated placements for been able to travel and work, Ingram her. has enjoyed the mix of places she has “My husband – a freelance filmmaker – worked in Victoria, and says patients and I bought a caravan and were planning vary, even between regional Victorian on travelling around Australia. I knew it Emma Ingram and her husband started living towns like Ballarat and Portland. would be harder for me to make interstate in their caravan while she locumed.

“I enjoy working in different practices workplace connections from Victoria – independents, chains, big and small. without the assistance of a recruitment hen optometrist Ms Emma There’s great variety, and I’m never bored. service. It is ideal being able to travel and Ingram made the leap from full- have access to national jobs at the same Every time I start somewhere new, it is a time employment to locuming bit of a stretch to adapt, but my skills are time,” she says. in August last year, she pictured herself sharper because of it,” she says.

Ingram and her husband started living in across the other side of the country “There are some skills I didn’t their caravan in Ballarat as they waited for within months. However, COVID-related necessarily utilise while working full-time the South Australian border to re-open. travel restrictions kept her plans on ice.

“Initially, our plan was to travel and locum in the same practice day-to-day, but Ingram was in her first year of a science for two years, and eventually find a place locuming keeps everything sharp, as you degree at The University of Melbourne don’t know which particular skills will be we could settle down and start a family when she began working as an optical needed when,” she says.

– in a place that suits us from a lifestyle assistant at Specsavers Bendigo, her Ingram has scrapped her initial twoperspective,” Ingram says. hometown. This formative experience year plan, now that she’s tasted the But their plans were delayed because cemented her desire to pursue an of border restrictions, and COVID has locuming lifestyle. n optometry career.

Before committing to an optometry degree, however, Ingram spent a “gap year” working full-time at Specsavers Bendigo, providing her first insight into working as a locum, with the practice employing locums on a regular basis.

After graduating with a Bachelor of Vision Science/Master of Optometry at Deakin University in 2019, she returned to Specsavers Bendigo as a full-time employee.

“I worked there for two years and that’s when I started to consider a change.

In February last year, I started thinking about making the leap to become a locum and in August I made the switch.”

During the intervening months, Ingram researched her options as a locum.

She was familiar with the Specsavers Emma Ingram, pictured here locuming at Oscar Wylee in Bendigo, says COVID-19 has made life Recruitment Services (SRS) locum app, difficult as a locum.

W

EVERY TIME I START SOMEWHERE NEW, IT IS A BIT OF A STRETCH TO ADAPT, BUT MY SKILLS ARE SHARPER BECAUSE OF IT.

INSIGHT July 2022 47

OCULAR ONCOLOGY

Choroidal melanoma. Image courtesy of Dr Li-Anne Lim.

INSIDE THE CLINICAL SPECIALITY OF

y g o l o c n o ocular

From a subspeciality that barely existed four decades ago, to one bursting with innovative treatments today, ocular oncology has developed to the extent that success is measured in saving eyes, preserving vision and ultimately saving lives. RHIANNON BOWMAN investigates.

O

cular oncology involves diagnosing and treating tumours that occur in or around the eye – tumours of the eyelid, conjunctiva, intraocular structures and orbit.

Sydney optometrist Dr Russel Lazarus, who has 30 years of clinical and academic experience and is part of an international network providing evidence-based resources to educate the public about visual health, explains that while ocular tumours may cause vision loss or loss of the eye itself, they can also be potentially life-threatening if cancer metastasises.

“Eye cancer survival rates depend on the type of tumour, and its size and location and the stage of the cancer at diagnosis,” he writes on The Optometrists Network website.

“Malignant (cancerous) ocular tumours can be primary, starting within the eye, or secondary, spreading to the eye from another organ. Two types of primary tumours develop within the eye itself – retinoblastoma

Dr Carol and Dr Jerry Shields, of Wills Eye Hospital in Philadelphia, US. Image: Wills Eye Hospital.

in children and ocular melanoma in adults.”

Lazarus says both types of tumours are rare; retinoblastoma accounts for 2% of all childhood cancers; ocular melanoma affects one in five million adults, worldwide.

Forty years ago, ocular tumours often required enucleation (removal of the eye). There was little clinical interest in intraocular tumours, and the subspecialty of ocular oncology did not exist.

Retinoblastoma – pre-treatment (left) and nine months post intra-arterial chemotherapy.

Image courtesy of Dr Li-Anne Lim.

48 INSIGHT July 2022

US-based husband-and-wife leaders in the field, Drs Carol and Jerry Shields, wrote in an Indian Journal of Ophthalmology guest editorial, ‘Trends in the management of intraocular tumors over 40 years’, that at that time “diagnostic challenges were steep, especially in the clinical recognition of various intraocular tumors as many clinicians were not familiar with wide-angle viewing with the indirect ophthalmoscope and

fundus photography was in its infancy”.

Today, the Shields’ believe ocular oncology has emerged as a vitally important subspecialty, “bursting with innovative treatments and remarkable success. More than saving vision, we have achieved ultimate goals of saving life and the eye”, they wrote.

Some of the advances the Shields’ have witnessed in their careers include: • New methods of intravenous, intra-arterial, and intravitreal chemotherapy have led to high rates of the globe salvage for retinoblastoma patients • Vitreous retinoblastoma seeds, a previously-doomed finding, are now reversed with chemotherapy lavage of the vitreous cavity • Treatment of metastasis with standard radiotherapy or plaque radiotherapy, as well as photodynamic therapy or intravitreal injections, has led to minimally invasive tumour control, often with the return of visual acuity • Tumour size and genomic status allow a better estimation of ultimate metastatic risk associated with uveal melanoma.

• Uveal melanomas can now be detected at an incredibly small size, under 2 mm in thickness, using OCT as well as documented risk factors • Melanomas that previously disguised as an innocent nevus can be unmasked by autofluorescence for early detection on-malignant choroidal hemangioma and retinal hemangioblastoma • N with their hidden threat for vision loss can be more clearly identified on indocyanine green or fluorescein angiography and OCT, with eradication using photodynamic therapy, photocoagulation, or localised radiotherapy.

(Source: Trends in the management of intraocular tumors over 40 years – Indian Journal of Ophthalmology) Advances in treatment continue. Last year, a West Australian motherof-three who already lost one eye to ocular melanoma was being treated with an experimental immunotherapy drug, Tebentafusp, as part of a trial at Sydney’s St Vincent’s Hospital.

The therapy has been found to improve overall survival rates for patients with metastatic ocular melanoma in clinical trials overseas, with St Vincent’s being the first Australian trial site.

Ocular oncology specialists are a small community in Australia,

comprising 12-15 specially trained surgeons. Insight spoke with three, from Brisbane, Sydney and Adelaide, about their path to becoming a specialist in ocular oncology in Australia, their clinical experience, new treatments currently undergoing clinical trials, and new benchmarks in collecting clinical data.

OCULAR ONCOLOGY REGISTRY UNDER DEVELOPMENT

“ULTRA-WIDEFIELD IMAGING HAS IMPROVED DETECTION OF CHOROIDAL MELANOMA IN PATIENTS WHICH WOULD OTHERWISE NOT HAVE BEEN PICKED UP UNTIL LATER” DR LI-ANNE LIM SYDNEY OCULAR ONCOLOGIST

Sydney-based ocular oncologist Dr Li-Anne Lim – also an experienced general ophthalmologist and cataract surgeon – graduated with a Masters in clinical ophthalmology from the University of Sydney. She then spent 12 months at the Henry C. Witelson Ocular Pathology Laboratory at McGill University in Montreal, Canada, before completing her ophthalmology training at Sydney Eye Hospital.

With scholarship support, Lim pursued further subspecialty fellowship training at Wills Eye Hospital in Philadelphia, US. Training under husband-and-wife leaders in the field, Dr Carol and Dr Jerry Shields, Lim exclusively diagnosed and managed intraocular and periocular malignant and benign tumours, and simulating lesions.

She says gaining experience at this high volume, tertiary referral centre allowed her to gain expertise in the clinical management of eye cancers, research and new imaging and therapeutic technologies.

Now a clinical senior lecturer at the University of Sydney and practising at Sydney Eye Hospital, The Children’s Hospital Westmead, and Chatswood Eye Specialists, Lim is a member of the International Society of Ocular Oncology (ISOO) and involved in the ocular oncology multidisciplinary team at The Kinghorn Cancer Centre at St Vincent’s Hospital in Sydney.

Together with Dr Michael Giblin, the first ophthalmologist in Australia to undergo fellowship training in ocular oncology, Lim works to provide the highest standard of care for patients with eye cancer.

She says technology is changing when and where patients are diagnosed with eye tumours.

“I’ve noticed recently, with the advance of ultra-widefield imaging and more optometrists using this technology in their practice, more than a handful of patients, who have been diagnosed with a mass but no symptoms, have been found accidentally at their optometrist through routine imaging. Ultra-widefield imaging has improved detection of choroidal melanoma in patients which would otherwise not have been picked up until later,” she says.

“Telehealth has also improved management of ocular oncology patients, with image-sharing and documentation accessible remotely, reducing the burden of travel for patients.”

Technology like OCT is also beneficial in detecting radiation sideeffects that require injections, Lim says.

Optos colour reconstruction photograph of the left eye showing a large inferior choroidal melanoma with exudative retinal detachment. Image courtesy of Dr David Sia.

During her fellowship at Wills Eye Hospital in Philadelphia, Lim says she was fortunate to be using technology not widely used in Australia, namely intra-arterial chemotherapy for the treatment of retinoblastoma.

INSIGHT July 2022 49

OCULAR ONCOLOGY

oncology patients. “The Kinghorn Cancer Centre at St Vincent’s Hospital in Sydney was recently awarded funding for an ocular nurse. Just as breast cancer awareness has focused on the importance of a breast care nurse to support patients [led by The McGrath Foundation], we’re building similar support for ocular oncology patients,” Lim says.

Looking ahead, Lim says trials for future treatment to save not just an eye, but save vision, are promising.

“I’m excited to see progress on potential treatment that may help to improve vision, such as anti-VEGF treatment used to treat radiation side effects,” she says.

Lim is part of a team of ocular oncologists gathering data in Australia to identify patterns in diagnosis and treatment.

“We’re in the process of building an ocular oncology registry, funded through the Save Sight Institute. We’re making progress; the registry is being built but is not yet live.”

MORE RESEARCH IS REQUIRED

Fundus images of a left choroidal melanoma. Image courtesy of Dr Lindsay McGrath.

Brisbane’s Dr Lindsay McGrath hopes the imminent ocular oncology registry described by Lim fills a gap in the current landscape, helping provide real world, long-term data that could be difficult to obtain in randomised controlled trials.

“Cutting-edge treatments like intra-arterial chemotherapy delivers chemotherapy directly to the eye – with less absorption to the rest of the body – with minimal side effects,” she says.

“We see about 30-40 new cases of choroidal melanoma a year in Queensland. A registry would be beneficial, because, at the moment, we don’t have an effective method or means to compare individual cases,” she says.

“We performed this treatment for the first time in Sydney last year, with paediatric ophthalmologist Dr Michael Jones. Previously, we couldn’t offer this treatment in Sydney as we didn’t have a neurosurgeon or intraarterial radiologist who could do it.”

McGrath graduated from optometry with honours from Queensland University of Technology in 2005. She then went on to medical school at the University of Queensland and completed a Masters of Philosophy in ophthalmology in 2013.

As part of the ocular oncology multidisciplinary team at The Kinghorn Cancer Centre at St Vincent’s Hospital in Sydney, Lim takes part in regular online meetings with colleagues across Sydney and New South Wales to provide holistic care for patients. She also collaborates with ocular oncologists and paediatric ophthalmologists across Australia and New Zealand to share and discuss retinoblastoma cases, a rare form of eye cancer that affects children under five years of age.

She undertook her specialty ophthalmology training in her home state of Queensland and completed her training at The Royal Victorian Eye and Ear Hospital, with an acting fellow role in the orbital, lacrimal and plastics team. She completed a further year of subspecialty training in ocular oncology, oculoplastics and the orbit at the Royal Hallamshire Hospital in Sheffield, UK.

“In countries like the US, ocular oncologists have a higher case load because they have a larger population. Here, we treat about 20 new cases of retinoblastoma a year, so sharing and discussing these cases can be beneficial,” Lim explains.

McGrath is a member of the Australian and New Zealand Society of

“Some types of retinoblastoma are genetically inherited. It has been so wonderful to see the changing face of retinoblastoma when treating families affected by this disease. Where we once only had treatments that were disfiguring, and often resulted in eye removal, it is such a joy to be able to see the children of retinoblastoma survivors being treated with eye sparing treatments like intra-arterial chemotherapy. Furthermore, pre-implantation genetic testing also means that the diagnosis may be avoided altogether, an important part of our ongoing care of children with retinoblastoma who mature to adulthood,” Lim says.

Approximately 150 Australians are diagnosed with uveal melanoma each year, of which approximately 50% of patients develop metastasis (cancer spreading to other parts of the body).

“Unfortunately that statistic hasn’t changed much over the last few decades, but we’re working closely with medical oncologists to address this. The trial at Sydney’s St Vincent’s Hospital of the bispecific protein drug, Tebentafusp, is showing promise.”

Lim says collaborating with other specialists, like paediatric ophthalmologist Dr Michael Jones, head of the department of ophthalmology at the Children's Hospital at Westmead, is one of the advantages of a career in ocular oncology.

She is also witnessing the infancy of greater support for ocular

Optos colour reconstruction photograph of the left eye showing a superotemporal choroidal melanoma. Image courtesy of Dr David Sia.

50 INSIGHT July 2022

ALL2

Ophthalmic Plastic Surgeons, British Oculoplastics Surgeons Society and International Society of Ocular Oncologists. She is also a member of RANZCO’s special interest group in ocular oncology.

“WE HAVE THREE PRIORITIES WHEN TREATING OUR PATIENTS; ONE, SAVE THEIR LIFE; TWO, SAVE THEIR EYE; THREE, SAVE THEIR VISION”

She joined Terrace Eye Centre in Brisbane in 2019. The centre holds a weekly ocular oncology clinic, which draws patients from the entire Queensland state, plus Northern NSW and the Northern Territory, referred by optometrists, ophthalmologists and GPs. “The bulk of cases are choroidal melanoma. Retinoblastoma management is done at the Queensland Children’s Hospital due to the expertise of the paediatric ophthalmology team there, as well as links with paediatric oncologists,” McGrath explains.

“I specialise in surgical and medical management of intraocular and extraocular tumours, squamous and melanocytic tumours of the conjunctiva, diseases of the eyelids, lacrimal system and orbit. We have three priorities when treating our patients; one, save their life; two, save their eye; three, save their vision. We’re able to save eyes more often now than 30 years ago,” she says.

McGrath says two main treatments – plaque radiation (or brachytherapy), and photodynamic therapy for small tumours and lesions – help save eyes.

“But if a patient presents late and the tumour is larger than if it had been detected earlier – which has happened as a result of COVID – we may need to remove eyes. We still remove about 10 eyes a year for melanoma, which affects predominantly Caucasian patients between 40 to 80 years of age,” McGrath says.

Although diagnostic equipment hasn’t changed a lot in the last 10 years, McGrath agrees with Lim that the advantage now, compared to 10 years ago, is better imaging equipment.

DR LINDSAY MCGRATH BRISBANE OCULAR ONCOLOGIST “We’ve seen an increase in referrals because of improved imaging – and that also means we’ve seen an increase in the number of cases that are, in fact, not melanomas – the patient may actually have a retinal tear, pre-curser lesions, or moles – but these all need investigating in their own right,” she says.

“From our point of view in clinic, these conditions all require critical examination and monitoring.”

While radiation is still the main treatment for eye cancer, McGrath says during her fellowship at the Royal Hallamshire Hospital in Sheffield she had access to equipment on the frontier of radiation treatment.

“In the UK, they have access to a different type of radiation – a proton beam, which is a newer type of particle. The machine costs millions and takes up a whole room, but it is used not just for treating eyes.

A prototype is currently being built in Adelaide, at Australian Bragg

TAKE ANOTHER LOOK AT

PREDNEFRIN FORTE Available now across Australia Indicated for non-infectious ocular inflammation1 and back in stock

Reference: 1. Prednefrin Forte Product Information.

PBS Information: PREDNEFRIN FORTE® is listed on the PBS for severe eye inflammation, corneal grafts and uveitis.

BEFORE PRESCRIBING, PLEASE REVIEW APPROVED PRODUCT INFORMATION AVAILABLE ON REQUEST FROM ALLERGAN BY PHONING 1800 252 224 OR FROM www.allergan.com.au/products Allergan Australia Pty Ltd. Level 20, 177 Pacific Highway, North Sydney NSW 2060. ABN 85 000 612 831. ©2022 Allergan. All rights reserved. AU-PRED-220008 V1. Date of preparation: February 2022. ALL2190.

ALL2190-7 _ Prednefrin ads Stage 2_v0.3.indd 1

03/03/2022 11:39

OCULAR ONCOLOGY

“THE FIELD HAS COME A LONG WAY, AND THE RATE OF ENUCLEATIONS HAVE SIGNIFICANTLY DROPPED" DR DAVID SIA ADELAIDE OCULAR ONCOLOGIST Centre for Proton Therapy and Research, but it’s potentially years away from completion. When it is complete, it will allow us to treat larger tumours, and potentially save more lives,” McGrath says.

Other leaders in the field are pushing the envelope in the treatment space.

The Australasian Ocular Melanoma Alliance (AOMA) is a research group that aims to further the care and treatment of patients with ocular melanoma across Australia and the world.

“The AOMA is run by medical oncologist Dr Anthony Joshua from NSW, who has his finger in international trials (Tebentafusp). Local drug companies don’t have a large eye cancer population to feed into here, in terms of trials, but international trials attract more patients, and newer drugs, aimed at helping save eyes, and promoting longer survival with metastases.”

One of those newer drug trials is belzupacap sarotalocan (previously known as AU-011). This drug is in Phase 2 development, and not on the market.

A virus-like drug conjugate (described as ‘essentially inactivated human papillomaviruses’), AU-011 is a potential first in cancer molecule used to treat tumours and preserve vision.

Through the Queensland Ocular Oncology Service, McGrath has had the privilege of working closely with Professor Nicholas Hayward who runs a melanoma research group at QIMR Berghofer Medical Research Institute in Brisbane.

“He is exceptionally highly regarded in cutaneous melanoma research circles worldwide, and we are lucky enough that Nick has put funding aside for rare melanoma subtypes like ocular melanoma, to help establish a research database, collecting patient’s tumour samples, and blood samples.”

Although ocular tumours are relatively rare compared to conditions like cataract or diabetic retinopathy, McGrath says ocular melanoma is a poorly understood tumour, and more research is required.

She is contributing to the literature; a paper she co-authored on ocular melanoma, titled ‘Whole genome landscapes of uveal melanoma show an ultraviolet radiation signature in iris tumours’, was published in peerreviewed journal Nature Communications in 2020.

“This is the first time that ultraviolet light has been implicated in iris melanoma, and further highlights the importance of shielding the eyes from ultraviolet radiation – particularly in Australia,” McGrath says.

TREATING CANCER HAS AN ‘URGENCY AND VALUE’ Dr David Sia is a dual-fellowship vitreoretinal specialist and ocular oncologist based in Adelaide.

He obtained his medical degree from the University of Otago, New Zealand, in 2009 and went on to undertake ophthalmology registrar training in Adelaide and Alice Springs.

Following completion of registrar training, Sia then pursued overseas

52 INSIGHT July 2022

fellowship training and completed a 13-month ocular oncology fellowship in London, UK at the prestigious Moorfields Eye Hospital, St Bartholomew’s Hospital and Royal London Hospital. This was followed by a two-year vitreoretinal fellowship in Edmonton, Canada, at Alberta Retina Consultants.

Upon returning to Adelaide in 2020, Sia was appointed as a vitreoretinal specialist and ocular oncologist at the Royal Adelaide Hospital, Flinders Medical Centre and Women’s and Children’s Hospital.

In addition, he holds a position as clinical associate lecturer at the University of Adelaide, is widely published and actively engaged in clinical research.

“I feel the biology of cancer is extremely interesting. The treatment of cancer has an urgency and value for saving life that is highly impactful.

Patients diagnosed with cancer are extremely worried and being involved in helping them is a great privilege,” he says.

Sia sees roughly 15-20 oncology patients a week, mostly uveal melanoma and ocular surface squamous neoplasia.

“I also receive referrals for conditions such as choroidal haemangiomas, choroidal metastasis, choroidal osteoma, conjunctival melanoma and vitreoretinal lymphoma. As I do retina work as well, I often get referrals for all sorts of weird and wonderful fundus lesions of uncertain diagnosis. This is part of what makes this specialty so interesting and challenging,” Sia says.

He says there have been exciting advances in the diagnosis and management of intraocular tumours in the past decades – but some limitations linger.

“The field has come a long way, and the rate of enucleations have significantly dropped. Quite a lot of enucleations performed can potentially be avoided if given the necessary resources and access to treatment. South Australia is still limited in the range of treatment options but I hope this will change in the coming years,” he says.

“Some of the most significant advances include molecular prognostication techniques for uveal melanoma such as gene expression profiling and other biomarkers. These allow a more accurate prediction, and classification of uveal melanoma into more aggressive and likely to metastasise or less likely to.”

He continues: “These have not only provided information to direct screening for patients, but also paving the way for identifying candidates for future adjuvant treatment to reduce risk of metastasis.”

But treatment for uveal melanoma has not changed much over the last decade, Sia says.

“Radiation by brachytherapy is still the mainstay. Computerised radiation planning and conformal loading of plaques is an exciting way of improving the accuracy and delivery of plaque brachytherapy.

“Several trials on using photodynamic therapy to treat uveal melanoma were released in the last decade, which showed a suboptimal response rate. It is still offered as a second or third line treatment option. There is strong data that intravitreal anti-VEGF injections following plaque brachytherapy is significant in preserving vision,” he says.

New methods for more targeted uveal melanoma treatment in order to preserve more vision are on the horizon, and immunotherapy for metastatic uveal melanoma has had a recent breakthrough, Sia says.

“I am excited about better treatments for uveal melanoma and metastatic uveal melanoma. More focused treatment for small uveal melanoma is on the horizon. A viral-like drug conjugate that specifically binds to uveal melanoma cells is injected into the eye and subsequently activated with laser to cause tumour cell destruction,” he explains.

“I am also excited for new immunotherapy drugs for uveal melanoma/ metastatic uveal melanoma, and the role of these as adjuvant or neo adjuvant therapy.” n

DISPENSING

FLY TO THE WINDS OF YOUR CUSTOMER – PART 1 WHEN A PERSON ENTERS THE STORE, IT’S IMPOSSIBLE TO KNOW WHAT QUIRKS LIE BENEATH. ACOD’S VIRGILIA READETT OFFERS A GUIDE ON HOW TO DISPENSE TO A CUSTOMER’S BEHAVIOURAL TYPE.

C

an you recall the best customer service you have ever received?

Did you feel they were simply ticking boxes, or did they ‘get’ you? I’m sure it felt effortless, like their service and product was tailored just for you. That’s because it was.

VIRGILIA READETT

“DOVES ARE NATURAL DIPLOMATS. THEY ARE PATIENT, SENSITIVE, SUPPORTIVE AND LOYAL”

Tailored customer services or adapting to the person you are serving isn’t new; in fact, it has been at the forefront of customer service training for decades.

How should our approach be tailored?

What methods suit which customer? It can be a case of trial and error. You’ll hit the mark for some – creating loyal customers.

But for others, their needs can seem a mystery. We are naturally drawn to those whom we have similarities with. Take a look at your friendship circle or co-workers you click with.

This can be applied to customer service in the optical industry. A process often referred to as ‘mirroring’ can be the feather in a successful salesperson's cap.

WHAT ARE THE BIRDS? Mirroring your customer quickly and accurately requires profiling their behavioural type. The next step is knowing how to respond to their category – or ‘bird-type’. More specifically, the D.O.P.E model – Dove, Owl, Peacock, Eagle – was developed by Richard M Stephenson and based on the work of Dr Gary Couture and Dr William Marston.

Without much explanation, one could simply form an idea of these behavioural types from the connotations of their avian names – but let’s break it down.

Doves are natural diplomats. They are patient, sensitive, supportive and loyal.

They seek a sense of belonging and want to feel like a supportive and caring member of small groups.

Logical, analytical, and reserved – these are the traits we associate with the Owl. They look for predictability, put logic before feelings and seek structure, facts and figures.

The Peacock – charismatic, outgoing and animated – prioritise people before tasks. They seek recognition and, to an extent, popularity.

Confident, ambitious, decisive, and impatient – our Eagles. They seek results

Logical, analytical, and reserved – these are the traits associated with patients that match the ‘owl’ personality type.

and look for a challenge. Power and authority are high on their agenda.

These behavioural traits have tell-tale signs in the optical environment.

PROFILING YOUR CUSTOMER The customer that sneaks in unnoticed and will wait quietly until no one else is waiting to ask for help – classic traits of the Dove.

Our beloved Owls head in well prepared with quotes and pamphlets, a list of frames they have researched and a question for every aspect of the dispense.

The whole practice knows when a peacock arrives. They involve their family, friends, every staff member, and even other customers in their frame selection.

They concentrate on the process rather than the end result.

And the Eagle, who may not have booked an appointment but will still expect to be seen the same day, they will make fast, decisive selections and usually a same day purchase. The perfect walk in.

FLY IN SYNC WITH YOUR CUSTOMER Once you have identified the customer’s behavioural type, how do you successfully adapt to them?

As a research task I asked my fellow teachers at ACOD to take the D.O.P.E behavioural test and picked their brain about their preferences as optical customers.

The results were enlightening and entertaining, and will be featured in Part 2 of this article in the August issue of Insight.

REFLECTIONS FOR YOU AND THE TEAM What are your next steps? The best starting place is self-awareness. Take the quiz to discover your “bird”: richardstep.com/dopepersonality-type-quiz/dope-bird-4-personalitytypes-test-questions-online-version. This will indicate the behavioural type that comes most naturally to you and therefore the customer type you feel most at ease serving.

Take note of your secondary bird – or second highest scoring bird. This is the behavioural type you can easily access or turn on. You slip, almost without noticing, into this different style.

It is the other two birds – your lowest scoring categories – that may take more energy or effort for you to adapt to. Be aware of this and work as a team where possible to let members shine where they have the best potential to do so. I’m sure the team will appreciate the Owls among you serving all the engineers.

In addition to the real-world applications, Part 2 of this article will provide detailed examples of certain D.O.P.E. behaviours, and how the optical dispenser can adapt to provide a memorable customer experience. n NOTE: References can be found in the online version of this article.

ABOUT THE AUTHOR: VIRGILIA READETT teaches with ACOD and has been in optics since 2012.

She holds a Certificate IV in Optical Dispensing, Certificate IV in Training & Assessing, and a Bachelor of Arts majoring in Communications.

INSIGHT July 2022 53

NEW PAEDIATRIC VISION IMPAIRMENT ALLIANCE ORGANISATIONS SUPPORTING FAMILIES WITH CHILDREN WITH VISION IMPAIRMENT HAVE FORMED A NEW PAEDIATRIC VISION IMPAIRMENT ALLIANCE FOCUSED ON ADVOCACY AT THE POLICY LEVEL, WRITES EMILY SHEPARD.

W

hen two separate parents of children with vision impairment were introduced by an orthoptist, they immediately knew they were both on the same page. Despite their children having different conditions, the barriers they were facing were all too familiar.

EMILY SHEPARD

“WHAT STARTED AS CASUAL CONVERSATIONS HAS FACILITATED AN ALLIANCE WE HOPE WILL SUPPORT MEMBER ORGANISATIONS TO DEVELOP SHARED RESOURCES”

• B atten Disease Support and Research Association Australia, dedicated to improving the lives and well-being of patients and families affected by the disease through family support, funding Having both established support vital research, and advancing education organisations to fill the gap they experienced and awareness of in Australia; in finding accurate information, support and • C HARGE Syndrome Australasia, knowledgeable professionals when their supporting families and individuals with children were diagnosed, Dr Megan Prictor this syndrome in Australia and New and myself, Ms Emily Shepard, have since Zealand with the mission to make the joined with others to establish the Paediatric person’s journey simpler and easier by Vision Impairment (PVI) Alliance. connecting families with information, Megan is the founder and director of Cataract Kids Australia, designed to improve support for children with cataracts and their families, enhance clinical care and build connections with research across Australia.

I’m the co-founder and director of UsherKids Australia, providing information, education and support for families of children diagnosed with Usher syndrome.

I can recall the initial discussion with Megan. We were essentially the same organisation, providing the same resources, with the same aims but just for a different condition. Our common goals were to provide families with accurate and timely, condition-specific information; to connect parents to gain support through lived experiences; and to create a network of knowledgeable healthcare professionals.

The challenges being articulated repeatedly by numerous condition-specific children’s vision organisations across the country, as well as by several orthoptists with extensive experience pursuing systemic improvements in the diagnosis and care of children with vision impairment, drove the formation of a new formal alliance.

The PVI Alliance has been created with the common goal of providing a united voice to the small but diverse group of organisations and individuals supporting Australian children with vision impairment and their families.

Its focus is at the advocacy and policy level rather than replicating individual support functions delivered by its member entities.

The PVI Alliance members are drawn from support groups across all forms of paediatric eye disease, as well as leaders in education, research and eyecare. The founding member organisations include

54

INSIGHT July 2022

Cataract Kids Australia, UsherKids Australia, as well as:

experts and other families; • C hildren's Tumour Foundation, providing hope for everyone impacted Alliance members are drawn from support groups

by Neurofibromatosis in Australia by across paediatric eye disease, as well as leaders in advocating for change, advancing education, research and eyecare. research and empowering this community with the knowledge, connections and work collaboratively with other like-minded support needed at every stage of persons and organisations. their journey; What started as casual conversations has • C VI Community Australia, a community facilitated an alliance we hope will support for parents, professionals, carers and member organisations to develop shared others to share learning and ideas about and shareable resources. More importantly, Cerebral Vision Impairment (CVI) in it will advocate strongly for systemic change Australia. that is needed in paediatric vision screening, The founding individual members include diagnosis, treatment and wraparound support. people active in the paediatric vision Collectively we are learning much impairment community: Dr Sandra Staffieri from each other while recognising and and Dr Susan Silveira, both research fellows building on our valuable common ground. and paediatric orthoptists, Dr Bronwen It is already evident that the alliance Scott, orientation and mobility specialist, Ms can leverage existing connections and Lisa Kearns, research genetic counsellor opportunities much more effectively, which and orthoptist, and Ms Natalia Kelly, ultimately benefits Australian children with specialist low vision orthoptist. vision impairment.

The PVI Alliance will fill existing and future gaps for families by responding to critical and contemporary issues directly relating to paediatric vision impairment concerns in health, education, advocacy and research.

This includes: 1. A dvocacy for children with vision loss in Australia, to influence policy that addresses identified unmet and emerging health and education needs.

2. T he alliance will focus on sharing resources that educate parents, carers, community and clinical staff to ensure children with vision impairment live life to its full potential.

The PVI Alliance members also seek to

For more information, visit www. pviallianceaustralia.org or email pviallianceaustralia@yahoo.com.

n

ABOUT THE AUTHOR: EMILY SHEPARD is a co-founder and Director of UsherKids Australia committed to making the lives of children with Usher syndrome and their families better by equipping parents with support and guidance when they need it most.

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

ASSESSING A PATIENT’S FITNESS TO DRIVE YOU WARN JOHN ABOUT THE RISKS OF DRIVING, ESPECIALLY AT NIGHT, WHILE WAITING FOR CATARACT SURGERY. HE SAYS HE NEEDS TO DRIVE TO CARE FOR HIS ELDERLY PARENTS. PATRICK CLANCY OUTLINES YOUR PROFESSIONAL RESPONSIBILITIES.

H DR PATRICK CLANCY

ealth practitioners quite often report feeling conflicted about assessing patients’ fitness to drive. On the one hand, you have a duty to protect the public where a patient may put others at risk by driving unsafely.

On the other, you have a duty of patient confidentiality, and may be concerned about the effect on their wellbeing if they lose their licence.

It can be very difficult to navigate such situations. Key strategies are to:

“WHERE THE ASSESSMENT IS UNCLEAR, OPTIONS CAN BE TO REFER THE PATIENT FOR A SPECIALIST REVIEW, OR FOR A FORMAL DRIVING ASSESSMENT”

• maintain a professional distance • be alert to patient pressure • start discussing driving early with patients with progressive conditions.

this requirement in a recent inquest into a fatal accident involving a woman with insulin-dependent diabetes who had been certified fit to drive. The patient had reported a suicide attempt after her licence had been suspended previously.

The coroner acknowledged the balance involved in maintaining a therapeutic relationship, which may make it difficult to address sensitive subjects directly.

However, the coroner was critical that there was no evidence the woman’s doctors had discussed her fitness to drive with her.

CLEAR POLICIES

Patients are required to self-report to the licensing authority if they have medical conditions that would adversely affect their ability to drive – this includes vision issues such as cataracts.

We generally advise doctors to implement a practice policy for fitness to drive assessments. Having a checklist of criteria and clear steps to follow can help you to be objective. It can make it easier for you to empathise with the patient while satisfying your legal and professional obligations.

PROFESSIONAL OBLIGATION TO WARN OF RISKS

It can also help you explain to the patient the areas you are concerned about.

In this situation, the first step would always be to have the discussion with the patient about your assessment and your concerns.

REFER FOR FURTHER ASSESSMENT

PATIENT RESPONSIBILITY

Patients may focus on why they need to drive, the type of driving they will do and the costs of being unable to drive.

You have a professional responsibility to warn them of the risks. That is, you must give clear advice to your patients if long or short-term health conditions, disabilities or treatments may affect their driving ability and pose risks to themselves or others.

This discussion is also important because a patient’s awareness of their condition, and ability to manage or accommodate it, will be factors in determining their suitability for a conditional licence.

It is also very important that you document this discussion and your advice in the patient’s medical record. It is also important that fitness to drive information be shared between a patient’s healthcare team. This may mean including your assessment and discussion in your report back to the patient’s general practitioner.

The Queensland Coroner addressed

Where the assessment is unclear, options can be to refer the patient for a specialist review, or for a formal driving assessment.

Patients may be able to continue to drive with conditions on their license, or subject to regular reviews of their condition.

REPORTING YOUR CONCERNS Unlike the situation with temporary conditions affecting a patient’s ability to drive (such as sedation), practitioners may have a positive duty to report ongoing conditions.

Patients are required to self-report to the licensing authority if they have medical conditions that would adversely affect their ability to drive.

RESOURCES State and territory licensing authorities have helpful resources for patients.

This can also help to provide impartial information about risks of driving (to patients and others), patient obligations, and options such as conditional licences.

The online version of this article will also feature links to an Avant factsheet on fitness to drive, and the 'Austroads: Assessing fitness to drive webpage'.

Austroads also released new national driver medical standards for assessing fitness to drive from 22 June 2022.

In South Australia and the Northern Territory, the law requires health professionals to report to licensing authorities if they believe a patient they have examined is likely to endanger the public by driving with an injury, illness or disability.

Disclaimer: This article is intended to provide commentary and general information. It does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practise proper clinical decision making with regard to the individual circumstances. n

In other jurisdictions, doctors have been the subject of complaints where they have not reported significant impairments to the state or territory licensing authority. All jurisdictions have laws that protect health practitioners from civil or criminal liability if they make such a report to a licensing authority in good faith.

ABOUT THE AUTHOR: DR PATRICK CLANCY is a senior medical adviser in the Advocacy, Education and Research team at Avant. He has been a doctor for over 25 years and was previously a member of a state medical board. Patrick has presented and written widely on medico-legal topics, with a focus on minimising the risks faced by doctors.

INSIGHT July 2022 55

CAREER

People ON THE MOVE

Insight's monthly bulletin to keep the Australian ophthalmic sector updated on new appointments and personnel changes, nationally and globally.

OPHTHALMIC SECTOR WELCOMES NEW HEALTH MINISTER Mr Mark Butler is the new Federal Minister for Health and Aged care. He will also serve as Deputy Leader of the House. Butler has eight ministerial appointments dating back from 2009 to 2013 under then-leaders Mr Kevin Rudd and Ms Julia Gillard. Most relevant were his appointment as Parliamentary Secretary for Health (2009-2010), Minister for Mental Health and Ageing (2010-2013) and Minister Assisting the Prime Minister on Mental Health Reform (2011-2013). His most recent role in opposition was Shadow Minister for Health and Ageing from January 2021 – May 2022.

CYLITE GROWS WITH NEW CLINICAL AND APPLICATIONS MANAGER Mela Bilyk joins Cylite as the Clinical and Applications Manager. She is responsible for helping lead clinical trials, as well as developing clinical training and support on the company's products. Her experience as an orthoptist has ranged from working at Macquarie University Hospital’s ophthalmic department and Focus Eye Centre. She has also provided clinical education as a Practitioner Teacher at the University of Technology’s Discipline of Orthoptics, and more recently in surgical ophthalmic sales at Alcon.

TRAINEE ALREADY LEAVING HIS MARK ON INDUSTRY Dr Joos Meyer has recently become a first-year trainee for the RANZCO ophthalmology training program and was appointed a member of the college's Trainee Representative Group. He is currently co-director of Eyeballs Made Easy, an online ophthalmology e-learning portal for medical students that serves as the curriculum for the University of Western Australia. He was also the founder and CEO of PRYMD labs, a social enterprise that delivered 300,000 doses of Vitamin A to developing world projects between 2014-2017.

NEW APPOINTMENT FOR FORMER OPTOMETRY AUSTRALIA PRESIDENT Former Optometry Australia National President Mr Darrell Baker has started a new position as a Council Member at the Australian College of Optometry (ACO). Baker, who is also a director of Blepharospasm Australia and operates an optometry business in Perth, assumed the ACO role in May, alongside president Mr Rodney Hodge and Ms Sophie Koh who were reappointed as Council Members. The ACO is governed by the Council, which acts as its Board of Management.

COOPERVISION PROMOTES LEADING MYOPIA RESEARCHERS CooperVision has announced expanded roles for two prominent researchers. Dr Baskar Arumugam, B.Opt., Ph.D., FAAO, (pictured) has been appointed Senior Lead Clinical Scientist, and Dr David Hammond, BAppSci(Microbiol), BAppSci(Optom), Ph.D., COT, has been appointed Lead Clinical Scientist on the CooperVision myopia research and development team. Both play integral roles in myopia R&D, including analysis of seven years of data from the MiSight 1 day trial. Image: Linkedin.

J&J VISION VISION FINDS NEXT GROUP CHAIRMAN Johnson & Johnson Vision has appointed Mr Peter Menziuso as Company Group Chairman.

After a 30-plus year career at the company, he now leads the full J&J Vision portfolio, including brands such as ACUVUE contact lenses, the TECNIS intraocular lens family, and TearScience LipiFlow. “Peter’s breadth of experience and passion for eye health position him well to lead J&J Vision,” said Ashley McEvoy, Executive Vice President and Worldwide Chairman, Johnson & Johnson MedTech.

Do you have career news to share?

Email editor Myles Hume at myles.hume@primecreative.com.au to be featured.

56

INSIGHT July 2022

2022 CALENDAR JULY 2022

6TH ASIA-PACIFIC GLAUCOMA CONGRESS

NORTH QUEENSLAND VISION

Kuala Lumpur, Malaysia 3 – 6 August apgcongress.org/

Cairns, Australia 9 – 10 July optometryqldnt.org.au/nqv

NSW RANZCO & OPHTHALMOLOGY UPDATES!

NATIONAL ACBO VISION CONFERENCE

Sydney, Australia 27 – 28 August ranzco.edu

Online 9 – 10 July acbo.org.au

AUGUST 2022 AUSCRS

SEPTEMBER 2022

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

Paris, France 23 – 26 September silmoparis.com

ORTHOPTICS AUSTRALIA ANNUAL CONFERENCE

CCLSA ICCLC 2022

Brisbane, Australia 28 – 31 October orthoptics.org.au

Sydney, Australia 15 – 17 October icclc2022.com.au

NOVEMBER 2022 PROVISION NATIONAL CONFERENCE

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

Melbourne, Australia 21 – 23 October eventbrite.com.au

EUROPEAN SOCIETY OF CATARACT & REFRACTIVE SURGEONS Milan, Italy 16 – 20 September congress.escrs.org

Brisbane, Australia 28 October – 1 November ranzco2022.com/

OCTOBER 2022

VISION EXPO WEST

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

RANZCO 53RD SCIENTIFIC CONGRESS

SILMO PARIS

HONG KONG INTERNATIONAL OPTIC FAIR Hong Kong 9 – 11 November event.hktdc.com

EYECARE PLUS NATIONAL CONFERENCE 2022 Broadbeach, Australia 28 – 30 October web.cvent.com

SPECSAVERS – YOUR CAREER, NO LIMITS Graduate Opportunities – Australia and New Zealand

All Specsa ve stores rs now with O CT

The Specsavers Graduate Recruitment Team are currently looking for new graduates to join our teams at Specsavers across Western Australia. Take advantage of our ‘Go with a friend’ bonus, sign on bonus as well as a generous regional salary and relocation package. Specsavers are the largest employer of graduate optometrists across Australia and New Zealand and we have continued to develop our comprehensive two-year Graduate Program, which provides newly qualified optometrists with a dedicated Mentor, support network and structured program to assist you in your development.

Interested in relocating to NZ?

Specsavers has a range of opportunities for NZ optometrists looking to return home. From North to South, we have opportunities for optometrists at all levels. And as a Specsavers optometrist, you’ll have the chance to advance your skills and become part of a business that is focused on transforming eye health outcomes in New Zealand. Be equipped with the latest ophthalmic equipment (including OCT in every store) and develop your clinical experience across a range of interesting conditions and an ever-growing patient base. You’ll also have the support of an experienced dispensing and pre-testing team, the mentorship of store partners and access to an exemplary professional development program. There’s no place like home – so if you’re ready to return, let us help you.

Optometrist Joint Venture Partnership opportunity - Corrimal, NSW We are currently on the lookout for expressions of interest for an optometrist to join us as a Joint Venture Partners in Lane Cove, NSW. Lane cove is a short 10-minute drive to Sydney’s CBD offering a village atmosphere and riverside living. Expansive walking tracks, camping, picnic and barbeque facilities are minutes away in beautiful Lane Cove National Park – a natural retreat where you can truly escape the big city. .

Earn up to $150,000 at Specsavers Wagga Wagga Specsavers is opening a brand-new store in Lismore offering 6 test rooms and market leading technology – including OCT. Flexible roster to support work/life balance – including rotating roster offering 3 consecutive RDOs. Work with an experienced, supportive and welcoming dispensing team. Great relationships with local ophthalmologists – including CPD and training events. Excellent opportunities for further career development – including pathway to partnership. Situated in Northeast NSW just over an hour from the bustling Gold Coast, Lismore offers warm weather all year round, affordable housing and a welcoming sense of community.

NSW & ACT Locum Availability Specsavers Shepparton are looking for an experienced locum optometrist to join their team from the 4th of July until 4th of August for the whole period or for any dates that you can provide support. Competitive rates are on offer and accommodation and travel will be included. The store and location offer a friendly team to work with and a great range of patients to help care for. This could be a very rewarding and refreshing opportunity for any locums looking to spend some time away from home.

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

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

marie.stewart@specsavers.com or 0408 084 134 WA, NSW & ACT Optometrist enquiries:

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

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

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

apac.graduateteam@specsavers.com

SOAPBOX

NEW APPROVAL FOR RETINOPATHY OF PREMATURITY palsy) downregulates VEGF, arresting vascularisation and, combined with loss of the benefits of the normal maternal-fetal interaction, retinal vaso-obliteration results.

Neurogenesis proceeds despite arrested vascular development.

At 32 weeks, the retina becomes metabolically active and again becomes hypoxic, upregulating VEGF, leading to pathologic vascularisation.

ROP is classified according to site. Zone 1 being centred at the optic disc and extending with a radius of twice the disc to macula distance, Zone 2 an annulus outside Zone 1 extending to the nasal ora and Zone 3 the most peripheral crescent of the temporal retina.

BY DR JEREMY SMITH

R

etinopathy of prematurity (ROP) is a vasoproliferative disorder of the premature retina that causes visual loss and blindness by the consequent effects of scarring and traction, creating macular displacement, macular distortion and retinal detachment.

ROP is the leading ocular cause of childhood blindness in developed nations and occurs predominantly in the very low birthweight infant (<1,250g).

The incidence of ROP blindness in infants is relatively low (1 in 820) due to high standard neonatal care, appropriate screening and effective treatments. Most infants (90%) develop mild self-limiting ROP which resolves without intervention, 50% of those under 24 weeks gestation develop severe ROP with visual impairment.

The world-wide prevalence of blindness due to ROP is 50,000.

Retinal vascularisation commences at 18 weeks’ gestation at the disc and reaches the ora serrata at 40-44 weeks. Vascularisation is stimulated by vascular endothelial growth factor (VEGF) which is induced by normal physiologic intrauterine fetal hypoxia.

Following preterm birth, the postnatal environment doesn’t match the in-utero environment that supported retinal vascular development.

Inevitable hyperoxia (to sustain life and reduce the incidence of cerebral

58

INSIGHT July 2022

‘Plus’ disease relates to vascular activity and is recognised by venous congestion and arterial tortuosity in the posterior retinal vasculature. ‘Pre-plus’ changes are less prominent.

Stages of ROP are defined by the appearance at the vascular/avascular junction. Stage 1 resembles a line, Stage 2 a ridge, Stage 3 extraretinal neovascularisation, Stage 4 partial retinal detachment (4a macula attached, 4b macula detached) and Stage 5 total retinal detachment.

In 1988 retinal ablation by cryotherapy was recommended for extensive Stage 3+ ROP with a 50% reduction in unfavourable anatomic outcome and improved visual results (CRYO-ROP) and in the 1990s transition to laser photoablation occurred; both modalities indirectly reducing VEGF and pathologic vascularisation and subsequent cicatrisation leading to Stages 4 and 5 ROP. In 2003, earlier laser intervention was recommended to treat less extensive Stage 2+ and 3+ ROP and this became the standard of care (ET-ROP). Success rates of 90% are attainable for Zones 2 and 3 under these guidelines.

In the past two decades, advances in neonatal care has resulted in significant increased survival for very low birthweight infants and a greater incidence of more severe ROP-Aggressive Posterior ROP. Conventional laser treatment is only effective in 50-60% of these cases and causes undesirable loss of peripheral visual field and greater myopia.

In 2011, intravitreal bevacizumab was reported as significantly beneficial in the

treatment of Stage 3+ ROP in Zones 1 and 2, with a particularly greater benefit in Zone 1, when compared to conventional laser ablation (BEAT-ROP).

Bevacizumab has not been approved for intraocular use and also results in significant suppression of VEGF in the peripheral circulation for many weeks in the neonate, having implications for neurodevelopment and respiratory and renal systems.

Ranibizumab is a smaller molecule that targets VEGF-A and, importantly, has a minimal and relatively transient suppressive effect on systemic circulating VEGF in the neonate following intravitreal injection.

The RAINBOW trial comparing ranibizumab 0.1mg and ranibizumab 0.2mg with conventional laser for Zone 1 and Zone 2 showed significantly superior treatment success (80% ranibizumab, 66% laser) and fewer unfavourable structural outcomes and need for re-treatment with ranibizumab.

Death, systemic and ocular adverse events were infrequent and evenly distributed among the treatment groups.

RAINBOW two-year outcomes, recently reported, have shown persistence of the superior structural outcomes, less high myopia (5% ranibizumab vs 20% laser) and better vision quality of life scores following ranibizumab 0.2mg. Ranibizumab did not appear to affect systemic nor neurologic development.

It is timely that the TGA has approved Lucentis (ranibizumab) for ROP, given an increasing population of at risk very low birthweight infants in whom laser outcomes are suboptimal and concern exists regarding systemic VEGF suppression with the use of other anti-VEGF drugs. A caveat with antiVEGF therapy in ROP is late reactivation necessitating ongoing follow up. n

Name: Dr Jeremy Smith Qualifications FRANZCO, FRACS Business/organisation: Royal Prince Alfred Hospital, Westmead Hospital, Children’s Hospital at Westmead Position Paediatric ophthalmologist Location: Sydney Years in profession: 30

IT IS TIMELY THAT THE TGA HAS APPROVED LUCENTIS FOR ROP, GIVEN AN INCREASING POPULATION OF AT RISK VERY LOW BIRTHWEIGHT INFANTS IN WHOM LASER OUTCOMES ARE SUBOPTIMAL.

See more, Treat more Optos’ latest ultra-widefield retinal imaging technology increases patient flow and satisfaction.1 Image: Optos Monaco: Scroll through OCT raster scans to look for fluid or pathology.

OCT, optomap colour, and optomap af imaging available with Monaco.

The ONLY single-capture ultra-widefield image in less than ½ a second.

Enhances practice efficiency and patient experience.2 Helps diagnose pathology earlier.3 Differentiate your practice and increase revenue.2 1. Tornambe, The Impact of Ultra-widefield Retinal Imaging on Practice Efficiency, US Ophthalmic Review 2017.

2. Successful interventions to improve efficiency and reduce patient visit duration in a retina practice, Retina. 2021.

3. Kehoe. Poster 19. Widefield Patient Care. EAOO 2016

T: +61 8 8444 6500 E: auinfo@optos.com

Optos.com

INSIGHT

NEW AT

JULY 2022

WWW.INSIGHTNEWS.COM.AU

MARCH WOOW Full page ad - INSIGHT - FAF.indd 4

30/05/2022 6:15:42 PM