Insight September 2021

INSIGHT SEPT

2021

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

The effect of lockdowns on consumer confidence will become clear post-lockdown.

PREPARING FOR OCULAR GENE THERAPIES Eyecare's next revolution will require all new skills, infrastructure and knowledge.

24/07/2021 7:57:14 PM

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SYDNEY OPTOMETRISTS PIN HOPES ON REBOUND

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INSIGHT September 2021 Front cover.indd 1

CYLITE GEARS UP FOR HP-OCT DEBUT

After eight years the Melbourne firm is set to unveil the fourth generation of OCT.

SAY ‘I DO’

to your new Specsavers optometry business ‘I DO’ want to be an owner in a partnership

‘I DON’T’ want to be an owner in a group

with average annual sales of $3 million per store

that has uncertain store performance

with no upfront capital investment

that requires personal bank borrowing to get started

that guarantees a fortnightly pay cheque and five weeks annual leave

that doesn’t guarantee a regular salary

delivers strong and sustainable profits

that is a mix of partner-owned stores competing with company owned stores

that’s investing over $60 million in marketing every year

that under-invests in TV, radio and print marketing

where I can make a genuine impact on community eye health

that is not committed to investing in OCT for every patient as part of standard eye care

where community partnerships are real, enduring and worth millions of dollars every year

where community ‘partnerships’ may not be as real as presented

With a network of over 350 partner-owned stores producing average annual sales of $3 million each, Specsavers continues to have a growing impact on the Australian eye care landscape – and also on the lives and livelihoods of our current army of 800+ optometrists, dispensing and audiology professionals who have joined us as partners in their own stores.

Profits are strong and sustainable, investment in technology is supporting ever improving health outcomes and our community partnerships are real and enduring with millions of dollars raised and distributed every year.

So, if you are an ambitious optometrist, dispensing or optical retail professional keen to discover the benefits of a proven partnership model, talk to us today.

Visit spectrum-anz.com or contact Marie Stewart on +61 408 084 134 or marie.stewart@specsavers.com.

INSIGHT SEPT

2021

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

GREATER SYDNEY OPTOMETRISTS HOPEFUL OF REBOUND 2.0 DESPITE LOCKDOWN FATIGUE

After a gruelling lockdown to date, optometrists in Greater Sydney and surrounding regions are hoping for a return to full appointment books in the coming months, but industry figures are torn on whether the sector will rebound as it has after previous lockdowns.

(LGAs) needed to have a COVID-19 test every three days.

At the end of July, the NSW Government overhauled lockdown measures affecting Greater Sydney, the Blue Mountains, Central Coast, Wollongong and Shellharbour, locking the restrictions in until at least 28 August.

It’s hoped Greater Sydney optometrists can replicate a surge experienced after the first April 2020 lockdown. Many are also drawing inspiration from their Melbourne counterparts after a significant lockdown in 2020, when Victorian bookings reportedly soared to the same volume as the rest of Australia combined shortly after restrictions lifted.

The measures have limited optometrists to urgent and essential care only, with routine care deferred until further notice. In some cases, optometrists living in the worstaffected local government areas

At the time of writing (3 August), industry leaders were hopeful optometrists could begin expanding their suite of available services from this month and recoup lost business since the shutdown began 26 June.

However, as Mr Steven Johnston, CEO of the ProVision network

previous. “ProVision has always anticipated a bumpy ride out of COVID and fortunately we were wrong in FY21, but in a very good way as we far exceeded our expectations, even with the rollercoaster ride in Victoria,” he said.

Dr Andrea Pham, her mother Anh and brother Andrew, of Eye Mechanics.

with more than 450 independents, pointed out, the Greater Sydney lockdown had presented new challenges. He believed each “recovery” became increasingly difficult as consumer confidence is impacted by the uncertainty.

While the financial support schemes were welcomed, he said it seemed every outbreak drew a program that differed from the

“The difference this time for Sydney and more recently Melbourne and Adelaide, has been that the government safety net apparatus has changed significantly. Lockdowns can have dramatic impact on incomes, and optometry is caught in the middle whereby members can provide clinical services but limited retail, which makes it extremely difficult to generate sufficient revenue to cover wages (without JobKeeper) continued page 8

ACCC TO DELIVER FINAL RULING ON HONEYSUCKLE The nation’s competition watchdog is expected to deliver its final ruling on the Honeysuckle buying group this month, with the Australian Society of Ophthalmologists (ASO) now pushing for the Federal Government to take a closer look at the proposal.

In May, the Australian Competition and Consumer Commission (ACCC) delivered an interim decision, allowing the formation of the new buying group born out of a partnership between nib health funds and American health services company Cigna Corporation.

The buying group would act on behalf of health insurance companies and other health payers and collectively negotiate contracts with hospitals, GPs and

other health professionals such as ophthalmologists and optometrists.

The ACCC attached a raft of conditions to its draft determination, but it’s decision to authorise the proposal sparked significant backlash, with 205 submissions, compared with just 30 submissions during the initial consultation phase.

A final decision was originally slated for 24 June but was delayed until this month so the ACCC could “seek and consider further information to inform its decision”.

Medical organisations subsequently have mounted a coordinated campaign against Honeysuckle, fearing insurers could possess significant control over clinical care pathways like in the US. The size of

the group was also of concern, with its potential to have disproportionate market power. Optometry Australia has previously highlighted potential issues for smaller optical operators and their ability to compete with their larger counterparts who often entered low or ‘no gap’ arrangements with health funds.

ASO vice president Dr Peter Sumich believes the ACCC will ultimately approve Honeysuckle this month.

This is because the watchdog’s remit is limited to whether the buying group would be anti-competitive.

“It is quite likely that it’s going to go through, but it will depend on what the ACCC attaches to their ruling; it could be a request for the continued page 8

DIGITAL INTEGRATION DRIVES EFFICIENCIES A Sydney eye clinic with 27 ophthalmologists who see 130 patients a day has made major savings by going paperless and completely digitising the way it handles ophthalmic data.

page 26

What is

HP-OCT ? “ ®

A beautiful example of the engineering excellence that is going to change people’s lives.

“

World-class product design and best-in-class medical technology that will have a significant positive impact on people’s lives around the world.

“

Designed, engineered and manufactured in Australia, the HP-OCT® is an innovative technology.

Find out what everyone’s talking about.

Register your interest at cyliteoptics.com

IN THIS ISSUE SEPT 2021

EDITORIAL

FEATURES

NATIONAL LOCKDOWN SOLUTION NEEDED As I write this, more than half of the country’s optometrists are either operating in or had just emerged from a lockdown. But depending on where you are, this means drastically different things.

29

GENE THERAPIES How the Australian ophthalmic sector is preparing for medicine’s next revolution.

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HOMEGROWN OCT Melbourne company Cylite is putting the final touches on its HP-OCT ahead of its launch.

A little over a month ago, South Australian optometrists could only let people pick up specs and contacts as “essential retailers”, and only provide care virtually – even if it was urgent. In Victoria, face-to-face essential care was allowed where telehealth services weren't clinically appropriate. In Greater Sydney, there’s a quagmire of restrictions to work through, exemplified by a COVID test every three days for some optometrists, depending on the local government area they're entering and exiting for work.

The arbitrary and inconsistent nature of lockdowns are a nightmare for optometry businesses to interpret, as well as the national bodies that support them. Each lockdown, Optometry Australia, for example, often needs to seek a clarification from the respective chief allied health officer. And what constitutes essential care is wide open for interpretation.

It’s also becoming harder for businesses to keep abreast of various support packages and eligibility criteria. This is a vital lifeline; I was advised of a Sydney optometrist almost 80% down on this time last year. It is cutting deeper than the April 2020 lockdown.

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PRESCRIBING POWERS Optometrists can prescribe oral medications in other countries, so why not in Australia?

46

VAPORISING FLOATERS A locally-developed laser is proving an ideal first-line floater treatment.

EVERY ISSUE 07 UPFRONT

51 MANAGEMENT

09 NEWS THIS MONTH

52 OPTICAL DISPENSING

49 PEOPLE ON THE MOVE

53 CLASSIFIEDS/CALENDAR

50 ORTHOPTICS AUSTRALIA

54 SOAPBOX

The recent rocky period has taught us that we’re far from in the clear, and there’s a likelihood of yo-yoing restrictions into 2022. This is until vaccination rates reach an appropriate threshold, which the government has indicated is 80%.

Hence, we need to enshrine a national lockdown blueprint so businesses can easily refer to their obligations once lockdowns are announced. This will also better serve national bodies to provide universal support instead of having to interpret different measures reinvented with each lockdown.

MYLES HUME Editor

INSIGHT September 2021 5

UPFRONT Just as Insight went to print, O=MEGA21 organisers cancelled the event scheduled for September 2-4 in Melbourne. “While there was a possibility that O=MEGA21 could be rescheduled in its original format, uncertainty around the ongoing spread of COVID-19 together with many people’s reluctance or inability to travel, meant postponing would have been an unwise decision,” ODMA chair Mr Robert Sparkes said. For optometrists relying on the event for their CPD requirements, Optometry

n

WEIRD

Victoria South Australia announced the return of the Southern Regional Congress to take place virtually on the same dates.

IN OTHER NEWS, well-known Australian optometrist Dr Tony Adams died on 16 July.

Professor Konrad Pesudovs paid tribute to his mentor and the man he described as “Australia’s greatest optometrist”.

He said Adams’s accomplishments were innumerable but include Dean of Optometry at University of California, Berkeley (1992–2001) and president of the American Academy of Optometry (1998–2000), among a host of awards.

Adams obtained a bachelor's degree from the University of Melbourne in 1962. He

went to Indiana University before joining Berkeley in 1968. FINALLY, triumphant tales of community-based trachoma programs in Western Australia have featured in a newly launched The West Australian Trachoma Storybook, highlighting the importance of primary prevention of the disease that predominantly affects Indigenous communities. The Public Health Advocacy Institute WA, part of Curtin University, produced the book led by the organisation’s Dr Melissa Stoneham.

“Screening is critical but primary prevention is equally important and so the storybook showcases 13 of these initiatives across regional WA,” she said.

STAT

n

WACKY

The English football team has been charged by Europe’s governing body after a laser was shone on to the face of Denmark goalkeeper Kasper Schmeichel in the Euro 2020 semifinal. Despite the disruption, he saved Harry Kane’s shot from the penalty spot, but the striker scored on the rebound.

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A tiger's eye has been saved in what is believed to be the first operation of its type in the world on a big cat. A hood graft procedure was performed on Ratna, a 17-year-old Sumatran tiger, at the UK’s Shepreth Wildlife Park, to treat a corneal ulcer. The eye had previously been operated on for a cataract.

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A UK surgeon removed 27 lost contact lenses from a woman's eye after spotting a “bluish mass” during a cataract work-up. The 67-year-old put the discomfort and dryness down to her age. She had been wearing monthly disposables for 35 years but didn't get her eyes checked regularly. n

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SCOPE-OF-PRACTICE It's not unusual for non-urgent patients to wait more than 300 days for their initial ophthalmology outpatient appointments in the public system – Optometry Australia. Full report page 44.

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INSIGHT September 2021 7

NEWS

BUREAUCRACY FRUSTRATES BUSINESSES continued from page 3

and rent (without the Leasing Code of Conduct) but also means they cannot stand down employees because technically they can open for business.”

Specsavers ANZ director of optometry Dr Ben Ashby said during the past 18 months the company had learned a lot about operating an optometry business across multiple lockdowns in various states and territories.

“One thing I think we have all learned is not to be too ready to try and predict what is around the corner. There have been so many surprises since March 2020 that it is wisest to expect more surprises over the coming months while the vaccine rollout is administered and completed,” he said.

“On a bright note, thus far, each easing of restrictions has seen a strong practice bounce-back with so many patients and customers wanting to re-book the eye test they have missed and update their prescription eyewear as they had previously planned to do. In tandem with this, our store teams will be focussed on prioritising those with the most pressing care needs and bringing them safely into the practice to ensure they are up-to-date.”

Mr Philip Rose, national business development manager of Eyecare Plus,

said on the other side of the Sydney lockdown, its independent practices would be focussed on catching up on the large patient recall backlog.

“It is also quite likely that we will see a resurgence of business activity in our practices as was experienced after the first lockdown and also in Melbourne after "ON THE OTHER SIDE, YES past lockdowns,” he said.

“The big unknown is, how will the absence of JobKeeper work out on consumers in general and particularly on our patients? With less discretionary income and less confidence to spend, both factors are possibly going to affect the post-recovery period, but who knows?

With over 50 daily cases infectious in the community, it is also hard to see when the restrictions will be lifted.”

Optometry NSW/ACT CEO Mr Andrew McKinnon said his information suggested many optometrists were seeing four to six patients a day instead of the 15 they normally might. The absence of JobKeeper had been an issue for owners.

BUSINESS WILL COME BACK. OPTOMETRY BOUNCED VERY STRONGLY IN 2020 AND I SUSPECT IT WILL BE THE SAME THIS TIME" ANDREW MCKINNON, OPTOMETRY NSW/ACT

the situation improve? My personal estimate is another four weeks (end of August), but I suspect that between now and then Sydney will return to a staged opening, with much of the city semi-released, but the LGAs with the numbers will remain pretty tightly controlled. On the other side, yes business will come back. Optometry bounced very strongly in 2020 and I suspect it will be the same this time.”

Mr Andrew Pham, of Eye Mechanics – an independent practice that opened in Gregory Hills in the southeast in December 2019 – said the business had experienced a significant drop in income lately, making it eligible for the NSW Government subsidies.

"We expect the payments to tide us over as we have kept all of our staff this time round, but how long we can go like this remains to be seen," he said.

“Once lockdowns are lifted, we expect a surge in bookings given many patients' annual or biyearly reviews have fallen within the lockdown periods. This is additional to new patients who are increasingly experiencing computer vision syndrome. Our patients have cited that working from home has resulted in significantly increased screen time compared to when at work.

We've seen a substantial uptick in dry eye management." n

“JobKeeper was clean and simple, everyone understood it. The new support packages are convoluted and the rules unclear. I can’t tell you how many calls I’ve had from members asking if I think they are eligible because they can’t work it out themselves,” he said. “When will

ASO SPEARHEADS UNITED FRONT AGAINST GROUP continued from page 3

and Medical Surgical Assistants Society of Australia.

government to review it or a suggestion that there be a regulator to oversee it. Or maybe they’ll say this is an unregulated area that should be,” Sumich said.

Sumich said the campaign – which involved a series of radio advertisements and social media posts – garnered 100,000 shares on Facebook, as well as 30,000 interactions on the platform.

“We told the ACCC we would very much like to make sure this doesn’t just go through to the wicketkeeper without something to suggest the government has to look at it.”

Cutting through to policymakers was the focus of the ASO’s campaign called Send the Eagle Home, a reference to Cigna Corporation and US-style managed care.

It received the backing of the Australian Medical Association (AMA), Council of Procedural Specialists (COPS) Australia, Australian Private Hospitals Association

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INSIGHT September 2021

“But most noteworthy was the way in which the medical profession came together,” he said.

“There were 120 applicants on an ACCC pre-determination conference call. Only three were in favour of Honeysuckle, everyone else was in opposition. You had the AMA, COPS, all speciality societies and the Council of Presidents of Medical Colleges, which you don’t see very often.”

In it’s draft decision, the ACCC ruled Honeysuckle could operate for five years,

as opposed to the 10 years initially sought.

However, the ASO believes this should be limited to 12 months only with a formally agreed format for review in 12 months.

Dr Peter Sumich, ASO.

Large providers Medibank, Bupa, HCF, or HBF in Western Australia also aren’t allowed to join the general buying group for hospital contracting, medical gap schemes and general treatment networks.

But those health funds can join a Broad Clinical Partners Program whereby Honeysuckle signs agreements with medical specialists so customers aren’t charged out-of-pocket costs for hospital treatment. However, this must be capped once it represents more than 40% of the private health insurer market in any state or territory. n

NEWS

EYE DOCTOR PERFORMS AUSTRALIAN-FIRST KERATOCONUS SURGERY IN BRISBANE The first corneal allogenic intrastromal ring segment (CAIRS) surgery in Australia has been performed at the Queensland Eye Institute (QEI), paving the way to better sight for keratoconus patients.

Ophthalmologist Dr David Gunn recently conducted the procedure that overcomes higher complications rates associated with current synthetic corneal implants by using donor tissue instead.

“We are so happy to be able to bring this innovative new treatment option to Australia,” Gunn, a cornea, cataract, laser and refractive specialist, said.

“CAIRS surgery is a major step towards opening up more treatment options for keratoconus with other procedures, rather than a full corneal graft with its invasiveness and higher risks. It can mean the end of reliance on hard contact lenses for some patients.”

According to Gunn, corneal cross-

linking treatment can stabilise keratoconus, but it generally doesn’t improve vision. Glasses can improve vision but become no longer useful later in the disease process, giving way to hard contact lenses use. Approximately 20% of patients will need a full corneal graft to regain sight.

said this brought improved safety and longevity due to better biocompatibility and lower risk of infection. It can have a greater effect due to more superficial placement and can be used in patients with more severe disease.

Dr David Gunn, QEI.

He said corneal implants could improve the shape of the cornea without removing tissue.

The current approach involves plastic corneal implants – known as synthetic intrastromal ring segments – which are effective but have higher complication rates. These include erosion of the implant to the surface of the eye and corneal melt or infection with many implants lasting only five to 10 years before removal.

Now, CAIRS surgery replaces the plastic with a ring of donor corneal tissue. Gunn

According to QEI, the procedure takes approximately 30 minutes and patients notice significant improvements to their vision within a month, with positive change likely to continue and remain permanent.

The technique was pioneered by Dr Soosan Jacob, from Dr Agarwal’s Eye Hospital and Research Center in India.

In an interview with the American Academy of Ophthalmology in 2017, she discussed the process of extracting the CAIRS segment from donor tissue, and how she performed the technique.

Keratoconus affects one in every 84 Australians aged in their 20s. n

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NEWS

AUSTRALIAN COLLEGE OF OPTOMETRY ANNOUNCES NEW COUNCILLORS AND HONORARY LIFE MEMBERS The Australian College of Optometry (ACO) has appointed two new council members and bestowed 12 awards including honorary life membership at its recent Annual General Meeting.

ACO members voted to elect Associate Professor Lauren Ayton and Dr Michelle Waugh – alongside reappointed council member Mr Timothy Powell – to join the council. The results were announced at the AGM on 22 June, following an election held earlier that month.

Ayton is an Associate Professor in the Department of Optometry and Vision Sciences, and the Department of Surgery (Ophthalmology) at the University of Melbourne. Her current research is in retinal disease and gene therapy, working with colleagues at the Centre for Eye Research Australia on several clinical trials.

As a leader in the profession, she has been the clinical team leader of the Bionic Vision Australia project, director of clinical and regulatory affairs at a Harvard and Cornell-affiliated start-up company, and is the director of SPARK Melbourne, a research commercialisation accelerator program.

Waugh was previously head of education in ACO’s Education, Membership and Marketing team and has served on Optometry Australia’s Medicare Benefits Schedule Advisory Group, and as treasurer

The Australian College of Optometry in Melbourne.

on the Executive Management Committee of Clifton Street Childcare Centre.

"MR MICHAEL AITKEN AND PROFESSOR SHARON BENTLEY WERE AWARDED HONORARY LIFE MEMBERSHIP, ACO’S MOST PRESTIGIOUS AWARD" AUSTRALIAN COLLEGE OF OPTOMETRY

and Professor Sharon Bentley were awarded honorary life membership, ACO’s most prestigious award. It is presented to those who have provided distinguished and meritorious service to the ACO and/or the profession.

Aitken and Bentley were among 12 members to be recognised for their contribution to the profession, which also included: Dr Suit May Ho who received the ACO Member Award for Outstanding Services; Professor Shaun Collin received the National Vision Research Institute Fellowship; Ms Natalie Watt received an ACO Fellowship; and Dr Marianne Coleman received the Nicola Family Travel Grant.

She has been actively involved in public eyecare, helping improve outcomes in communities in rural England and volunteering with Brien Holden Vision Institute in rural Sri Lanka.

The college also invited Australian universities to nominate their most outstanding optometry graduate through combined evaluation of academic excellence and professional commitment.

Ayton and Waugh join reappointed council member Powell, a rural optometrist practising in northwest Tasmania, council president Mr Rodney Hodge, Ms Denise Gronow, Professor Linda Denehy, Mr John Chaney, and Ms Sophie Koh.

They were presented to: Ms Janine Sing (Deakin); Ms Esmeralda Stefanopoulos (Flinders); Mr Shi Yue Feng (University of Melbourne); Ms Stephanie Huang (UNSW); and Mr Lachlan Munro (QUT).

The ACO Outstanding Graduate Award for ACO Certificate in Ocular Therapeutics – recognising the candidate who achieved the highest score across all assessments for their graduating year of the ACO Certificate in Ocular Therapeutics – was presented to Mr Andrew McMillan. n

The ACO also acknowledged outgoing council member Associate Professor Mitchell Anjou AM for his contribution since 2015.

Former CEO Ms Maureen O’Keefe also recently departed after eight years in the role.

Also, during the AGM, Mr Michael Aitken

MORE THAN HALF OF OPTOMETRY NOW REGISTERED WITH KEEPSIGHT DIABETIC EYE CHECK PROGRAM More than 700 optometry practices across Australia are now supporting the eye health for people with diabetes, as another major optometry retail network joined KeepSight.

Luxottica announced during National Diabetes Week in July that its 365 optometry practices – operating as OPSM and Laubman & Pank – would join forces with Diabetes Australia (DA) to integrate with Australia’s diabetes eye check reminder program, which initially rolled out in 2019.

The additional practices mean 60% of the optometry sector is now part of KeepSight, according to DA, with efforts now focused on developing technical solutions that allow all optometry practices to integrate their patient management systems with the

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INSIGHT September 2021

means even more people with diabetes will now be registered with KeepSight, and this will help ensure they get their necessary diabetes eye checks,” he said.

scheme. Mr Peter Murphy, Luxottica Retail ANZ director of eyecare and community, said KeepSight was a unique initiative with the potential “to make a real dent in the burden of diabetes-related eye disease on our health system”.

“We are very aware that timely preventative healthcare can have a positive impact on people with diabetes and working with KeepSight is a great step for us to continue offering this to our patients,” Murphy said.

DA CEO Professor Greg Johnson said more than 175,000 people were now registered to receive regular alerts and reminders about their diabetes eye checks. “The integration of OPSM and Laubman & Pank with KeepSight

Luxottica's 365 stores joined the initiative.

“Any eyecare provider can enrol a person with diabetes with KeepSight. We are thrilled that Luxottica has taken the step to invest in an integrated registration process which will make KeepSight registration quick and easy for both the person with diabetes and the practice.”

During July, more than 75,000 people registered on the National Diabetes Services Scheme received a personalised health message encouraging them to get a diabetes eye check and register with the KeepSight program. n

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NEWS

THREE PROFESSIONAL CHAIRS TO BOOST PERTH’S EYE RESEARCH EFFORTS Lions Eye Institute (LEI) in Perth has joined forces with The University of Western Australia (UWA) to create an inaugural endowment fund to establish a UWA Chair in Optometry Translational Research.

The position will require collaboration with the existing Ian Constable Chair in Discovery and Translational Ophthalmic Science, and another newly-created role called the Lions Curtin Chair in Ophthalmic Big Data.

Both entities have committed $3 million, bringing total funding for the position to $6m. Key industry partners will also be approached for additional financial support to ensure the endowment fund and chairmanship are financially sustainable, LEI said.

The Lions Curtin Chair in Ophthalmic Big Data is jointly funded by Curtin University and the Lions Save-Sight Foundation WA.

The Chair in Optometry Translational Research will build a new capacity in analytics across optometry and ophthalmology.

According to LEI, research will focus on new or improved methods of detecting and managing ocular disease earlier and evolving new eyecare pathways with the primary goal of reducing preventable blindness within the community by making services more accessible.

It is expected the role will be advertised in the coming months and the inaugural chair appointed for the start of the 2022 academic year.

intelligence interpretation of screening data to improve early detection and treatment of eye disease.”

Lions Eye Institute in Perth.

An international search for a suitable candidate for The Ian Constable Chair in Discovery and Translational Ophthalmic Science is also currently under way, with a plan to have the position filled in the new year.

The role has been developed to honour the role of LEI founding managing director and patron, Professor Ian Constable AO, in researching and treating blindness and vision loss over five decades.

The role is underpinned by a new affiliation agreement between LEI and Curtin University, and will also be advertised in the coming months with the intention of having the chair appointed early in 2022.

This position aims to develop new techniques for earlier diagnosis and treatment of glaucoma and retinal vascular diseases. Funding for the chairmanship is in place, following a dedicated fundraising drive that resulted in the commitment of several generous benefactors.

According to LEI, the new Chair in Ophthalmic Big Data will provide leadership of research locally and undertake internationally competitive research.

“It will play a major role in understanding and improving eyecare systems and pushing clinical diagnostic boundaries based on large and continuous related datasets,” the institute said.

Founded in 1983 by Constable, LEI is a not-for-profit incorporating one of Australia’s largest ophthalmic practices, including a day surgery unit and a laser vision centre. It also houses the Lions Eye Bank, Lions Optics, Lions Outback Vision and the Lions Save-Sight Foundation WA. n

“The role will capitalise on advanced imaging technology and build artificial

STEM CELL PROJECT TO ADDRESS BLINDNESS IN ADULTS RECEIVES FEDERAL GOVERNMENT FUNDING A stem cell expert at the University of Sydney, Children’s Medical Research Institute (CMRI), has been awarded almost half a million dollars to develop stem cell derived-retinal organoids to test genetic therapies.

Dr Anai Gonzalez-Cordero is one of three researchers to share in $6.3 million in funding awarded to the University of Sydney from the Medical Research Future Fund (MRFF) 2020 Stem Cell Mission.

Her research output aims to overcome the leading cause of blindness in the working-age population, where the majority of inherited retinal conditions leading to total blindness are due to loss of photoreceptor cells.

She joined the University of Sydney and the CMRI in 2019 after working as a Research Fellow at the Institute of Ophthalmology, University College London, UK.

Gonzalez-Cordero’s share forms part of a larger sum of $18.7 million in funding for the Stem Cell Mission, focusing on research that develops and delivers innovative, safe and effective stem cell medicines to improve health outcomes, announced by Federal Health Minister Mr Greg Hunt.

Gonzalez-Cordero’s $498,419 grant will aim to harness researcher expertise in human stem cell biology, genetics,

The initiative is said to be a priority of the Morrison Government’s $20 billion MRFF and will provide $150 million

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INSIGHT September 2021

towards research over nine years.

ophthalmology and gene therapy to test the efficacy of new therapies.

Associate Professor James Chong and Associate Professor Wendy Lipworth, also from the University of Sydney, received funding for their stem cell projects.

Dr Anai GonzalezCordero, CMRI.

Chong was awarded $4.9 million for induced pluripotent stem cell derived cardiomyocytes – a new therapy for nooption end-stage heart failure.

Lipworth was awarded $799,543 for ethics and evidence in stem cell medicine.

Other recipients in the 2020 Stem Cell Mission funding included Murdoch Children’s Research Institute, which received $3.6 million spread across four projects, and the University of Melbourne, which received $1.5 million for two projects. n

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Transitions Optical introduces two NEW product innovations to its range of extra dark lenses for extra light protection: Transitions® XTRActive® new generation and Transitions® XTRActive® PolarizedTM 1. Based on tests on polycarbonate grey lenses; up to 10% darker than Transitions Vantage @ 23°C and up to 5% darker @ 35°C. 2. Based on tests across materials on grey lenses, achieving transmission below 45% @ 23°C behind a standard windscreen. The lens achieves a polarisation efficiency of up to 30% behind the windscreen. 3. Based on tests across materials on grey lenses @ 23°C, using ISO 12312-1 standard.

4. Compared to other products in the Transitions portfolio. Based on tests across materials on grey lenses @ 23°C. ‘blue light’ is calculated between 380nm and 460nm.

Transitions, XTRActive and Vantage are registered trademarks and Transitions XTRActive Polarized, Transitions Light Intelligent Lenses, and the Transitions logo are trademarks of Transitions Optical Inc. used under license by Transitions Optical Limited. ©2021 Transitions Optical Ltd. Photochromic performance and polarisation are influenced by temperature, UV exposure and lens material. www.transitions.com

NEWS

SPECIAL DESIGNATION TO HELP OPTHEA EXPEDITE LEAD DRUG CANDIDATE THROUGH THE FDA Melbourne biopharmaceutical company Opthea announced the US Food and Drug Administration (FDA) has granted Fast Track designation for the company’s lead drug candidate OPT-302 for neovascular age-related macular degeneration (nAMD).

The American regulator’s program provides several benefits to help advance development and expedite the review of novel therapies for serious conditions for which there is an unmet medical need, with the aim of accelerating patient access to the new therapy.

The new designation acknowledges the significant unmet medical need in the management of nAMD, and the potential role that OPT-302 may have in addressing it, Opthea stated. OPT-302 is a VEGF-C/-D ‘trap’ inhibitor that is administered in combination with existing anti-VEGF-A therapies such as Lucentis and Eylea.

The company is now eligible for more frequent regulatory meetings and communications with the FDA, as well as a rolling review of completed

sections of its Biologic Drug Application (BLA) that will help expedite the Phase 3 development program and subsequent approval review process.

Under the Fast Track designation, OPT302 may also be eligible for ‘accelerated approval’ and ‘priority review’ if relevant criteria are met.

“Given the need to improve therapeutic options for wet AMD patients, we welcome this Fast Track designation for OPT-302 and the regulatory support it provides in expediting the Phase 3 development program to advance this promising novel treatment to patients sooner,” Opthea CEO and managing director Dr Megan Baldwin said.

“The recognition from the FDA to grant OPT-302 Fast Track designation reflects the seriousness of wet AMD as a debilitating eye disease and the importance of advancing new therapies such as OPT-302 to address the significant unmet medical need for wet AMD patients, many of whom experience an incomplete response to VEGF-A inhibitors despite regular, ongoing therapy.”

Dr Megan Baldwin, Opthea.

She continued: “By targeting a novel mechanism of action, OPT-302 has the potential to be a truly differentiated treatment option that when used in combination offers patients improved vision outcomes over standard of care anti-VEGF-A monotherapy.”

Opthea is currently recruiting patients into two concurrent global, multi-centre, randomised, doublemasked, shamcontrolled Phase 3 trials known as ShORe (Study of OPT-302 in combination with ranibizumab) and COAST (Combination OPT-302 with aflibercept study).

Both clinical studies will enroll around 990 treatment-naive patients each and assess the efficacy and safety of intravitreal 2.0 mg OPT-302 in combination with 0.5 mg ranibizumab (Lucentis) or 2.0 mg aflibercept (Eylea), compared to ranibizumab or aflibercept monotherapy, respectively.

Shares in ASX-listed Opthea – which has a market capitalisation of $435 million – rose sharply after the FDA announcement from $1.26 to $1.40. At the time of print, it was trading at $1.28. n

CORNEAL EROSION MORE PAINFUL THAN ANY PHYSICAL INJURY FOR AUSTRALIAN RUGBY LEAGUE GREAT Rugby league legend Wally Lewis has battled through broken arms, and fractured legs and cheekbones, but it was a bout of corneal erosion and dry eye disease that almost brought the Queenslander to his knees.

Now, the Maroons great-turned-sports presenter has urged Australians to prioritise their eye health after he was treated by Dr John Hogden from leading Brisbane clinic The Eye Health Centre (TEHC).

In an interview with his 9News colleagues, ’The King’ said he endured four to five days of irritated eyes, which he put down to excessive eye rubbing, as well as blurred vision that he thought was a migraine.

Soon a headache behind his left eye intensified, prompting him to seek out the expertise of an eyecare professional.

"My pain level had reached something that I had never experienced," he said.

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INSIGHT September 2021

of pain and loss of vision suggestive of a possible sight-threatening condition – either angle closure glaucoma or significant corneal disease. Hence, he was seen immediately,” Hogden said.

Maroons great Wally Lewis. Image: Channel 9

"I've had broken arms, I've fractured bones in my legs, fractured my cheekbones but none of that came into the same ballpark as what the pain was like in the eye. The greatest fear for me was that I was losing part of my sight."

Hogden diagnosed Lewis with corneal erosion, as well as dry eye.

“Wally rang with severe symptoms

“Corneal erosions are very painful and can proceed to more sight-threatening problems if not treated adequately. His case highlights us to all the importance of eyecare and preventative eyecare."

Hogden said Lewis first presented to an optometrist, who referred him to TEHC. “His optometrist did a wonderful job getting him to the right specialist.

Optometrists are critical to providing care to patients in the community,” he said.

“The important collaborative relationship The Eye Health Centre has with community optometrists is very important for the community, our patients and both professions." n

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Transitions Optical introduces two NEW product innovations to its range of extra dark lenses for extra light protection: Transitions® XTRActive® new generation and Transitions® XTRActive® PolarizedTM 1. Clear to extra dark photochromic category. Tests across polycarbonate and 1.5 grey lenses using Transitions Optical’s standard testing method. Outdoors at 35°C achieves <18%T. Behind the windscreen at 23°C achieves between 18%T and 43%T. 2. Compared to the previous Transitions XTRActive generation across materials tested on grey lenses fading back to 70% transmission at 23°C. 3. Compared to other products in the Transitions portfolio. Blue light indoors (380nm-460nm) measured at 23°C, behind the windscreen, outdoors at 23°C and 35°C among polycarbonate and 1.5 grey lenses in the clear to extra dark photochromic category.

Transitions, XTRActive and Vantage are registered trademarks and Transitions XTRActive Polarized, Transitions Light Intelligent Lenses, and the Transitions logo are trademarks of Transitions Optical Inc. used under license by Transitions Optical Limited. ©2021 Transitions Optical Ltd. Photochromic performance and polarisation are influenced by temperature, UV exposure and lens material. www.transitions.com

NEWS

MILDURA CHILDREN TO BENEFIT FROM OPHTHALMOLOGY TRAINING PROGRAM Monash University is implementing a new program to train Mildurabased doctors and medical students in ophthalmology to improve the Dr Rahul Chakrabarti, eye health of local Monash University. children.

Dr Rahul Chakrabarti – a Monash University medical graduate who completed his first, second and fourthyear clinical placements in Mildura – will be returning to the regional city once a month to conduct ophthalmology clinics and provide hands-on tutorials for Monash medical students.

Chakrabarti, an ophthalmologist, is involved in ophthalmic education in Melbourne for ophthalmology registrars, medical students, emergency medicine trainees and GPs and is passionate about educating medical students in the specialty.

“It's not just a matter of helping patients see better, there is also the issue of making doctors more comfortable in examining eyes, whether it's in general practice or the emergency department,” he said.

“For the most part, doctors are unfamiliar with ophthalmology which is often poorly covered in medical training. It's just a matter of demystifying a lot of eye conditions through skills-based teaching.”

Chakrabarti, who grew up in Whyalla in South Australia, remembers the long wait his mother endured for gall bladder surgery because of the difficulties in getting a surgeon to a regional town.

“It's important that people in regional areas have the same access to the same surgeries that people in metro areas have, which is why I am so happy to be able to bring my clinical skills and training to Mildura on a regular basis,” he said.

Chakrabarti visited the Mildura Eye Specialist clinic on 8-10 July and doing a once per month operating list at Mildura Base Public Hospital. n

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EYES RIGHT OPTICAL INTENSIFIES ECO-FRIENDLY APPROACH Eyes Right Optical has moved to 100% compostable courier bags for deliveries as the company continues to expand its sustainable practices.

National brands manager Ms Lisa Wymond said it was important the company continually sought methods to reduce the impact of its business on the environment. The eco-friendly decision to move to compostable courier bags will see postage rates stay the same for customers, but is costing Eyes Right more per delivery.

The eyewear wholesaler’s decision forms part of a wider trend in the optical sector whereby more suppliers and practices are moving to sustainable practices to align with consumer expectations.

“Eyes Right has done eco-friendly practices before they were mainstream and expected from consumers, it’s just the right thing to do,” Lisa Wymond said.

Last year, the business developed a Sustainable and Ethical Practices Policy that included other eco-friendly changes the company has implemented over the years, as well as what its own suppliers do. This came in response to more frequent queries from customers about its environmental practices.

“Eyes Right Optical is committed to operating our office and warehouse in

Mark and Lisa Wymond in the veggie patch that has been introduced for staff.

the most environmentally sustainable and ethical way possible,” she said.

“Over the years, we have implemented the following processes and practices into our business model, including 176 solar panels on the roof of the warehouse (10 years ago), LED lighting throughout the office and warehouse, and paper recycle bins throughout the office and warehouse.”

The company has also invested in hybrid cars for its sales team, a staff veggie patch and electronic invoicing. It recycles all paper and cardboard, reuses returned bubble wrap, and consolidates its shipments from overseas – resulting in less packaging material and lower carbon emissions.

Wymond said Eyes Right also held its optical suppliers – such as Design Eyewear Group, Morel and Kenmark Eyewear – to the same standards. n

AUSTRALIA'S EYE BANK PEAK BODY REBRANDS The Eye Bank Association of Australia and New Zealand (EBAANZ) has redesigned its logo and launched a new look website as part of a rebrand to represent the transformative impact of eye tissue donations.

Mr Luke Weinel, chair of the peek body for eye banking, eye donation and allocation in Australia and New Zealand, said without donors, many would be without access to a sight restoring transplants, and surgeons and researchers would be without donations to support eyecare research.

The design uses the eye lids to symbolise the donor-recipient relationship.

to recipients”. New vibrant colours have been incorporated to attract attention to ensure the contributions donors made towards eyecare weren't forgotten.

“And we wanted our brand to reflect their contribution,” he said.

“The design uses the ‘eye’ to focus on our two nations, and the ‘eye lids’ to connect and symbolise the unique relationship between the donor and recipient,” Weinel added.

Weinel said the re-brand reflected “the new life the gift of donation offers

In 2020, there were 1,443 ANZ donors, and 2,495 corneal transplants in ANZ. n

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NEWS

COOPERVISION EXPANDS AND UPDATES SILICONE HYDROGEL 1-DAY CONTACT LENS FAMILY CooperVision recently unveiled major updates to its portfolio of MyDay silicone hydrogel 1-day contact lenses, including a new lens for presbyopia.

In the first of the announcements, the company revealed that optometrists can now fit an even greater number of astigmatic patients in a premium silicone hydrogel 1-day contact lens after expanding the parameters for its MyDay toric.

The lenses are now available in aroundthe-clock axes, in the most commonly prescribed sphere powers.

“These new MyDay toric parameters expand our commitment to providing a wide range of stable, comfortable silicone hydrogel 1-day toric options for astigmatic patients,” Mr Joe Tanner, CooperVision’s ANZ professional services manager, said.

“From sphere to toric to multifocal, and in every modality, CooperVision continues to offer the broadest range of soft contact lenses in the industry.”

In July, the company also launched the MyDay multifocal contact lens, the first to feature its trademarked Binocular Progressive System. It describes this as

CooperVision’s MyDay contact lens family.

an innovative three-add approach catering to all levels of presbyopia with simplified fitting, optimal visual acuity at all distances and comfortable wear.

MyDay multifocal contact lenses are available in a power range of +8.00 diopters (D) to -10.00D in 0.25D steps, and -10.50D to -12.00D in 0.50D steps, and in low (+0.75D to +1.25D), medium (+1.50D to +1.75D) and high (+2.00D to +2.50D) add power.

"FROM SPHERE TO TORIC TO MULTIFOCAL, AND IN EVERY MODALITY, COOPERVISION CONTINUES TO OFFER THE BROADEST RANGE OF SOFT CONTACT LENSES IN THE INDUSTRY" JOE TANNER, COOPERVISION

“MyDay multifocal contact lenses are ideal for younger presbyopes as well as patients with more advanced presbyopia looking for a way to stay in, return to, or begin contact lens wear.”

Initial studies showed 86% of patients agreed that MyDay multifocal met their vision needs, and 90% of patient expectations were met or exceeded for vision stability during the day.

The three-add method in CooperVision’s Binocular Progressive System uses different lens designs to optimise vision for all levels of presbyopia. These allow the eyes to work in tandem for a simple initial fit and an easy progression as the near requirement increases.

The company said it now means optometrists can fit 98% of patients with two pairs of MyDay multifocal lenses or fewer when following the fitting guide.

CooperVision ANZ brand manager Ms Jessie Taylor said single-vision contact lens wearers often lived active lifestyles, but once presbyopic, typically they were unable to experience the same clear vision.

The MyDay multifocal is included in CooperVision’s OptiExpert app, which provides a suite of digital tools that aid clinical decision making, help reduce chair time and increase patient success with contact lenses, the company said. n

“As a result, they often turn to reading glasses [instead of] their contact lenses or drop out of the category entirely," she said.

OPTOMETRISTS TO RECEIVE ONLINE SEXUAL ABUSE TRAINING TO PROTECT SENIOR AUSTRALIANS The Federal Government is partnering with the Older Persons Advocacy Network (OPAN) for an online learning package aimed at helping optometrists, aged care providers and other health professionals deal with cases of sexual abuse.

Funded via a $168,000 government grant, OPAN is working with leading researcher Dr Catherine Barrett to develop Abuse of the older person: eLearning program for health professionals, which will help health professionals prevent, identify, and respond to elderly assault cases.

Minister for Senior Australians and Aged Care Services Mr Richard Colbeck said it was an important contribution to reinforce the safety of senior Australians, following the sobering findings of the Royal Commission into Age Care Quality and Safety earlier this year.

“Assaults on the elderly – in any form –

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INSIGHT September 2021

are deplorable,” Colbeck said.

“These incidents were underlined in the findings of the Royal Commission into Age Care Quality and Safety and the Morrison Government is more determined than ever to ensure those in care are treated with respect and dignity.”

OPAN’s online program, which will consist of 33 online learning modules, will also be aimed at health and allied health workers, such as GPs and optometrists, who may be the only people some senior Australians confide in after being assaulted.

Barrett will also launch a #ReadyToListen social media campaign to encourage senior Australians and their families to report sexual assault.

Colbeck said the initiative would complement the government’s $17.7 billion response to the Royal Commission.

It will consist of 33 learning modules.

“One of the five pillars of our comprehensive response is a $942 million investment in driving systemic improvements to residential quality and safety, and the learning package is certainly consistent with that objective,” he said.

“I welcome this initiative as a positive step towards building the skills and capacity of aged care providers to better identify, prevent and respond to sexual assault.”

Colbeck said the government’s Serious Incident Response Scheme (SIRS) was another key part of providing greater protections to consumers.

SIRS for residential aged care, including flexible care in a residential aged care setting, started on 1 April 2021.

It will be expanded into aged care home services from 1 July, 2022. n

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1. Holden, BA, Fricke, TR, Wilson, DA et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology. 2016; 123:1036–42. Available from: doi: DOI: 10.1016/j.ophtha.2016.01.006

NEWS

IMMEDIATE SEQUENTIAL BILATERAL CATARACT SURGERY MAY LEAD TO WORSE OUTCOMES Immediate sequential bilateral cataract surgery (ISBCS) may lead to worse outcomes The study compared compared with refractive outcomes. delayed sequential bilateral cataract surgery (DSBCS), according to a new study in JAMA Ophthalmology.

In the retrospective cohort study using data from the IRIS Registry, 1.8 million bilateral cataract surgery patients were grouped according to ISBCS, shortinterval (1-14 days delay) classified as DSBCS-14, and long-interval (15-90 days) classified as DSBCS-90.

In the DSBCS-14 group, the uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA) of the first surgical eye was higher by 0.41 and 0.89 letters, respectively, compared with the DSBCS-90 group. For the second eye, the UCVA and BCVA was higher by 0.79 and by 0.48 letters, respectively.

In the ISBCS group, UCVA and BCVA was lower by 2.79 and 1.64 letters, compared with the DSBCS-90 group.

For the second eye, the UCVA and BCVA was lower by -1.67 and by -1.88 letters, respectively.

“Approximately two million cataract operations are performed annually in the US, and patterns of cataract surgery delivery are changing to meet the increasing demand,” the authors noted.

“Therefore, a comparative analysis of visual acuity outcomes after immediate sequential bilateral cataract surgery vs delayed sequential bilateral cataract surgery is important for informing future best practices.”

Age, self-reported race, insurance status, history of age-related macular degeneration, diabetic retinopathy, and glaucoma were controlled for in the study.

The authors noted that more studies are needed to determine the clinical relevance of the results.

A recent Australian survey published in RANZCO’s latest Eye2Eye magazine suggested ISBCS has minimal penetration locally with only 4.1% of respondents offering the service to patients. n

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INSIGHT September 2021

NEW TECH ‘WILL CHANGE NIGHT VISION LANDSCAPE FOREVER’ New infrared night-vision technology that is extremely lightweight, cheap and easy to mass produce could be applied to standard glasses and make it safer to drive at night, Australian researchers claim.

A team from the Australian National University (ANU) have developed a first-of-itskind thin film, based on nanoscale crystals, that allows people to see clearly in the dark.

Lead researcher Dr Rocio Camacho Morales said they have "made the invisible, visible".

“Our technology is able to transform infrared light, normally invisible to the human eye, and turn this into images people can clearly see – even at distance,” she said.

“We've made a very thin film, consisting of nanometre-scale crystals, hundreds of times thinner than a human hair, that can be directly applied to glasses and acts as a filter, allowing you to see in the darkness of the night.”

Currently, high-end infrared imaging technology requires cryogenic freezing to work and are costly to produce. This new system works at room temperatures.

Mr Dragomir Neshev, director of the ARC Centre for Excellence in Transformative MetaOptical Systems (TMOS) and ANU Professor in Physics, said the technology used meta-

Dr Rocio Camacho Morales says the technology could be applied to spectacles. Image: Jamie Kidston/ANU

surfaces to manipulate light in new ways.

“This is the first time anywhere in the world that infrared light has been successfully transformed into visible images in an ultra-thin screen,” Neshev said. “It's a really exciting development and one that we know will change the landscape for night vision forever.”

The new technology has been developed by an international team of researchers from TMOS, ANU, Nottingham Trent University, UNSW and European partners.

The researchers say the technology, described in Advanced Photonics, would be useful for police and security guards, while reducing chronic neck injuries from currently bulky night-vision devices. n

INTERNATIONAL TEAM CLASSIFIES TWO DOZEN SUBTYPES OF UVEITIS An international coalition of eye researchers used machine learning to develop classification criteria for 25 of the most common types of uveitis, a collection of more than 30 diseases characterised by inflammation inside the eye.

The Standardisation of Uveitis Nomenclature (SUN) Working Group, funded by the US National Eye Institute, published its classification criteria in the American Journal of Ophthalmology.

“In the past, clinical research in the field of uveitis has been hampered by the lack of widely-accepted and validated diagnostic criteria,” said Dr Douglas Jabs, the project leader, said.

“These classification criteria are a major step forward for epidemiological studies, translational studies, pathogenesis research, outcomes research, and clinical trials. They hopefully will yield better diseasespecific approaches to diagnosis and

Until recently, uveitis classification was based on the primary location of inflammation.

treatment.” Until recently, classification of uveitis was based on the primary location of inflammation. However, types of uveitis affecting the same anatomic location can have different causes, courses, prognoses, and treatment needs.

According to the study, previous work by the SUN Working Group demonstrated that even uveitis experts can disagree on diagnosis, making apples-to-apples comparisons difficult when conducting clinical research. n

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NEWS

NEW EXTRA DARK LENS RANGE BY TRANSITIONS Transitions Optical is releasing two new technologies in its extra dark photochromic lens range, Transitions XTRActive Polarized and Transitions XTRActive new generation.

The two new technologies address the needs of glasses wearers who are frequently exposed to bright and reflective light, and people considered very light sensitive, the company says.

“Transitions XTRActive Polarized breaks the paradigm of conventional polarisation and traditional photochromics,” Transitions said. “The lens is unpolarised when it’s clear indoors. Featuring dynamic polarisation, outdoors XTRActive Polarized darkens and polarises. As the lens gets darker, the level of polarisation increases.”

According to the company, wearers experience reduced glare outdoors and a better vision experience. Vision is also said to be sharper, in addition to a larger field of view, and brighter and more vivid colours.

Transitions XTRActive Polarized achieves a polarising efficiency of up to 90%. It is extra dark outdoors darkening up to a Category 3 NOVA EYE MEDICAL_INSIGHT-PRINT.pdf

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sunglass; even in hot temperatures. Behind the windscreen, Transitions Polarized activates up to Category 2. While the lens darkens in the car, the level of polarisation is low due to car windscreens blocking UV rays. The lens also offers high blue light filtering both indoors and outdoors, along with 100% UV blockage.

The company’s Transitions XTRActive new generation is designed to deliver extra darkness and light protection. It is the darkest Transitions lens in hot temperatures and in the car. In wearer tests, Transitions XTRActive new generation reportedly achieved an overall satisfaction rating of 98%.

Compared to the previous Transitions XTRActive generation, it is 35% faster to fade back indoors, along with being darker in hot temperatures and darker in the car.

“Transitions XTRActive new generation is the only photochromic lens to achieve Category 3 sunglass at 35°C,” the company stated.

“When driving Transitions XTRActive achieves Category 2 behind a windscreen. In wearer tests, 86% of participants were very satisfied

with the overall vision experience in the car.”

As with Transitions XTRActive Polarized, Transitions XTRActive new generation features high blue light filtering indoors and outdoors, and 100% UV blockage.

Transitions XTRActive new generation.

Mr Stuart Cannon, Transitions Optical general manager of Asia Pacific, said the company’s own research showed nine out 10 glasses wearers experience light sensitivity, with 30% being very light sensitive.

“The Transitions XTRActive range of extra dark lenses is designed to address the needs of very light sensitive glasses wearers or those that are exposed to intense bright light, hot temperatures and reflective light in their daily lives,” he said.

Eyecare professionals can access short education modules on the two new XTRActive technologies, social media, newsletter and website content on Transitions Plus: www. transitions-plus.com. Point-of-sale materials are also available. Those who haven't registered, use registration code InsightXA. More info about the new XTRActive range is available at www.XTRActive.com.au. n

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NEW PRESCRIPTION LENS PLATFORM FOR SMART GLASSES

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"Style is a way to say who you are without having to speak."

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Glasses cases today are as much of a fashion statement as your handbag, clutch or wallet.

The prescription lens platform for smart glasses is technology-agnostic.

Dutch firm Luxexcel announced a next generation manufacturing platform that makes it possible for businesses to integrate prescription lenses into the production of smart glasses in their manufacturing facilities.

The platform, Luxexcel VisionPlatform 7, includes new features geared for manufacturing smart lenses that are lightweight, thinner and can be used in commercial frames similar to traditional eyeglasses, the company stated.

Mr Fabio Esposito, CEO of Luxexcel, said the launch of the platform represented a new era in the manufacturing of prescription smart lenses. To compete in the race to launch consumer-ready smart glasses, eyewear manufacturers need to address prescription in their devices, he said.

"More than 75% of the adult world population today requires prescription lenses. Luxexcel provides a disruptive solution where smart technology is seamlessly combined with a prescription lens, rather than adding prescription power to the smart device as an afterthought,” Esposito said.

“Luxexcel is accelerating the market introduction of true consumer smart glasses by allowing technology companies to manufacture prescription smart eyewear in the comfort of their own manufacturing home.”

This launch follows Luxexcel’s product demo earlier this year, demonstrating the three vital elements of augmented reality smartglasses – prescription lens, a waveguide, and a projector in a fashionable device – can be combined into a 3D printed prescription lens.

Esposito said the company’s comprehensive material knowledge and family of custom materials ensured the integrated objects bond well with the prescription material. VisionPlatform 7 also prints difficult-to-manufacture features such as the air gap required for a waveguide, and printed hard coating, all without birefringence.

The platform is also technology-agnostic and integrates with components such as waveguides, holographic optical elements, and liquid crystal foils during the 3D printing process. The platform includes high-tech hardware, proprietary materials and advanced software, and processes. Luxexcel is based in The Netherlands, with offices in Belgium and the U.S n

The new Sorella ‘Glam’ collection is a combination of contemporary design, fashion and functionality. Our aim was to produce a glamorous, luxury case designed to carry 2-3 pairs of glasses that could also double as a clutch bag for a night out. ‘ That will take you from your desk to dinner ’ There are 3 colours in the range a Luxe Rose Gold, Silver & Black all with a soft grey suede fabric lining.

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COMPANY

TOPCON ACQUIRES ITALIAN OPHTHALMIC DEVICE PRODUCER

The Aladdin biometer and Myah biometer/ corneal topographer.

Tokyo-based Topcon Corporation has confirmed the acquisition of Visia Imaging S.r.l, an Italian ophthalmic device manufacturer that specialises in anterior segment hardware.

In a statement, Topcon expects the deal to enhance its development and manufacturing capabilities of devices and software focusing on myopia and IOL calculation, complementing its portfolio of posterior segment imaging devices that include fundus cameras and OCT machines.

Visia was founded in 1993 and for many years Topcon has been a distributor of its technology, including the CC-100 series visual acuity charts, CA-800 topographer/ corneal analyser, Myah biometer/corneal topographer and Aladdin biometer.

The company stated that the acquisition would give its Topcon Healthcare business additional product design and development capabilities to accelerate the release of new products.

“I am so pleased that Visia Imaging is becoming part of Topcon Healthcare and very excited for the next chapter in our long relationship,” Mr Alessandro Foggi, CEO of Visia, said. “Visia Imaging is focused on development and manufacturing of [hardware/software] solutions for eyecare with high expertise in anterior segment.

I am confident to release new beautiful products to support Topcon in becoming a market leader in myopia management, and to increase Topcon’s presence in cataract surgery with premium IOL calculation.”

Mr Fumio Ohue, managing executive officer of Topcon Corporation, added: “With the integration of two companies, one Japanese and one Italian, with strengths in optical design, mechanical engineering, and manufacturing of medical devices, we continue to recognise our belief in enhancing synergistic effect combined with values of true reliability and innovative technology which come from both Topcon and Visia. n

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FDA APPROVAL NIGH FOR LUCENTIS PORT DELIVERY SYSTEM Biotech company Genentech could find as early as next month whether its port delivery system (PDS) containing ranibizumab is approved in the US for treating neovascular age-related macular degeneration (nAMD).

The San Francisco-headquartered company, which became a subsidiary of Roche in 2009, announced the Food and Drug Administration (FDA) accepted its Biologics License Application (BLA), under priority review. If approved, its PDS would be the first and only eye implant with continuous drug delivery offering an alternative to frequent eye injections, the current standard of care.

The European Medicines Agency has also validated a Marketing Authorisation Application.

According to Genentech, the FDA is expected to decide on approval by 23 October.

Dr Levi Garraway, Genentech’s chief medical officer and head of global product development.

compared to what is currently achieved in the clinic.”

PDS is a permanent refillable eye implant, approximately the size of a grain of rice, designed to continuously deliver a customised formulation of ranibizumab (Lucentis).

“Anti-VEGF therapy brings significant benefit to people with wet AMD, but optimal results require frequent trips to the doctor’s office for eye injections. This burden leaves many people under-treated and susceptible to vision loss,” Dr Levi Garraway, chief medical officer and head of global product development, said.

The BLA submission is based on positive results from the Phase 3 Archway study primary analysis, that showed 98% of nAMD patients treated with PDS could go six months without additional treatment prior to the refill exchange. In addition, these patients achieved vision outcomes equivalent to patients receiving monthly ranibizumab eye injections. The PDS was generally well-tolerated, with a favourable benefit-risk profile.

“If approved, PDS would transform wet AMD treatment by providing up to six months of uninterrupted therapy that could potentially improve vision outcomes

Genentech is recruiting for other Phase 3 studies including for diabetic macular edema (Pagoda trial), and diabetic retinopathy without DME (Pavilion). n

ETNIA BARCELONA ACQUIRES LOOL EYEWEAR IN FRESH DEAL Spanish eyewear producer Etnia Barcelona has taken over Lool Eyewear, a Catalan eyewear brand focused on technology and lightness.

The details of the acquisition were not disclosed, however Etnia Barcleona anticipates closing 2021 with a global billing of €80 million (AU$128 million), representing 20% growth over 2019, and 42% over 2020.

According to Vision Monday, the company said: "Through this acquisition, Etnia Barcelona reaffirms its growth strategy for the optical eyewear market, growing its portfolio with an eyewear brand that boasts a technological spirit and specialises in lightweight eyewear, while also offering potential in sustainability.

Etnia Barcelona is expecting revenue of AU$128 million in 2021.

“Etnia Barcelona has consolidated its position as a company focused on the optical eyewear market, with the development of both its own brands and the integration of other independent brands." n

INTERNATIONAL

TEXAS CUTS RED TAPE TO ALLOW OPTOMETRISTS TO PRESCRIBE ORAL MEDICATIONS Optometrists in Texas can now prescribe oral eye medications and independently manage glaucoma, marking the first significant expansion of scope-ofpractice in the state in two decades.

The state’s amended optometric scope-of-practice act grants therapeutic optometrists’ authority to independently manage glaucoma patients in lieu of prior requirements for mandatory comanagement with an ophthalmologist, as well as the ability to prescribe any oral medication used to treat eye conditions.

The law will take effect on 1 September this year.

Texas Optometric Association (TOA) president Dr Steve Nguyen said it was a major win for Texas’ patients.

“It has been very inefficient, and in some cases more costly, for patients to get the eyecare they need for conditions that require oral medication

prescriptions. Oftentimes, we had to send the patient elsewhere or get a different healthcare professional to write the needed prescription, which only served to delay the patient’s care or cause them additional inconvenience,” Nguyen said.

“Also, required glaucoma comanagement was inhibiting patient care, hurting treatment plan compliance and adding costs to patients and payers. Now, patients will be able to get the eyecare services that they need at the time they need them, directly from their optometrist.”

He said the new legislation would go far in alleviating frustrations stemming from unnecessary inefficiencies.

“Previously, doctors [optometrists] could only prescribe oral medications in select drug classes and only for short times, creating a situation where doctors could not fully manage patients’ problems. So, too, doctors could diagnose and treat

glaucoma with topical eye drops only after getting a mandatory “second opinion” from an ophthalmologist.

Texas is the latest state to expand the optometry scope.

“Optometrists in Texas will now be able to help patients without these decadesold regulations that amounted to nothing more than red tape and inefficiency for patients and doctors alike,” Nguyen said.

Elsewhere is the US, Mississippi’s optometric scope-of-practice was expanded in March to authorise injectable authority; allow for excision and removal of lesions; an enhanced pharmaceutical authority; and the ability for credentialed optometrists to perform laser capsulotomy.

In April, Wyoming authorised certain surgical procedures and amended drug prescribing authority. In June, the New York State Assembly passed legislation authorising optometry to prescribe a formulary of oral therapeutic pharmaceutical agents for eye diseases. n

DATA MANAGEMENT

DIGITAL INTEGRATION

y e n o m d n a e tim

SAVES HOSPITAL

Chief orthoptist Michael Cosstick performing OCT on a patient at the Westmead Hospital Eye Clinic.

A major Sydney eye clinic that sees 130 patients a day has gone paperless and completely digitised the way it handles ophthalmic data. It's created efficiencies that allow specialists to spend more time with patients.

T

he major integration of a new data management solution at Westmead Hospital Eye Clinic, which included migrating more than 120,000 historic patient scans, has reduced daily clinics by up to two hours and helped the hospital save thousands per month on printing costs.

worklists on each device and offering multi-modality displays of all historical examination data on a single platform. Specialists can make efficient and confident clinical decisions by utilising features and plug-ins for glaucoma, retina and cataract.

The clinic, which is part of NSW Health’s Western Sydney Local Health District, introduced Zeiss’s ophthalmic data management software, Forum, in April this year to decrease patient monthly waiting time and improve clinical workflow.

Cosstick says it took several years to undertake the sophisticated Forum HL7 digital integration. Initially, this was due to difficulty in securing the hospital’s approval and making allowances in the budget.

Westmead Hospital Eye Clinic chief orthoptist Mr Michael Cosstick says implementing the fully electronic workflow took five years to come to fruition, and replaced the original system consisting of six ophthalmic devices working in a standalone capacity. This was in addition to hard copy printing for all results that were then being scanned into the hospital’s electronic medical records.

He says the existing system needed updating for several reasons including the fact each device had its own database. In the event of critical hardware failure, patient data would have been lost, and it was difficult for doctors to collate results over a long period of time across different devices.

“Often doctors had to leave their consulting room to look at results themselves. For instance, with our fundus camera, we weren't printing pictures, so they'd always have to come to the camera to diagnose retinal pathology,” he says.

“The hard copies of our results were often labelled as of poor quality in the medical records, there was a one-to-two-day turnaround on scanning, and we were spending at least $3,000 per month on consumables associated with printing.”

According to Zeiss, Forum is a paperless ophthalmic data management solution that streamlines practice workflow by generating automated daily

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INSIGHT September 2021

Westmead’s eye clinic is large comprising 10 administrative staff, 10 nursing staff, six orthoptists, 27 ophthalmologists, five fellows, and six registrars. It conducts 30,000 appointments per year, roughly 130 patients on average per day.

“When it came time for integration, the devices had to be added to the hospital network, and there was a lengthy period of testing to ensure that results were populating in both Forum and the electronic medical record,” Cosstick says.

“We then had to migrate all of our existing data from our devices to Forum.

This included 30,000 patients' scans from our OCTs, and 96,000 visual field exams, some of which dated back to 1992.”

According to Cosstick, it was the first ophthalmic enterprise solution in an Australian public hospital that integrated with existing hospital medical record applications (such as iPM and Powerchart) to create a model of data storage that is both futureproof and scalable to future technological advancements.

KEY FINDINGS Due to the introduction of Forum, Cosstick says medical staff have been granted 47.4 hours per month to spend with patients. Clinicians have saved 102.8 hours per month on scan acquisition and 15.8 hours per month on printing.

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This means ophthalmologists can now make more informed clinical decisions based on the scan results, and detect subtle ophthalmic changes, which would otherwise be missed in a high volume, fast-paced environment.

“This ultimately allows them to specifically tend to the needs of the patient,” Cosstick says.

“I knew that we would save time each day because we were no longer printing, and the doctors now had the patient results at their fingertips, but I was shocked that we’re now saving one-to-two hours a day. This means that patients aren't waiting as long to see a doctor, and clinics finish earlier.”

In addition, the hospital has stopped spending $3,044 per month on consumables such as paper, printer toner and stickers. One thousand sheets of paper are no longer being sent weekly to the medical records department that required 1.5 fulltime equivalent staff to accommodate the high volume.

In future, Cosstick believes Forum will have the capability to expand into Westmead’s operating theatres, so doctors can access biometry and other clinical notes. There is also scope to receive clinical test reports from community providers when assessing patients off site.

“Longer term, Forum could assist with large scale medical research especially if other major hospitals were to adopt the same system in their clinics,” he adds.

Mr Renato Antolovich, retina and glaucoma marketing manager for Zeiss Medical Technology ANZ, says Forum was first released in 2009 and now there are more than 400 sites across Australia and New Zealand using the software.

He says it’s a scalable image management solution that suits optometric and ophthalmic practices of all sizes that have both Zeiss and non-Zeiss equipment.

“It has most impact in consulting rooms of medium to high volume settings efficient and

NOVA where EYE MEDICAL_INSIGHT-PRINT.pdf 27/7/21need 4:11 pm workflow is paramount and2 clinicians to make

Specialists can make efficient and confident clinical decisions by using features and plugins for glaucoma (pictured here), retina and cataract.

confident decisions from data spread across multiple modalities,” he says.

“Forum also reduces patient waiting times and improves data integrity by allowing end users to select patients from automated daily worklists derived from the integrated EMR (electronic medical record).”

He adds: “Zeiss ANZ is particularly proud to be involved in Westmead’s Forum integration. We are thrilled to hear of the significant improvements it has brought to the delivery of quality of eyecare, patient experience and operational costs in this high-volume tertiary institution.” n

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GENE THERAPY

REWRITING EYE DISEASE:

Are we ready for gene therapies?

In 2020, ophthalmology became the first medical field in Australia to secure approval for a gene therapy. The one-off treatment can restore vision in people once resigned to a lifetime of blindness and is expected to pave the way for many more. MYLES HUME analyses the opportunities and challenges posed by ocular gene therapies.

I

n a new biography on the American biochemist Professor Jennifer Doudna, famous for her pioneering work in CRISPR gene editing, bestselling author Mr Walter Isaacson explains how the world has entered the third great revolution of the modern era.

The first of these began in the early 1900s in the field of physics when geniuses like Albert Einstein published their work. This was followed by the digital revolution in the second half of the 20th century, bringing us the computer and internet. Now, as Isaacson writes in The Code Breaker, the 21st century has brought the life sciences and biotech revolution where scientists can manipulate or rewrite the code of life to overcome disease.

Ophthalmology is one field at the forefront of this revolution, which is now beginning to cement its place in Australia. Doudna’s seminal work with the CRISPR-Cas9 platform – which earned her the 2020 Nobel Prize in Chemistry along with Professor Emmanuelle Charpentier – could shape eye disease in years to come, and is helping to inspire various programs in Australia in the closely related field of gene therapy.

While these approaches have existed as lab experiments for several years, the Therapeutic Goods Administration’s approval of Luxturna was a flashpoint for Australia in August 2020. It marked the country’s first true, ‘in-vivo’ gene therapy for any disease. The therapy helps to restore vision for patients with inherited retinal disease (IRD) caused by pathogenic biallelic RPE65 gene mutations and is expected to be the first of many brought to market for previously untreatable IRDs. For more common eye diseases like glaucoma and age-related macular degeneration (AMD) – caused by multiple factors rather than a single genetic fault – there is also promise, with several gene therapy trials already advancing to Phase 2 and 3.

The groundswell of gene therapy programs is cause for excitement among Australian practitioners, patients and health systems, but it has also sparked all new considerations around infrastructure, sustainability and health economics.

INSIGHT September 2021 29

GENE THERAPY

He says there are two broad disease groups where gene therapies are being investigated. The first is Mendelian disorders where the eye disease is caused by a single gene. Those that result in IRDs can be due to mutations in any of the >300 retinal genes. These are collectively the most common cause of blindness in working age Australians.

The other group of diseases are more well-known – such as glaucoma and AMD. Although they aren’t specifically genetic diseases, there is a strong genetic component, and genetic manipulations can be performed to treat pathways of these diseases.

One such therapy in this space is GT005 to slow geographic atrophy (GA) progression, which is being commercialised by UK firm Gyroscope Therapeutics. LEI and the Centre for Eye Research Australia (CERA) are participating in trials related to this therapy, which has advanced to Phase 2. GT005 is designed to stimulate a person’s cells to create Complement Factor I (CFI) deficient, a protein that a subset of GA patients are deficient in.

The adenovirus family structure used for gene delivery to the eye.

"THE PROCESS OF DIAGNOSING THESE PATIENTS CAN BE JUST AS COMPLEX AND INVOLVED AS THE PROCESS OF TREATING THEM" DR FRED CHEN LIONS EYE INSTITUTE

GENE THERAPIES EXPLAINED Before going further into the article it's important to understand gene therapy. In gene therapy, the effect of a mutation is offset by inserting a healthy version of the gene into the target tissue/organ, and the diseaserelated genes remain in the genome. In the more complicated gene editing, such as CRISPR-Cas9, the incorrect DNA sequence within the gene is removed and replaced with the correct sequence, thus permanently altering the genome.

Lions Eye Institute (LEI) clinician researcher Dr Fred Chen says some of the early work in retinal gene therapies began in Western Australia when – more than two decades ago – Professor Ian Constable and Professor Elizabeth Rakoczy began developing an approach that uses retinal cells as a bio-factory to continuously secrete anti-VEGF molecules for treating neovascular AMD, avoiding the need for frequent intraocular injections.

Their research was the first in Australia to use a gene therapy in ophthalmology or any other medical field, and was also the first to progress to human trials locally in 2014. The therapy has been licensed by US firm Adverum Biotechnologies (formerly Avalanche Biotechnologies), which plans to advance the therapy to Phase 3 trials later this year.

Chen says the eye is a perfect organ for gene therapy because cells in the retina rarely divide and they are enclosed in an immune privileged site within the body. Administration of the gene vector is also relatively straight forward, and the effect of gene therapy can be monitored directly and accurately with high-resolution multimodal imaging technology.

30

INSIGHT September 2021

In IRDs, Chen says the groundbreaking Luxturna therapy adopts the most basic form of gene therapy, known as replacement therapy. It involves loading the RPE65 gene into an adeno-associated viral (AAV) vector, which then infects the retinal cell. The genetic segment is then used by the cell’s protein-producing machinery to create functional RPE65 protein.

“For recessive diseases this approach works well because a functional gene isn’t there, and the missing gene can be replaced by healthy gene copies delivered via an AAV,” he explains.

“But some dominant conditions are more difficult to treat with gene therapy because the disease manifestation is not due to the lack of the normal protein from the gene, but rather due to a build-up of some faulty protein made from the mutated gene. Therefore, simply adding normal gene copies cannot fix this type of problem. The alternative in such dominant-negative disease mechanism is to edit the mutation in the DNA, or alter RNA processing, using molecules that may interfere with splicing.”

Chen says RNA-level therapy is a hot area in gene therapies at present, and LEI is working with Perth company PYC Therapeutics in this space for retinitis pigmentosa 11 (RP11), a dominantly inherited retinal degenerative disease caused by mutations in the PRPF31 (pre-mRNA processing factor 31) gene.

“The RP11 treatment restores the amount of protein coded by the RP11 gene by using an RNA therapy to influence regulators of RP11 gene expression. The end result is greater amount of RP11 protein to overcome insufficiency due to the deleterious mutation,” he says.

Following Luxturna, Chen expects more IRD gene therapies to arrive soon, potentially for choroideremia and X-linked retinitis pigmentosa.

He is hopeful of more gene therapy trials being set up in Australia as the country expands its capability to genetically diagnose patients with IRDs. In WA, patients are being actively tested through either a clinical or a research pathway facilitated by the Genetic Services of WA or Australian Inherited Retinal Diseases Registry, respectively.

“None of these gene therapies can be administered without first genetically diagnosing these patients. There is a significant cost in setting up the infrastructures and genotyping these patients. It is important not to forget that the process of diagnosing these patients can be just as complex and involved as the process of treating them,” he says.

“In the past, serious life-threatening diseases have been prioritised for genetic testing, for obvious reasons. However, clinical geneticists are taking more interest in genotyping IRDs given the increasing number of IRD treatment trials and the approval of Luxturna.

"My hope is that genetic testing for suspected genetic eye diseases becomes standard care in Australia.”

NEED FOR RADICAL THINKING CERA managing director Professor Keith Martin’s gene therapy efforts have focused on glaucoma, by using a recombinant AAV vector system.

The virus works by introducing therapeutic genes to make retinal ganglion cells more resistant to damage. Initially, it is hoped the therapy will target the 10 to 15% of patients who don’t respond to regular treatment and are advancing towards blindness.

Martin began developing the therapy while at the University of Cambridge before co-founding Quethera in 2016, now a wholly-owned subsidiary of Japanese firm Astellas Inc. The therapy is making good progress towards human clinical trials.

Part of his work has also focused on regenerating the optic nerve, with the most recent work in this area combining two molecules thought to improve axon function – brain derived neurotrophic factor (BDNF) and tropomyosin receptor kinase B (TrkB) – in one treatment. Mice with glaucoma treated with this approach showed improved optic nerve activity and signs of improved vision.

“We have now got some strong candidates that can get regeneration back to the brain with a single dose of gene therapy in these models – that's a bit further away from clinical use, but it shows in principle what we thought was going to be extremely difficult in the past, which is regenerating the optic nerve, may actually be more feasible than many people first thought,” he says.

“Gene therapy is now a tool we can use in a whole variety of situations, and that's why it's so powerful. It can be applied in situations where patients are missing a particular gene, but also to toughen up cells and make them more resistant to injury, and stimulate regeneration by

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"IT CAN BE APPLIED IN SITUATIONS WHERE PATIENTS ARE MISSING A PARTICULAR GENE, BUT ALSO TO TOUGHEN UP CELLS AND MAKE THEM MORE RESISTANT" PROF KEITH MARTIN CERA

tweaking those pathways.” Martin says one of the major hurdles in the gene therapy space is the amount of energy devoted to developing treatments for individual IRDs. Doing so is time consuming and not all genes associated with IRDs can fit into viral vectors currently being used.

It’s also an incredibly expensive undertaking for companies and health payers. Reports in the US suggest Luxturna costs up to US$850,000 (AU$1.18 million) for both eyes. Companies will seek to recoup many years of research and investment, but because they only treat a narrow patient group, the cost per patient is high.

“Part of setting the price in the US was looking at the cost saving of avoiding blindness in someone who is treated early in life, and that's not just in terms of cost in care, but what they are able to contribute to the economy throughout their life,” Martin explains.

GENE THERAPY

Along with Phase 2 trials for Gyroscope Therapeutics’ GT005 gene therapy to slow the progression of GA, CERA has been selected for several retinitis pigmentosa trials, and is also developing its own singlegene therapies.

Martin says it’s all part of a plan to make CERA and its affiliates (The Royal Victorian Eye and Ear Hospital and University of Melbourne) a go-to gene therapy centre, especially when pharmaceutical companies view Australia as a favourable location and regulatory environment to perform studies.

The organisation is still building its gene therapy trial capacity and has already gone to great lengths for what is a tightly regulated area. That comes down to having the right theatre facilities and appropriately trained staff, while the end-to-end handling and preparation process is practised and heavily scrutinised before given approval. With the gold standard treatments involving a subretinal injection, there’s also the hefty cost of an OCT-integrated microscope to consider.

“For Luxturna, we expect there to be a small number of centres within Australia that will be providing these treatments, both in terms of facilities and expertise, and that will grow. There are currently five surgeons in Australia who have delivered gene therapies and we have two of them [at CERA], but we hope once we get this up and running we will be able to provide training, and information and knowledge transfer,” Martin says.

A retinal organoid at the Stem Cell & Organoid Facility at Children’s Medical Research Institute in Sydney. The cones are in red and ganglion cells in green.

“One of the issues for Luxturna, for example, is that it may seem very expensive, but there's probably only between 16 and 20 patients in Australia who would meet the criteria. The cost for something like AMD clearly cannot be that high to be economic. That’s because the years of vision loss that are avoided is likely to be much less, and it's a more common condition. It is a trade-off: the more common a condition, the more pressure there is going to be to bring that cost down to make sure it's accessible to health systems and patients.”

Administering the treatments only forms part of the puzzle. As Chen pointed out, identifying potential patients before genotyping and phenotyping, and then linking them with therapies and trials they may benefit from requires extraordinary levels of coordination. Inherited diseases also have implications for families, so genetic counselling is also built into the picture.

This holistic approach was the motivation behind the Ocular Genetics Service that opened at the Eye and Ear in 2019. It is dedicated to patients who have an IRD, are at risk of inheriting or passing on an eye condition or have a genetic disease that affects their eyes.

Another issue is that many of the target diseases involve the loss of photoreceptor cells, which the most advanced IRD gene therapies need to work. Martin believes more radical approaches to create therapies that are “disease agnostic” are necessary, as opposed to developing a different therapy for each genetic disorder. One example is reprogramming cells within the retina, such as Müller cells to replace photoreceptors to help restore vision. This could be achieved through techniques like CRISPR.

“It’s the first truly integrated ocular gene therapy clinic in Australia, with genetic counsellors on site, alongside optometrists, ophthalmologists and clinical geneticists working closely together in the same space, seeing the same patients,” Martin says.

“It might seem crazy turning a glial cell (Müller) – a non-neuronal cell in the retina – into a new photoreceptor, but that's exactly what happens in amphibians and fish when they injure their retina. The Müller cells within the retina de-differentiate and then repopulate the missing, lost neurons, so we are trying to establish the missing switches that stop us humans from being able to do that because it's something we have likely lost along the line of evolution. We are trying to work out how it works in other animals and replicate that in the human eye.”

A NATIONAL APPROACH

"THE WORK WE'RE DOING NOW WILL BE A TREMENDOUS ADVANTAGE WHEN OTHER THERAPIES ARE APPROVED AND MORE TRIALS COME TO AUSTRALIA" PROF ROBYN JAMIESON CMRI

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INSIGHT September 2021

“We think this is the gold standard model, where you can offer a onestop-shop for diagnosis and characterisation of disease; you capture this information, so these patients are ready to go both for approved treatments, or recruitment to clinical trials down the line.”

Ophthalmic clinical geneticist Professor Robyn Jamieson agrees more coordination is required if Australia is to provide equitable access to ocular gene therapies.

Jamieson leads the Eye Genetics Research Unit at the Children’s Medical Research Institute (CMRI) in Sydney, among other roles, which has established an end-to-end gene therapy program in NSW that – with the collaborations established – will be valuable across Australia.

The first component involves a multidisciplinary approach to secure the diagnosis. Eye specialists and geneticists work collaboratively to correctly diagnose patients, their stage of disease and determine their suitability for therapies and trials. This approach arose from 30 years of experience with the multidisciplinary Genetic Eye Clinic at Sydney Children’s Hospitals Network, Westmead. But the results aren’t always clear cut, leading to the second component of the system. In 10 to 15% of cases patients display 'variants of uncertain significance' – a genetic variant that has been identified through testing but whose significance to the function or health of the individual is not known.

To overcome this, functional genomics can be performed where a sample is taken from the patient and turned into induced pluripotent stem cells. These are then grown into organoids (retina in a dish) over

esteemed Professor of Human Molecular Genetics and pioneer in the field of gene therapy in the eye. There, she investigated six viral vectors to evaluate which performed best in human retinal cells, establishing key principles to treat human organoids with AAV gene therapy in vitro.

Meanwhile, Jamieson is developing and using the organoids to test novel therapies for retinitis pigmentosa and cone-rod dystrophy.

The third and final arm of the program is setting up for pharmaceutical clinical trials or administration of approved therapies. Using this approach, Jamieson believes this can bring together the relevant research institutions, clinical trial centres and diagnostic laboratories across Australia for maximum benefit for patients.

Dr Anai Gonzalez Cordero, of CMRI in Sydney, says a challenge is trying to fit genes for some diseases into commonly used adeno-associated viral vectors.

many months, where the diagnostic team can then assess the patient’s mutation more closely and hopefully determine a diagnosis.

These organoids are grown by Dr Anai Gonzalez Cordero, group leader in stem cell medicine and the manager for the Stem Cell & Organoid Facility at CMRI. Aside from functional genomics, the organoids are used for therapeutic genomics whereby researchers test their own novel therapies. Gonzalez Cordero herself is looking into therapies for Stargardt disease and Usher syndrome, a key challenge being that these genes don’t fit into regular adeno-associated (AAV) viral vectors. She’s applying knowledge she acquired during her time working at the University College London’s Institute of Ophthalmology, under Professor Robin Ali, an

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With much of the genomic testing in the research setting, she says this creates a bottleneck and inequity in access. Genetic diagnostic capacity could be significantly increased through greater collaboration with NATAaccredited laboratories.

“We have applied for funding to various government organisations so we can get the whole multidisciplinary team approach as a concept across the country, because sometimes these things tend to operate in isolation and people aren’t realising what’s available for patients,” she says.

“We have engaged organisations in all states across Australia to push forward with this idea, and with the funding we are hoping to appoint coordinators in each state and nationally to facilitate that. We’ve also engaged diagnostic laboratories in those states to get extra funding for them to help push this forward for more patients, and also have people there for coordinating the genetic services with the ophthalmic services.

The work we are doing now will be a tremendous advantage for when other therapies are approved and more trials come to Australia.” n

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IMAGING

FROM THE GROUND UP

T C O e d a m Australian- TO HIT THE MARKET

Melbourne company Cylite is putting the final touches on its Hyperparallel-OCT ahead of its official launch next month. The company discusses its journey up until this point and the sophistication that sets its technology apart.

A

major feat in Australian engineering is taking place next month when the first official iteration of the homegrown Cylite Hyperparallel-OCT (HP-OCT) is presented to the local market.

It’s an unlikely story. A team of physicists and engineers – armed with their own expertise and money before additional backing – toiling for eight years to design and build an OCT system from scratch in Australia.

An instrument sporting the ‘Australian Made’ mark, which works to overcome the shortcomings in existing models while combining capabilities not often seen in a single OCT, is more remarkable when you consider the company is operating in one of the most competitive ophthalmic segments. The OCT market is worth around AU$775 million, and largely dominated by big-budget multinationals from the US, Germany and Japan.

At the time of writing, Cylite was planning the HP-OCT’s first official public showing to take place at the Orthokeratology Society of Oceania on the Gold Coast on 1 October. Then, COVID permitting, it’s hoping to head north to Noosa from 20-23 October when local ophthalmologists can get their first glimpse at Australasian Society of Cataract and Refractive Surgeons (AUSCRS) Conference.

The fact Cylite has chosen these events to launch hints as to where its

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INSIGHT September 2021

creators initially expect the system to have the biggest impact.

OCT has mostly been perceived as a retinal imaging system. While the Cylite HP-OCT has this capability, its greatest initial strength is in the front of eye where the company says it creates true volumetric, or 3D, images of intricate anterior segment structures in a single snapshot. Scans are acquired at industry-leading rates of more than 300,000 A-scans per second. This means it can capture a full biometry scan in seconds, enabling accurate, motionartefact-free measurements of all ocular surfaces.

The company expects the highly precise measurements to be a mouthwatering prospect for practitioners involved in myopia management and scleral contact lens fitting, as well as cataract and refractive surgeons.

With the launch now imminent, CEO and co-founder Dr Steve Frisken says the company has been keen to shift the focus from the hardware that makes the system so unique, to educating the market about the advantages in the clinic and research lab.

For a while now, the HP-OCT has been in the hands of several institutions testing its capabilities to measure and monitor conditions such as keratoconus, closed-angle glaucoma, presbyopia, cataracts, corneal

metrology of all eye surfaces.

2

1

4 3

6

5

Dr Simon Poole, vice-president of business development, is also a founding member. He has 40 years’ experience in photonics in both academia and industry. And chief scientist Mr Trevor Anderson has 25 years’ experience in industrial R&D, government research labs and start-ups, with expertise in optical communications and signal processing.

In recent times, the company added Ms Kylee Hall as its vice-president of commercial and clinical. She was previously responsible for Zeiss’ Australian and New Zealand medical business group.

Cylite received its CE mark for the European market in late 2020, paving the way for Australian registration earlier this year. After the Australian launch the company will work towards the European and the UK markets, with the US slated for further down the track.

Keratoconus patient – 1. True dense 3D volume image. 2. B-scan slice (corresponds with horizontal yellow line in 4). 3. B-scan slide in Z axis or enface axis (corresponds with yellow line in 5) shows the thinning/distorted posterior cornea. 6. A vertical B-scan along the vertical dotted line in image 4.

infections and biomechanics, to name a few. One of those universities, UNSW in Sydney, acquired the device after OCT co-inventor, Dr David Huang, praised it to a senior lecturer at an international conference in 2018.

“The value proposition is built around the fact we get this full 3D visualisation of the eye, but it's not only having that capability of seeing the volume, we can provide really accurate measurements of the different ocular surfaces that are meaningful for many diseases,” Frisken explains.

“Given the unique dense snapshot capture of the technology, we can take a B-scan slice of the eye in any direction, X, Y or Z (enface) axis; we haven’t seen any competitor try to do this at the front of the eye, so we think we have a really strong advantage in this space for a while to come.”

The company also has projects under way looking at OCT-angiography to measure vascular flow at the front of the eye. It also expects further developments on the retina, among a host of other applications. But it isn’t getting ahead of itself.

“When you move into this type of medical space and are developing a technology from the ground up, you’re talking about a long-term bet, and we are now seeing a financial model that can work for us on the first release of product,” Frisken says.

“There is a whole roadmap of ideas where we think this basic building block will continue to deliver in many other areas, but we have to walk before we run, so we are putting the roadmap thinking in the background, and focusing on the first release product, and working hard to define what it can do.”

START-UP TO FULLY-FLEDGED FIRM Cylite was founded in 2013 in Melbourne with the backing of four prominent Australian scientists drawn from the fields of photonics, optics, instrumentation, and software development.

The HP-OCT’s first official showing in Queensland is being met with anticipation. It’s already received major plaudits, including Engineer Australia’s highest honour – The Sir William Hudson award – in 2020. This year Cobalt Design, Cylite’s industrial design partner, and Cylite itself received the Victorian Premier’s Design Award.

Hall, who is leading the commercial launch, says the company has also been inundated with institutions locally and globally wanting to use the system on loan. This is in addition to numerous calls from overseas distributors wanting to know when they can access the technology.

Such pent-up excitement is humbling; however it comes with the weight of expectation.

That’s why Cylite has been narrowing its focus on its production capabilities and software development. Part of that has been expanding its staff count to around 50 people and leasing a second building near its headquarters within the Monash Technology Precinct in Melbourne.

The company is also well financed heading into the next phase with backing from Main Sequence Ventures, which manages the CSIRO Innovation Fund.

“We have been working particularly hard on our user interface,” Hall explains.

Mr Grant Frisken is the chief technology officer with more than 20 years’ medical and real time software experience. He designed the Medmont E300 software, considered the gold standard in corneal topography.

“It has taken seven to eight years to fine-tune the hardware and micro-optics that make it so unique, but the user interface is what people will ultimately judge the product on. Its ease of use, how it displays the information when a scan is captured, and what you’re able to do with that information.”

Grant Frisken understood the limitations of current technologies, so he urged his brother to build a team that could harness the accuracy of OCT for

Cylite’s software, Focus, has been

Brothers Steve and Grant Frisken were the masterminds. Steve Frisken has 25 years’ experience in photonics, having previously founded Photonic Technologies (acquired by Nortel) and Engana (acquired by Finisar). He is also a prolific inventor, with 45 US patents in optics and the inventor of the Dynamic Wavelength Processor that has generated more than $AU1.3 billion in cumulative revenue.

Cylite says its HP-OCT offers volumetric imaging for both anterior segment and retina at industry-leading scan rates.

INSIGHT September 2021 35

IMAGING

segment (anterior cornea, posterior cornea, anterior lens and posterior lens).

The micro-optics within the HP-OCT then ‘dithers’ the grid of 1,008 beams over the eye and snapshots are acquired, capturing highly detailed volume images all registered to one another, ensuring accuracy.

According to the company, this differs significantly from existing systems that effectively scan a single spot over the eye in a raster style scanning pattern.

“Motion artifacts are a common issue for existing OCTs to overcome.

Traditional OCTs build volumes from B-scans stitched together, whereas the HP-OCT acquires these volumes at the initial capture,” Hall explains.

“True volume with the Cylite HP-OCT means that post-capture, the user can slice the volume in any direction they want, X, Y or Z axis and they won’t have any gaps, holes or B-scan stitching artifacts to deal with.”

EARLY ADOPTERS Dr Maitreyee Roy, a senior lecturer within the School of Optometry and Vision Science and director of the Optics and Radiometry Lab at UNSW, is among early adopters of the Cylite system globally.

Cylite founders (from left) Steve Frisken, Trevor Anderson, Grant Frisken and Simon Poole.

engineered from scratch locally as well. Hall says there’s no legacy system here; the review component has been built on the latest web-based software and utilises advanced knowledge from the gaming space to ensure images can be displayed and manipulated easily.

“We are developing it with the future in mind, so it can interact with technology developments within the AI space, for example,” she says.

“We’re also passionate about enabling researchers access to the raw data they need to advance research in the ophthalmic and optical space. Too many products cut the data down and lock it up.”

Medical device design of this calibre is an anomaly in Australia, but it’s even rarer for companies to conduct their production locally. During the past 18 months, Cylite has tripled its Melbourne production team.

Frisken says the company sources its specialised optical components from suppliers both locally and internationally. Cylite has a clean room for assembling the optical components, and performs the complicated optical alignment process in-house.

“To do production in this environment, you need to have a really good quality control system, which we have built from the ground up; we have been successful in gaining our ISO:13485 and subsequent CE mark on that basis,” he says.

“At the end there is a whole calibration process; there’s a separate group focused on ensuring the instrument provides exact measurements, that's the algorithmic side of things and the software development to do that. It has all been done out of our facilities in Melbourne.”

BESPOKE DESIGN Much of the marketing around the Cylite HP-OCT has centred on it being “the 4th generation of OCT”. This is because it follows in the footsteps of Time-Domain OCT, the original commercial device introduced by Zeiss in 1996, Spectral-Domain OCT (SD-OCT), still the incumbent technology, and Swept-Source OCT, which hasn’t reached the same heights due to its higher price tag.

Cylite’s HP-OCT most closely resembles SD-OCT, but the system has fundamental technological differences that place it in a new category.

As mentioned earlier, she first became aware of the technology by Huang, the OCT co-inventor, who told her he was impressed with the technology at the ARVO 2018 meeting in Hawaii.

She successfully applied for a UNSW infrastructure grant, with the university set to use it for five potential research areas: advanced contact lens research and anterior eye, myopia research, corneal biomechanics, diagnostic and ocular disease including closed-angle glaucoma and keratoconus, and vision-related projects like presbyopia and quantifying lens accommodation and bionic eye.

“I was impressed with their measurement techniques because they have developed a unique ability to capture volumetric images,” she says.

“Because HP-OCT can provide accurate metrology measurements of the anterior chamber, it is useful for several diagnostic and clinical applications, including accurate corneal topography and corneal thickness measurement – desirable for fitting contact lenses.

“It’s also good for screening disease like keratoconus, and monitoring induced corneal changes for things like orthokeratology, and improving quantitative ocular models to predict refractive outcome for corneal or cataract surgery. For myopia progression, it could be helpful because it can continuously measure the on and off-axis and align the model of optical properties of that eye.”

For future upgrades, Roy believes it will be important to improve its posterior imaging analysis, create a normative database, and use one software platform – because she says it currently uses different software for image acquisition and then image analysis. (Roy is currently using the research software).

Another researcher, Dr Edmund Tsui, is an Assistant Professor of Ophthalmology at the Stein Eye Institute within the University of California, Los Angeles (UCLA). He’s been using the Cylite system on dense cataracts and seeing how it compares with FDA approved biometers (it’s too early to provide results) and has been imaging patients from his uveitis clinic.

At a recent ARVO Imaging in the Eye 2021 Conference, he presented his findings on using the HP-OCT to image herpes zoster stromal keratitis.

Firstly, it is based on a bespoke micro-optics design (or free space optics), as opposed to fibre optics used in many other systems.

Because it captures a single widefield volume image that’s 16.8 by 9.6mm, he says it is ideal for patient education because he can show a complete 3D image of how the scars can impact vision, while also demonstrating how their condition improved over time with treatment.

A key element within the micro-optics system is the microlens array which creates a grid on the eye of 1,008 beamlets enabling simultaneous A-scans to be captured with an acquisition time of about one millisecond. The acquisition time is short enough to freeze any eye movement, allowing highly accurate measurements of the topography of each optical surface within the anterior

“I can then scroll through the corresponding B-scans and see where any scars remain. The benefit of the HP-OCT being able to capture entire cornea all at once, without having to perform multiple scans on the cornea, is two-fold: it is easier for the operator to obtain images and the rapid acquisition time allows imaging across a wide area of the anterior segment without motion artifacts.” n

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INSIGHT September 2021

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PRESCRIBING

A HARD PILL TO SWALLOW:

n o i t a c i d e m oral PRESCRIBING RIGHTS FOR OPTOMETRISTS

Australian optometrists are not permitted to prescribe oral medications, in contrast to comparative countries where their counterparts have been prescribing them for years. Insight investigates why this is the case in Australia.

O

ptometrists in the UK have been permitted to prescribe oral medications since 2008. In New Zealand it has been since 2014, while in Canada, optometrists have lists they can prescribe from in different provinces. And in the US, 45 of 50 states have introduced legislation allowing optometrists oral prescribing powers.

But for Australian optometrists, their prescribing authority is limited to topical ocular medications such as eye drops and ointments, which can only be authorised by the country’s 4,135 therapeutically-endorsed optometrists. When it comes to oral drugs, all must refer patients to GPs or ophthalmologists.

Optometry Australia (OA), the profession’s national peak body, has strongly advocated to turn this around. It says the need to visit a second health practitioner for a simple prescription can mean additional patient cost as well as a loss of convenience. In some cases, patients will not access the oral medication, potentially putting their eye-health at risk.

For several years, the organisation has been calling for change – and recently reinvigorated its campaign. With Australia lagging behind comparative

nations, it says it doesn’t have to look far for evidence supporting qualified optometrists to prescribe oral medications such as antibiotics, antiinflammatories, and anti-viral agents.

However, if optometry is to successfully push for change, it will need to convince ophthalmology. That’s unlikely to happen soon, with both RANZCO and the Australian Society of Ophthalmologists against the move, stating that optometrists don’t not have the appropriate medical training and experience, which could compromise patient safety.

SLOW BUT STEADY GROWTH When New Zealand’s Medicines Act was amended in 2014, it gave registered optometrists with therapeutic accreditation the regulatory freedom to prescribe any medication that was within the scope-of-practice of optometry, as defined by the Optometrists and Dispensing Opticians Board (ODOB).

Authorities across the Tasman, including ODOB and the Ministry of Health, have tracked optometrists’ oral medication prescribing habits since 2014, and recently released data shows oral medication prescriptions are on the rise.

INSIGHT September 2021 39

PRESCRIBING XX

"FOLLOWING LEGISLATIVE CHANGE, MORE THAN HALF OF ELIGIBLE OPTOMETRISTS HAVE HAD REASON TO PRESCRIBE AN ORAL MEDICATION" DR PHILIP TURNBULL UNIVERSITY OF AUCKLAND Dr Philip Turnbull and Professor Jennifer Craig, from the School of Optometry and Vision Science and the Department of Ophthalmology, respectively, at The University of Auckland, analysed NZ’s data.

“In the five years following the legislative change, more than half of eligible optometrists have had reason to prescribe an oral medication, and the proportion of oral medications continues to grow year-on-year,” Turnbull and Craig note in ‘Oral medication prescribing by optometrists in New Zealand’, published online in Clinical and Experimental Optometry in March this year.

They report that oral medications accounted for nearly 4% of scripts in 2019, or approximately 1 in 25 prescriptions. In 2020, it marginally surpassed 4% of scripts (4.03% compared to 3.88% in 2019).

A total of 53% of optometrists with prescribing rights – and who were registered at the end of 2019 – had prescribed at least one oral medication; 8.6% had issued more than 30 scripts.

“Interestingly, there wasn’t a huge rush to start prescribing, and the growth has been quite slow. The increase in independent glaucoma prescribing is much greater than for oral medications,” Turnbull tells Insight.

Most prescriptions in NZ were for antibiotics, which comprised 60% of all oral medications prescribed. Antihistamines made up 8.2%; antivirals made up 7.4%; and analgesics 2.2%.

Turnbull and Craig reported that, in the antibiotics class of medicines, azithromycin (which alone represented 39% of all prescribed oral medications) and tetracycline was prescribed for the management of meibomian gland dysfunction.

“Oral meds are almost entirely for managing dry eye, with smaller numbers for infections (bacterial, viral, toxoplasmosis), inflammation, and antiglaucoma. There are also optometrists prescribing prophylactic oral antiherpetic medication,” Turnbull says.

He says the advantage of allowing oral medication prescribing, at least in NZ, is a far wider range of medications.

“Drugs available in topical form and suitable for the eye are rather limited,” Turnbull explains. “It’s also useful for optometrists that work in hospitals or ophthalmology clinics, where they can consult with others, then prescribe any medication that is required. This is a big win for the patient, as they don’t need to rebook or pay extra.”

He says allergy is by far the biggest reason for an optometrist issuing a medical prescription overall and having access to oral and nasal spray antihistamines are nice additional tools to have available.

“It’s important to also note that New Zealand doesn’t just have access to oral, but the law change meant drug modality doesn’t matter. We also have hospital-based optometrists prescribing injectable medications, such as Avastin, for example. They don’t actually inject the medication, which is currently out-of-scope, but by prescribing at the initial consult, they can ensure it is ready for the patient when they arrive for their injection,” Turnbull says.

“There’s also a low amount of skin ointments being prescribed too for treatments around the eye, which are better managed by an optometrist with appropriate tools and knowledge base, than a general practitioner, for example.”

Significantly, authorities in NZ have neither been alerted to any out-of-scope prescribing of oral medications, nor have there been any reported adverse incidents specifically relating to optometrists issuing therapeutic prescriptions.

“This suggests that despite their newly granted authority to manage a broader range of ocular conditions, the optometry profession, as a whole, is practising appropriately and appears still to be referring and/or comanaging rather than independently managing cases requiring more complex therapeutic management,” Turnbull and Craig conclude.

IS AUSTRALIA FALLING BEHIND? According to the latest Optometry Board of Australia data, 4,135 (60%) of optometrists in Australia are therapeutically endorsed.

Could those 4,135 optometrist’s skills be better deployed to meet community need? OA national president Mr Darrell Baker believes so. In July, he took the

In New Zealand, where optometrists have been able to prescribe oral medication for seven years, 4% of prescriptions by optometrists were for oral medications in 2019.

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INSIGHT September 2021

lead in announcing the organisation’s new policy platform on evolving scopeof-practice named ‘Working Together for Better Eye Care’. Oral therapeutics were among six areas OA is calling for change so the nation’s “seriously under-utilised” optometric workforce can combat urgent issues looming over the eyecare sector.

under-utilised compared to our counterparts in similarly developed nations,” Baker says.

“We believe it is in the interests of patients, communities and health system efficiency, to enable therapeutically qualified optometrists to prescribe oral medications relevant to their scope-of-practice,” Baker says.

So, is Australia falling behind other nations, including New Zealand, parts of Canada, the US and the UK, that permit optometrists to prescribe oral therapeutics?

“International evidence, including from New Zealand, also attests that optometrists prescribe oral medications safely.”

In its report, OA argues that the need to visit a second health practitioner for a simple prescription can mean additional patient cost as well as a loss of convenience.

“In some cases, patients will not access the oral medication, potentially putting their eye health at risk,” the report states. “These issues are more pronounced for rural and remote patients where there are fewer GPs, longer wait times, a lack of after-hours services and challenges accessing specialist ophthalmology services.”

It goes on to say that any decision to allow optometrists to prescribe oral medications would follow a detailed consideration of the public benefits and risks by the Australian Health Practitioner Regulation Agency and the Optometry Board of Australia.

According to OA, optometrists perform 10 million eye checks annually and are the first port of call for 80% of people.

“Increasingly, optometrists are treating, managing and triaging patients with eye disease, as well as filling gaps where there is not timely access to care. However, the skills of Australian optometrists continue to be seriously

“The only way we can get on top of Australia’s looming eye-health crisis is for optometrists to be supported to practise to their full scope to enhance patient access and increase the efficiency of Australia’s eye-health system.”

The answer, Baker says, is clear.

“We are still struggling with issues in terms of early identification of eye disease and access to treatment that were identified a decade or more ago – and many of them have arguably gotten worse.

“We must enhance how our eyecare systems work to meet the needs of our communities. This demands change and innovation. Yet, even with excellent evidence that highlights how optometrists are assisting to address serous eye health conditions in other advanced nations, the pace of change in Australia remains unacceptably slow. We are calling for faster progress in the interests of our communities.”

PROOF IN THE PUDDING Oral therapeutics was a presentation topic at Optometry NSW/ACT’s Super Sunday conference in 2018, and was meant to be at Optometry Victoria South Australia’s now-cancelled O=MEGA21 conference this month.

For a profession that doesn’t have prescribing rights, why is it important that optometrists in Australia are informed about oral therapeutics?

“Optometrists must have a good understanding of treatment options available for their patients to ensure they are putting in place the most relevant

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PRESCRIBING

"OPTOMETRISTS ARE INCREDIBLY CONSERVATIVE. A SIMILAR PATTERN EMERGED WHEN TOPICAL THERAPEUTICS WERE INTRODUCED" A/PROF DARYL GUEST UNIVERSITY OF MELBOURNE - RETIRED

Looking to counterparts in New Zealand, Guest says it is not unusual that optometrists may have been slow to begin prescribing oral medications when legislation was introduced in 2014.

“Optometrists are incredibly conservative. A similar pattern emerged in Australia when topical therapeutics were introduced. Initially, optometrists were very cautious to prescribe, but the younger generations are eager to utilise ocular prescribing rights including access to orals. They have said: ‘We want this’,” Guest says.

Optometry Australia’s 2040 project demonstrates younger generations of optometrists consider oral prescribing rights should form part of their future scope-of-practice.

Guest believes New Zealand’s decision to allow optometrists to prescribe oral therapeutics was, in part, based on business economics.

management plan and referral pathway for each presentation, and so they can support their patients in understanding what treatment options they may be offered,” Baker says.

Associate Professor Daryl Guest agrees. He is a long-time advocate of utilising his scope-of-practice to actively, but indirectly, prescribe oral therapeutics to patients.

The former University of Melbourne Eyecare Clinic director and retired owner of a multi-site practice in north-west Tasmania, Guest has been doing so since legislation was introduced in Tasmania to allow optometrists to prescribe therapeutics.

“Why did health authorities in New Zealand go ahead with legislation to allow optometrists to prescribe oral therapeutics? My theory is that the New Zealand health system was operating under significant financial stress, hence the need to better utilise resources and scope-of-practice. There is a strong health economics aspect, but notably, there hasn’t been any reported adverse events since optometrists began directly prescribing oral medications.”

“The proof of the pudding is in the eating,” Guest remarks.

“I’ve been prescribing oral therapeutics – through a GP – since the turn of the century. As a primary care practitioner, if I had a patient that would benefit from a six-to-12-week course of doxycycline, I couldn’t personally write a script, but I had a close working relationship with a GP in the same building, and I would knock on their door, and they would issue a prescription,” he says.

"RANZCO DOES NOT SUPPORT OPTOMETRISTS PRESCRIBING ORAL MEDICATIONS"

Guest, who will be stepping down as a member of the Optometry Board of Australia in October, estimates that he has co-ordinated 300 or more scripts, all signed-off by a GP.

PROF NITIN VERMA RANZCO

“We’re not talking about sight-threatening disorders; we’re talking about nonsight-threatening conditions, such as meibomian gland dysfunction, and about the patient’s quality of life. We’re talking about anti-inflammatories to treat dry eye that hasn’t responded to conservative treatment.”

Guest says despite potential pushback from a section of organised medicine, prescribing oral therapeutics is generally not in the sphere of secondary or tertiary care, and predominantly should be handled by primary practitioners as part of community-based care.

This month, Guest had prepared to present a lecture titled ‘Orals: The next frontier’ at the O=MEGA21 clinical conference.

He says his lecture was not intended for recent graduates or early career optometrists who are both well-versed in oral therapeutics through their university training.

“I’m addressing those optometrists who are 15 to 20 years out in the profession, who didn’t graduate with therapeutics training but have since completed a therapeutics course. I’m saying to them: ‘Let’s remind you what the issues are when you’re prescribing a medicine that’s ingested orally rather than administered in the eye. It’s often the same molecule, but you’re giving it a different way’,” Guest says.

His lecture also discussed the issues around translating didactic knowledge of oral prescribing into everyday practice.

“I’m saying to those that have been practising for 20 years: Can you explain to the patient the possible side-effects of an oral medication, such as potential gastrointestinal reactions? Is the patient pregnant, or are they planning to get pregnant? Are they more likely to be exposed to UV, as some medications can make you more sensitive to the sun,” he says.

Guest also emphasises the importance of optometrists taking responsibility for medications they prescribe and working closely with pharmacists and GPs as part of a wholistic management approach.

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INSIGHT September 2021

RIGHT OF REPLY RANZCO president Professor Nitin Verma says ophthalmologists are qualified medical practitioners with a long and comprehensive medical and surgical training course spanning over a decade and a half.

“As such, they are best placed to diagnose and treat the patient with eye disease. Part of their training involves the prescription of systemic medication that also requires extensive medical training, clinical judgement, and experience,” he says.

Verma says oral medicines are uncommonly prescribed in the management of most ocular conditions and – except in some disease categories – their use is generally not considered routine.

“When required, however, there are significant considerations including the choice of agent, dose, risk of adverse reactions and the management of co-morbidities. Additionally, there are a broad range of systemic and topical drug interactions and side effects that doctors are aware of and are capable of managing. Some of these could be associated with serious morbidity and could even be fatal. Ophthalmologists are prepared for this through their extensive basic medical and ophthalmic education which trains them to recognise and manage these events,” he says.

“Extending prescribing of oral medications to optometrists, who do not have the appropriate medical training, the experience and above all, do not have the need to prescribe oral medication routinely, could compromise patient safety.

“Finally, the responsibility of looking after the patient with an ocular

problem needing oral medication does not stop at the prescription of the drug but also extends to having the knowledge and infrastructure to be able to handle the side effects and adverse drug interactions that could ensue.

The reality is that the system is not set up for that and any adverse reaction in this regard could be very serious,” Verma says.

He says RANZCO cannot comment on the decision of other countries to allow optometrists to prescribe oral medication, except to say that each country has a different health system.

“To illustrate the point that the right to prescribe oral therapeutic agents is not needed, the data from New Zealand is self-illuminating. In 2019, only about 4% of prescriptions by optometrists were for oral medications, and the most commonly prescribed medication was an oral antibiotic. We believe that for ocular disorders serious enough to need oral antibiotics for their management, early referral to an ophthalmologist should be considered.

“In summary, RANZCO does not support optometrists prescribing oral medications and holds the view that in such uncommon situations where they are considered necessary for the reasons outlined above, involvement of an ophthalmologist in the management of the problem would be the appropriate course of action.”

Australian Society of Ophthalmologists (ASO) president Associate Professor Ashish Agar says organisation’s position is in alignment with the Australian Medical Association (AMA), as outlined in their 2019 policy document.

Its policy states that only medical practitioners are trained to make a complete diagnosis, monitor the ongoing use of medicines and to understand the risks and benefits inherent in prescribing.

“Only medical practitioners currently meet the high standards required

"IN THE INTERESTS OF PATIENT SAFETY, WE AGREE WITH THE AMA THAT THEY SHOULD ONLY BE PRESCRIBED BY MEDICAL PRACTITIONERS" A/PROF ASHISH AGAR ASO by the NPS MedicineWise Prescribing Competency Framework in order to safely prescribe independently," it states.

“The AMA therefore does not support independent prescribing by nonmedical health practitioners outside a collaborative arrangement with a medical practitioner. Prescribing by non-medical practitioners should only occur within a medically led and delegated team environment in the interests of patient safety and quality of care.”

Further, according to its policy, the AMA recommends a system of mandatory referral to a registered medical practitioner where appropriate clinical criteria and outcomes are not achieved within a specific time frame.

“Oral agents can have, and have had, serious adverse effects including death, and so in the interests of patient safety, we agree with the AMA that they should only be prescribed by medical practitioners,” Agar says. n

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SCOPE-OF-PRACTICE

Optometry’s latest

MOVE FOR EXPANDED SCOPE

In a new push, Optometry Australia is calling for change in six areas – including oral medications and intravitreal injections – so the nation’s under-utilised optometric workforce can get to work tackling urgent eye health issues. Insight unpacks the organisation’s key proposals.

T

he peak professional body for optometrists has seized on the timing of an imminent Federal election and the Aged Care Royal Commission’s damning report to demand concerted action to address the nation’s eye health challenges.

In July, Optometry Australia (OA) released a new policy platform, ‘Working Together for Better Eye Care’, offering a stark reality check on Australian eye health and practical methods to tackle some of the biggest issues.

The organisation’s national president Mr Darrell Baker says the skills of Australian optometrists continue to be “seriously under-utilised” compared to their counterparts in similarly developed nations.

This view underpins the organisation’s six key recommendations that will require a substantial – and potentially controversial – expansion of the current optometry scope to implement.

He says there are many reasons for change. For example, public ophthalmology wait times in areas like cataract surgery are disappointingly long.

Collaborative eyecare remains in its infancy, and only about 50% of patients with diagnosed diabetes get access to the eye examinations they need.

it is not unusual for less urgent patients to wait more than 300 days for their initial ophthalmology outpatient appointments in the public health system, with COVID-19 exacerbating the problem.

Also compounding the issue is the maldistribution and under-supply of ophthalmologists, cited in recent reports. Despite this, OA states it is not unusual for ophthalmologists to spend time undertaking eyecare for which other eye health professionals, such as optometrists, have the training and regulatory authorisation to deliver.

“More efficient referral and triaging practices and a commitment to allowing all eye health professionals to practise to their full scope would have the added benefit of freeing up the limited and specialised time of ophthalmologists,” the organisation argues.

For that reason, OA is recommending collaborative care models between ophthalmologists and optometrists to be integrated into the mainstream health system for patients with stable glaucoma, pre and post-operative cataracts, paediatric eyecare and early-stage diabetic retinopathy.

This concept builds on what OA describes as a “growing number of successful formal and informal collaborations between optometry and ophthalmology around Australia” that “seek to reduce public ophthalmology wait times and enhance access by using optometrists to assess and manage patients who would otherwise be seen by ophthalmologists”.

ORAL AND INTRAVITREAL PATHWAYS While optometrists have been safely prescribing ocular medications since therapeutic legislation was introduced in Australia (the dates of which vary from state-to-state), in other countries regulations have been extended to allow optometrists to prescribe oral medications, and even administer intravitreal injections.

"Whilst significant progress has been made, we have not closed the gap in Indigenous eye health, with First Nations Peoples three times more likely to be blind or visually impaired; and a tsunami of age-related macular disease is rapidly approaching," he explains.

The indisputable contrast in scope-of-practice has prompted leaders in the profession in Australia to recommend that optometrists be permitted to prescribe oral medications for eye health conditions.

“The only way we can get on top of Australia’s looming eye health crisis is for optometrists to be supported to practise to their full scope to enhance patient access and increase the efficiency of Australia’s eye health system.”

In this issue, we cover this topic in depth on pages 39-43, which includes new data on prescribing attitudes in New Zealand, and delves into why ophthalmology doesn’t support such a move.

OPHTHALMOLOGY SUPPLY One area Optometry Australia (OA) believes needs urgent attention is the longstanding problem of public ophthalmology wait times.

The report notes that ophthalmology consistently has one of the longest median and maximum public wait times of the medical specialties. OA states

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INSIGHT August 2021

Geographic access, especially outside the metropolitan centres, has also been outlined as a significant barrier to patients receiving intravitreal injections, which in Australia, can only be administered by ophthalmologists.

OA is calling for pilot models of care that utilise optometrists to enhance access to intravitreal injections for age-related macular disease and diabetic macular oedema. It points out that given the undersupply and

geographic maldistribution of the ophthalmology workforce, the Federal Government’s MBS Taskforce Review recently recommended enabling intravitreal injections be administered by appropriately trained nurse practitioners, optometrists, and GPs. “In countries like the UK, the US and New Zealand, non-ophthalmologists are playing an enhanced role in enabling access to intravitreal injections, with high levels of patient satisfaction and increased throughput in retinal clinics,” OA states.

guidelines, templates and pathways for common eye health conditions, with a facilitated transition to electronic referrals.

It’s also recommending the government introduce telehealth MBS items for brief optometry consults where face-to-face visits are impractical, and enabling ophthalmology reports and advice to be relayed to patients.

While acknowledging how initiatives such as the KeepSight program – introduced in 2019 – have been developed to support people with diabetes by sending reminders, OA believes more needs to be done in this space.

It says better use of digital systems to emphasise the need for regular eye examinations is necessary to lift the current low levels of compliance, along with a major public awareness raising campaign.

Optometry Australia president Darrell Baker.

The notion of optometrists providing eye injections is controversial in Australia and has been opposed by RANZCO and the Australian Society of Ophthalmologists in recent times. Federal Health Minister Greg Hunt is now considering the proposal as part of the MBS review and will deliver his decision soon.

DIGITAL TECHNOLOGY OA also cited an overall lack of connectedness within the eye health system as a cause of sight loss from preventable conditions. This has been characterised by siloed approaches, buck passing and last-century IT systems.

It wants to address this problem immediately as the profession is witnessing significant technological advances transforming eyecare and the role of optometry, which OA expects to continue over the next two decades.

It is calling for the implementation of consistent ophthalmology referral

AN ULTIMATUM Citing an overall lack of focus by government, industry, and health professionals on the fundamental importance of eye health as a public and population health issue, OA is calling for urgent action.

“Australia has a clear choice as a nation. Either we give eye health the priority it deserves or face a future with increasing numbers of Australians unnecessarily having to live with the personal, social, and economic impacts of blindness and vision loss,” the organisation’s ‘Working Together’ report says.

It concludes: “Their timely implementation will remove bottlenecks, reduce wait times, prevent unnecessary blindness and vision impairment, and enhance the overall efficiency of the eye-health system. At the same time, there must be an increased commitment to investing in public ophthalmology and public optometry, and in closing the gap in Indigenous eye health.” n

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VITREOLYSIS

t n e m t a e r t A laser APPROACH TO FLOATERS Invasive surgery is often a step too far to eliminate vitreous floaters for many, but DR CON MOSHEGOV says an Australian-developed YAG laser therapy is proving to be an ideal first-line option for selected patients.

P

atients troubled by vitreous floaters can be particularly motivated to seek treatment, but are frequently left disappointed when told they’ll need to learn to live with the irritating structures drifting through their field of vision.

The often-benign nature of symptomatic floaters can mean they’re underestimated by busy optometrists and ophthalmologists focused on more sight-threatening conditions.

But for many patients, floaters are frustrating and debilitating. In fact, a 2013 article in the International Journal of Ophthalmology found 76% of 603 people surveyed reported seeing floaters, with 33% saying they caused noticeable vision impairment. There is also a multitude of online forums teeming with aggravated sufferers.

One barrier to treatment is the perception that patients will require a vitrectomy to become floater-free, which may not be worthwhile for many due to its higher complication risk and likelihood of cataract formation. Less invasive vitreolysis, or laser floater treatment (LFT), with conventional YAG lasers have also been investigated but struggled because they weren’t optimised for the procedure.

This was the impetus for Adelaide company Ellex (now part of Quantel Medical, a subsidiary of Lumibird Medical) to focus its efforts on what it describes as the only holistic and CE mark approved1 laser solution for floaters. The platform is called Reflex Technology available across both the Tango Reflex and Ultra Q Reflex laser systems. It features more efficient and safer energy profiles, while also enhancing visualisation of the anterior and posterior vitreous.

Ophthalmologist Dr Con Moshegov, of George Street Eye Centre in Sydney’s CBD, was among the first in Australia to introduce Ellex’s Reflex Technology into his practice in 2013. He was astonished by the response after listing the first-line, in-office procedure on his website.

“We had people come to our clinic for vitreolysis from all over, including a professional shooter from New Zealand who was heading to the [Glasgow] Commonwealth Games who complained of floaters getting in the way of his competitive ability,” he recalls.

“Floaters are common, but for many years people have been told they’ve got to learn to live with them, they’ll become less apparent over time, but the changes Ellex made to the YAG laser has made it a very attractive

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INSIGHT September 2021

proposition to offer to these people.”

INGENIOUS DESIGN Moshegov is under no illusions that vitrectomy remains the definitive treatment due to its ability to essentially remove every floater. However, the risks of cataract formation, retinal detachment and endophthalmitis are important considerations.

“Laser cannot compete with an operation, but it is not an operation and that is its advantage; it doesn’t carry the risk of infection or the higher chance of complications,” he says.

Dr Con Moshegov, of George Street Eye Centre in Sydney.

“With vitrectomy, everyone eventually gets a cataract and if this happens before you become presbyopic in your 40s, that’s a very unfortunate scenario.”

According to Moshegov, the use of YAG lasers to eliminate floaters can be found in literature as far back as 1993. But for various reasons it never took off.

Part of the problem is the configuration of conventional YAG lasers that made it impossible for the practitioner to align their view with that of the laser beam. This meant the illumination and laser were delivered from a low, noncoaxial position with larger convergent zones, making it difficult to target and treat floaters.

Moshegov says the beauty of Ellex’s redesigned system means he can align his sight coaxially with the laser beam, greatly enhancing his visualisation of floaters often located in the mid and posterior vitreous.

Having greater spatial context is also vital to ensure the laser is clear of ocular structures to avoid causing a cataract or retinal burn, for instance.

“Ellex have come up with a very simple, but very clever, twist on the design

of the YAG laser,” he says. “It's a solution in which a mirror bounces light off a chamber below, into the eye that allows the surgeon to see straight ahead and bounce the light off the red reflex.

to the posterior capsule, which does create fragments, that will eventually sink out of view. Larger floaters will require some dissection as part of the vaporisation process.

"When the surgeon presses the button to allow the laser beam to go through, the mirror comes down, the laser goes through and then the mirror pops up again, and it all happens so quickly that the surgeon doesn’t even perceive that, for a split millisecond, they lost a view of the fundus.”

Although it isn’t a contraindication, Moshegov believes it is also easier to treat pseudophakic eyes than phakic eyes. This is because the optical clarity is better in a pseudophakic eye than one with an ageing natural lens, and there is no risk of inducing a cataract. At worst, a pit or two can be seen on an IOL, but multifocal IOLs make focusing the laser beam more challenging.

According to Ellex, the Reflex Technology being described includes True Coaxial Illumination (TCI) that generates a titratable red reflex as a contrast comparison and a precise aiming beam. This is incorporated within a unique slit lamp illumination tower that converges the user’s sight line, target illumination and treatment beam into one optical path.

The company says the technology also features a superior energy beam profile. An issue with conventional YAG laser is the required high energy levels, which can damage surrounding ocular tissue or cause an intraocular pressure (IOP) spike.

“They shaped the beam to concentrate on a miniscule target, generating significant plasma to vaporise the floater,” Moshegov says.

“With older lasers you had to use more energy to achieve the same result and because it wasn’t so concentrated, you had the danger of causing the emanated shockwave to damage surrounding tissues.”

Moshegov says, while this is still possible with the Ellex platform, the system has another key feature to minimise risk. It allows the ophthalmologist to ‘off-set’ where the most intense portion of the beam will be located – either in front of or behind the target.

“Preferably you off-set behind because that way you can focus on to the floater and have a safety margin, because the actual beam is going to concentrate behind it."

SELECTING THE RIGHT CANDIDATES Floaters are opacities in the vitreous cavities that cast shadows on the retina. Patient selection is a vital part of vitreolysis, with the size, location and density of floaters usually determining eligibility.

BUSINESS CASE In terms of the business case for adopting such technology, Moshegov says it has been a solid revenue earner for his practice, alongside his main areas of focus – cataract and refractive surgery.

Many people irritated by floaters are highly motivated to seek treatment.

Most have found their way to Moshegov’s clinic through a description of the procedure on his website.

However, the versatility of the Tango Reflex laser also makes it a viable proposition. It features two types of laser; YAG for vitreolysis and frequency doubled N:dYAG for selective laser trabeculoplasty for glaucoma. Ellex says that Red Reflex technology improves YAG overall, achieving high-definition capsulotomies, enabling excellent visualisation and elimination of broken fragments, preventing a common patient complaint of sudden floater development after this treatment.

“So, if a surgeon needs a new YAG laser for posterior capsulotomies, why wouldn’t you spend a bit extra on the instrument that can do the whole lot,” Moshegov says.

“Even if you don't take up vitreolysis, you will still be recouping the capital expenditure on the laser by doing those other things like capsulotomy and SLT.” n NOTE: Dr Con Moshegov has no financial disclosures and didn't receive benefits from Ellex.

1. Tango Reflex has a CE Mark (Conformite Europeenne) for the indication of laser vitreolysis. It is currently not approved for this in the US.

Moshegov says the best candidates have Weiss ring floaters, which are solitary, well circumscribed and located in the middle of the vitreous cavity.

These are commonly caused by a posterior vitreous detachment.

He also uses Reflex Technology to treat diffuse, cloud-like floaters (amorphous), which can be harder to eliminate.

“With these it can take two, three, four sessions before making it translucent enough for the patient to be happy,” he says.

“The worst type of floaters aren’t even highlighted or outlined, it’s like a curtain or veil of opacification, something called a thickened posterior hyaloid face; it's the interface between the detached vitreous and what's behind it. I avoid using vitreolysis for that type of floater.”

Ellex’s Reflex Technology emits a fournanosecond burst of energy at a potent power density to vaporise and covert floater collagen and hyaluronic molecules into a gas, which is then resorbed into the eye.

Moshegov says it has been a challenge to convince his colleagues about this process due to a common belief floaters are merely broken into smaller fragments.

He believes this misconception has come about due to the way YAG lasers are applied

Reflex Technology is available across both the Tango Reflex (pictured here) and Ultra Q Reflex laser systems.

INSIGHT September 2021 47

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CAREER

People

ON THE MOVE A wrap on the latest appointments and industry movements within the Australian ophthalmic sector.

CYLITE INTRODUCES NEW SENIOR PRODUCT MANAGER Matthew Wensor, a stalwart of more than 23 years with Carl Zeiss, has taken a position of senior product manager with Cylite, a Melbourne manufacturer of the new Hyperparallel-OCT (HP-OCT). “An opportunity to work with the team developing the next generations of OCT isn’t something that comes along very often in your hometown,” he said.

A NEW BRAND MANAGER FOR MYOPIA MANAGEMENT Jacqui Regan has recently been appointed as CooperVision's brand manager for myopia management – ANZ. She is an experienced healthcare marketer, having worked at agencies such as Saatchi & Saatchi Healthcare, Leo Burnett and more recently Medicine X, a healthcare digital communications agency. She has completed a graduate certificate in marketing and is completing her master’s in marketing at Curtin University.

CHANGES WITHIN THE UNSW’S OPTOMETRY SCHOOL Regine Chapman-Davies has recently transitioned from a visiting clinical supervisor to part-time staff optometrist at the School of Optometry and Vision Science, at the University of New South Wales in Sydney.

DEAKIN GRADUATE BECOMES LECTURER AT UWA Deakin University Master of Optometry graduate turned academic, Dr Khyber Alam, has been appointed lecturer in the School of Allied Health at The University of Western Australia. Alam, an Afghan refugee who arrived in Melbourne aged 13 with his family in 2007, received the Deakin Young Alumni of the Year award in 2019. He has also completed a PhD in vision impairment and an MBA at Deakin University.

EXPERIENCED INDUSTRY FIGURE JOINS PROVISION AS BUSINESS COACH Tina Adel recently started at ProVision as a business coach. She has over 20 years’ experience in the optometry industry, having held practice manager, account manager and most recently various strategic management roles. Tina’s experience and history relating to both business growth and supporting individual development give her a solid foundation and insight into understanding the challenges and potential opportunities of independent optometry.

NEW BOARD CHAIR FOR THE FRED HOLLOWS FOUNDATION Jane Madden has joined the foundation as board chair as former Victorian Premier John Brumby announced his retirement at a recent AGM. Jane has a passion for international development and more than 25 years’ experience across public and private sectors, with positions at senior levels of Australian Department of Foreign Affairs and Trade, Australian Trade and Investment Commission, and Prime Minister and Cabinet, and diplomatic postings to Japan, South Africa and France, including as Australia’s Ambassador to UNESCO.

Do you have career news to share?

Email editor Myles Hume at myles.hume@primecreative.com.au to be featured.

INSIGHT September 2021 49

CATARACT KIDS AUSTRALIA AND ORTHOPTISTS AS A PARENT OF A CHILD WITH CATARACTS, MEGAN PRICTOR KNOWS THE STRUGGLE OF AFFECTED FAMILIES. THAT’S WHY SHE SET UP CATARACT KIDS AUSTRALIA, A CHARITY THAT’S FORMED A STRONG BOND WITH ORTHOPTICS.

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MEGAN PRICTOR

"ORTHOPTISTS ARE OFTEN THE FIRST PROFESSIONALS A NEWLYDIAGNOSED CHILD WITH CATARACT AND THEIR FAMILIES WILL SEE"

Cataract Kids Australia exists to enhance the support and information provided to families, work with clinicians to optimise treatment outcomes, and improve connections with the research community. Here, I reflect on our approach that aims to influence and impact, leading to sustainable change rather than criticise as an ‘outsider’.

This can be a tricky balancing act, considering our role also includes advocacy for individual families.

Orthoptists are often the first professionals a newly-diagnosed child with cataract and their families will see.

Early on, orthoptists likely understand what the family then may not: that the story will not end with the baby’s successful lensectomy; that visual rehabilitation is a long (and hard) game, where complications are common; and, most importantly, that orthoptists will be that baby and family’s guide, advisor and cheer squad throughout.

Depending on location and context, orthoptists may be involved in assessing a child’s vision, prescribing occlusion therapy, ordering contact lenses and teaching families how to insert and remove them, and liaising with ophthalmology and other health professionals and support organisations.

They will listen to parents articulating their anxieties about daily management and long-term outcomes, and engage with kids across all ages, moods, behaviours and capabilities. This means orthoptists are superbly placed to contribute and learn; to smooth the journey for each child and family and advocate for paediatric cataract care at a system level.

In establishing Cataract Kids Australia, I felt it was vital to engage with all relevant professional disciplines, principally ophthalmology, orthoptics,

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government, and other stakeholders.

In practical terms it means both entities promote each other via their websites and newsletters, and that Cataract Kids can engage with Australian orthoptists more easily from ‘inside the tent’.

ataract Kids Australia is a registered charity promoting the vision of kids affected by cataract. As a parent of a child with bilateral congenital cataract, I founded the organisation in 2017 after many discussions with other families and healthcare professionals involved in caring for children with cataract.

INSIGHT September 2021

Beyond this formal agreement, the relationship between orthoptics and Cataract Kids includes orthoptists presenting online webinars for families on topics like occlusion therapy and vision testing; and joint advocacy on vision screening and funding gaps. Orthoptists are also involved in the nascent Paediatric Vision Alliance Australia together with Cataract Kids Australia and other entities such as Usher Kids Australia, CVI Community Australia and Charge Syndrome Australasia.

Orthoptists play a key role guiding families who have a child with cataract. Image: Sarah Craven Photography.

optometry and others in allied health (eg. play therapy, occupational therapy), paediatrics and primary care. To that end, the corporate governance of the organisation has deliberately included an orthoptist and ophthalmologist, as well as me as a patient advocate, to ensure that at least some of the main disciplines have a ‘seat at the table’.

The benefits of this are both practical and in the optics. It means Cataract Kids can, at an organisational level, draw upon a deep understanding of clinical, structural and policy issues in care provision. It also means clinicians can see themselves and their professional peers as an important part of the overall undertaking rather than Cataract Kids Australia being pigeonholed as ‘just’ a peer support group. If the organisation is perceived as being only for patients and their families, there is a greater risk its efforts to improve diagnosis and treatment could be dismissed as simplistic or misunderstanding.

In December 2020, Cataract Kids entered a Memorandum of Understanding with Orthoptics Australia.

This has significant benefits for both parties in our efforts to deliver a uniform message to the public, the professions,

I believe Cataract Kids and Orthoptics Australia each benefit significantly from this purposeful engagement approach, and the benefits extend more broadly.

Synergism makes our collective voices louder; it strengthens both individuals and the entities they represent. Our chances of achieving sustainable change are significantly enhanced because we are building on mutual trust, equipping each other with knowledge and resources, and celebrating joint wins.

I’m excited by our progress to date and the potential for future gains, particularly in enhancing families’ understanding of the critical role orthoptists play in the care of their child affected by cataract. I’m also motivated by our joint efforts to embed early childhood vision screening nationally and to improve the identification of eye problems in neonatal and primary care. n

ABOUT THE AUTHOR: Megan Prictor (LLB(Hons), PhD) is the founding director of Cataract Kids Australia and a founding member of the Paediatric Vision Impairment Alliance. She is also an editor with Cochrane Eyes and Vision.

ORTHOPTICS AUSTRALIA strives for excellence in eye health care by promoting and advancing the discipline of orthoptics and by improving eye health care for patients in public hospitals, ophthalmology practices, and the wider community. Visit: orthoptics.org.au

MANAGEMENT

THE SHOW MUST GO ON – PLANNING ON THE RUN OPERATING A HEALTH PRACTICE IN THE CURRENT ENVIRONMENT IS FRAUGHT WITH UNCERTAINTY. KAREN CROUCH EXPLAINS HOW TO PREPARE TACTICALLY AND STRATEGICALLY FOR THE YEAR AHEAD.

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KAREN CROUCH

"TRACKING MECHANISMS ARE VITAL TO ENSURE PERFORMANCE IS ON TRACK OR REQUIRES ADJUSTMENT"

ere’s a novel challenge for practice owners and business planners in general.

including weekends? All aspects deserve review to determine whether there is need for changes to preserve competitive edge.

• Technology: has new technology improved patient care, productivity or reduced costs? Does the benefit of acquiring new technology justify investment?

The concept of future planning assumes information is available or predictable and even possible to influence for goal setting and stretch targets. But how does one achieve this when the future is a moving target?

In early 2020, we assumed the COVID-19 ‘distraction’ would pass, but here we are without a clear end in sight, regardless of various governments’ best intentions and “future plans”.

The answer is to persist with the traditional business plan to the best extent possible while assuming the need for adjustment and modification will be necessary. Instead of performing these vital actions only prior to the usual financial year, it’s never too late to ensure practices are appropriately prepared for the dynamic 2021-2022 period ahead.

As a starting point, let’s look at the business-as-usual development of the annual business plan.

Business plans typically comprise two main sections: tactical and strategic. While one is short term and operational (micro level), the other aims to achieve longer term objectives (macro vision).

TACTICAL PLAN This is the ‘business as usual’ framework by which the practice functions (e.g. healthcare services, revenue generation, expense containment) to ensure financial viability and support for initiatives to achieve strategic goals. Features include: • Expenses: line-by-line budgets, based on historical experience or ‘educated guesstimates’ for start-ups. Figures should recognise cyclical peaks and factor in CPI increases.

• Income: annual revenues, based on practitioner numbers, working hours, charging rates and consultation/treatment numbers.

• Measuring: tracking mechanisms are vital to ensure performance is on track or requires adjustment. Monitoring is achieved through measurement factors that staff and practitioners agree to:

It’s important to consider what competitors offer such as weekend opening hours.

-K PIs: performance rates e.g. 90% patient satisfaction, patient numbers; - r atios (e.g. salaries-to-expense, incometo-expense) benchmarked to industry norms; - t racking systems that measure performance to targets, including ‘variance explanations’. Better than budget performance highlights; poorer outcomes present opportunities to analyse problems and remedy them.

• Non-financial: it may be necessary to adjust, or introduce new clinical/ administrative procedures to ensure compliance with changing business imperatives or external factors (legislative/regulatory).

• Human Resources: this vital element covers plans to develop staff and practitioners, targeting ‘employer of choice’ status.

•C apital: if expansion or upgrades are planned, related costs (borrowing) and repayments should be included.

• Profit & Loss: ultimately, the net difference between expenses and revenues will reflect the targeted profit for the year.

The most convenient method of preparing an annual budget is to extrapolate current ‘year-to-date run rates’ for the following year. Suggested areas for closer, detailed scrutiny relate to landscape changes.

• Competition: have other practices opened in the area? What services do they offer that your practice may not? Apart from product or service differentiation, it may be something more client-focused like longer opening hours

• Previous year’s results: if objectives have been exceeded, higher goals, including stretch targets, should be introduced to provide greater motivation for success and the practice mantra that ‘satisfactory results are just enough, we aim to exceed expectations’; • Continuous Improvement: have employee meetings and forums been adequately focused on operational productivity and the general theme of ‘working smarter, not just harder’?

STRATEGIC PLAN This section is vital to the growth prospects of a practice, aimed at optimisation of new opportunities, business expansion or reputation enhancement (recognised leaders in a particular field).

If the strategic plan covers a three-year period, business plans should target progressive and realistic completion of stated goals so aspirations are successfully achieved by the three-year period.

As part of measurement/monitoring, it’s advisable to review business plans quarterly to ensure end-of-year tactical and strategic goals are met.

Overall, the annual business plan should correlate with the practice/owners’ strategic plan which, in itself, will probably require adjustment to reflect the current, transient environment. While the above planning actions are expressed in business-as-usual terms, it will be necessary to amend plans, sometimes on the run, to accommodate COVID-19 related business conditions and compliance mandates. n

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

INSIGHT September 2021 51

DISPENSING

A BRIEF GUIDE TO FRAME ADJUSTMENT – PART 1 THE FINAL ADJUSTMENT IS THE ICING ON THE CAKE IN THE DISPENSING PROCESS AND CAN OFTEN BE A DEFINING MOMENT IN THE PATIENT JOURNEY. THAT’S WHY IT IS SO IMPORTANT TO GET RIGHT, WRITES MURRAY O’BRIEN.

O

ne of the most important steps in successful eyewear dispensing is the final adjustment. Customers may not remember you if this function is performed correctly, but they most certainly will if it’s not.

MURRAY O'BRIEN

"TAKING TIME AND LEARNING THE PROPER SKILLS IS NOT ONLY YOUR RESPONSIBILITY TO THE CLIENT BUT GOOD BUSINESS PRACTICE"

As dispensers we have an enormous impact on the wellbeing of people who engage our services. It’s incumbent upon us to ensure the eyewear dispensed is not only accurate with regard to prescription but that also, from an anatomical perspective, functions correctly.

Ultimately, however, we must do no harm. Spectacles are a medical device, so it’s important to recognise we can physically impact the customer if our responsibilities aren’t taken seriously.

The harm we can cause is usually minimal, mostly soreness caused by skin irritations behind the ears and on the nose, or the familiar indentations down the side of the head called ‘tram-tracks’. Rarely, more serious complications can occur where skin is actually broken.

Properly adjusted spectacles should allow for comfortable, easy and functional wear. They should stay on the head without slipping under most circumstances, but adjustments also ensure the best vision can be achieved by optimising the tilt, facial wrap and straightness.

My step-by-step guide to adjusting frames, includes: 1. Place the frame on the client’s head by tilting the end tips up, pushing them on, then lowering them on to the nose and ears. You must place them on yourself, so you can feel the tension on the side of the head. The sides should just touch the side of the head without any pressure. The distance between the temple tips must be adjusted to ensure they are the same width as the head at the top of the ears.

2. Check the horizontal alignment.

The spectacles usually should be perfectly aligned with the eyes, after

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INSIGHT September 2021

An example of temple tips that have been adjusted with curve to compensate for the mastoid process.

all we are most concerned with ideal vision. Induced vertical prism from crooked alignment can seriously disturb visual comfort.

3. With spectacles on the client, look behind their ears to observe the point at which the bend in the temple tips will need to begin. Often this will require the bend in the tips to be straightened before moving the bend to where it needs to start. If you’re not good at guessing, mark the point on the temple.

4. Next, observe where the ears attach to the head behind the ears.

Every individual is different. Most importantly, note the prominence of the mastoid process. It’s extremely large in some people and pressure on the bone will cause discomfort, sometimes extreme. The larger the mastoid process the more the temple tips will need to be bent out to avoid placing pressure.

5. Bend the tip to the correct angle just behind the top of the ear. The tip should follow the exact line where the ear attaches to the head. If that line dips, then the tip should be curved to the exact radius to perfectly follow the dip behind the ear. On some frames this may require substantial heat and/ or strong fingers to achieve. This method means the area of the temple tips are spread over the greatest surface area without undue pressure on one particular spot. This will

achieve the greatest holding power and comfort.

6. Observation is the key. Look carefully and make incremental changes.

Take the glasses on and off until it is perfect. Complete the adjustment behind each ear one at a time.

People are often asymmetrical so the shape required for one temple tip may be different to the other.

7. Nose pad adjustment. The pads should sit flush, without one edge of the pad applying more pressure than the other. The angles required for a large European nose are different to Asian bridges. Use your pad adjusting pliers with gusto to form whatever angle is required.

Properly adjusted spectacles should be comfortable with no undue pressure, and never slip under normal circumstances. The final adjustment is just as important as any other part of the dispensing process. Taking time and learning the proper skills is not only your responsibility to the client but good business practice.

Part 2 to will be a guide to the actual practice of frame adjustment. n

ABOUT THE AUTHOR: MURRAY O’BRIEN owns Designed Eyes in Rosebud, Victoria, where he works in full retail optics. He is also past president of the Australian Dispensing Opticians Association (Vic) and has previously worked in lens fitting work, specialising in rimless.

2021 CALENDAR SEPTEMBER 2021 EURETINA 2021 VIRTUAL International 9 – 12 September euretina.org

VISION EXPO WEST 2021 Las Vegas, US 22 – 25 September west.visionexpo.com

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

OSA ANNUAL CLINICAL N AND SCIENTIFIC MEETING

OCTOBER 2021 ORTHOKERATOLOGY SOCIETY OF OCEANIA 2021 CONFERENCE Gold Coast, Australia 1 – 3 October www.oso.net.au

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

EACE 2021 - FUTURE OF P OPHTHALMOLOGY Sydney, Australia, 31 October personaleyes.com.au/events

RANZCO ANNUAL SCIENTIFIC CONGRESS

Sydney, Australia 10 October optometry.org.au

Brisbane, Australia 19 – 23 November ranzco.edu

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

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

NOVEMBER 2021

SUPER SUNDAY 2021

DECEMBER 2021

JANUARY 2022 OPTI 2021 Munich, Germany 14 – 16 January opti.de/en

ORTHOPTICS AUSTRALIA ANNUAL CONFERENCE Brisbane, Australia 20 – 22 November orthoptics.org.au

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

100% OPTICAL London, UK 22 – 24 January 100percentoptical.com

SPECSAVERS – YOUR CAREER, NO LIMITS Graduate Opportunities – NSW The Specsavers Graduate Recruitment Team have several exciting graduate opportunities available across regional NSW, with generous salary and relocation packages available. With continued growth in providing eyecare to patients across ANZ, now is an exciting time to join a company that is leading and defining the future of the optical profession. At Specsavers you will have access to cutting edge technology and be part of the driving force bringing optometry into the forefront of the healthcare industry.

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Experienced Optometrists can expect to earn in excess of $250k!

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

Opportunities available in regional QLD and SA. Ready to come home Kiwis?

Specsavers has a range of opportunities for NZ optometrists looking to return home. From North to South, we have fantastic opportunities for optometrists at all levels. 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 for use with every patient) and develop your clinical experience across a range of interesting conditions and an ever-growing patient base. You’ll also have the support of an experienced dispensing and pre-testing team, the mentorship of store partners and access to an exemplary professional development program.

Full-time Optometrist Opportunity – Specsavers Port Pirie, SA Specsavers Port Pirie are looking to talk to a community and patient focused optometrist. You will be surrounded by a supportive and highly experienced team of dispensers who will ensure a smooth transition from yourself to patient, allowing you to have the best opportunity to do what you do best.

Full-time Optometrist Opportunity – Specsavers Whitford, WA Specsavers Whitford has an opportunity for an optometrist to join their patient focused and friendly team on a full-time basis. Located within Westfield Whitford City Shopping Centre, the clinic boasts four tests rooms with state-of-the-art equipment and an attractive salary package on offer.

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

marie.stewart@specsavers.com or 0408 084 134 Australia Employment enquiries: Madeleine Curran – Recruitment Consultant

madeleine.curran@specsavers.com or 0437 840 749 Locum employment enquiries: Cindy Marshall – Locum Team Leader

cindy.marshall@specsavers.com or 0450 609 872 New Zealand employment enquiries: Chris Rickard – Recruitment Consultant

chris.rickard@specsavers.com or 0275 795 499 Graduate employment enquiries: apac.graduateteam@specsavers.com

SOAPBOX

BUILDING AUSTRALIA’S GENE THERAPY CAPABILITY infrastructure, strong partnerships between clinician and basic scientists, close links with industry sponsors and ready access to patients with a genetic diagnosis to participate in trials.

The collaborative relationships here in Melbourne provide a great example of Australia’s potential to become a world leader in ocular gene therapy. We have a specialist eye hospital in the Eye and Ear, a world top-five eye research institute in CERA and the nation’s highest concentration of biomedical researchers and biotech companies.

T

he rapidly evolving field of gene therapy offers a unique opportunity for Australian eye surgeons and scientists to join forces and lead the world in preventing blindness.

Until recently, patients with inherited retinal diseases and conditions with more complex genetic risk factors like dry AMD had no hope of a cure.

Now gene therapies are offering real prospects of saving and restoring sight.

With the approval of Luxturna to treat Leber’s Congenital Amaurosis – and 40 clinical trials for various conditions under way globally – it’s an exciting time for patients, clinicians and scientists.

I’m part of a team from the Centre for Eye Research Australia (CERA) and Royal Victorian Eye and Ear Hospital delivering an Australian first clinical trial of an investigational gene therapy for dry AMD. So far, we’ve delivered the investigational treatment – administered by sub-retinal injection – to three patients. The surgical technique involves using a canula as thin as a human hair to deliver 0.01 ml of fluid containing viral particles filled with the corrective gene underneath the retina.

As the existing pool of experienced retinal gene therapy surgeons attract more trials to Australia, we will be able to offer similar training opportunities to aspiring surgeons at home. This will create a self-perpetuating cycle where our growing capabilities will enable us to attract more trials, in turn creating more opportunities for our surgeons to upskill and improve the standard of care.

One of the beauties of clinical research is the positive knock-on effect it has across the health system as more clinicians are exposed to innovative practices.

In Australia, there are only a handful of surgeons experienced in delivering ocular gene therapies.

The team at the Eye and Ear and CERA involved in the current trial also includes theatre staff, orthoptists and optometrists – all of whom are learning new skills and taking them into practice.

Here in Melbourne that includes Associate Professor Penny Allen, the head of vitreoretinal surgery at the Eye and Ear, who is also well known for her work on the bionic eye – and me.

But surgical skill is only one part of the equation to bring more gene therapy trials to Australia and support local scientists to develop therapies at home rather than overseas.

I studied medicine at the University of

54

Tasmania before completing my PhD at the University of Cambridge and then ophthalmology training at the Eye and Ear. In 2014, I was extremely fortunate to receive a Nuffield Scholarship from the Australian Academy of Sciences to study with renowned vitreoretinal surgeon and gene therapy researcher Professor Robert McLaren at Oxford University. My training included being part of a worldfirst gene therapy trial for choroideremia – an opportunity that kick-started my interest in retinal gene therapy research.

INSIGHT September 2021

We need essential clinical

The combined skills of the teams at CERA and the Eye and Ear were instrumental in attracting the current AMD trial to Melbourne, and providing local patients with access to a potentially life-changing treatment.

The Eye and Ear’s state-of-the-art new surgical facilities, including advanced microscopy equipment essential for retinal gene therapy surgery, have also been critical.

But no matter how good our facilities, research, or technical skill – we can’t build Australia’s gene therapy capabilities without forging strong links with patients.

Again, Melbourne is uniquely positioned in this regard as home to Australia’s only one-stop Ocular Genetics Clinic at the Eye and Ear. I’m proud to be part of the team at the clinic, which includes genetic counsellors, clinical geneticists, orthoptists and ophthalmologists to diagnose patients with genetic eye diseases and support them.

We love this work, and a great achievement is being able to link patients with trials or treatments. With the developments in ocular gene therapy research, it’s heartening there’s hope on the horizon for some patients. n

Name: Dr Tom Edwards Qualifications: MBBS, PhD (Cantab), FRANZCO Organisation: CERA, Royal Victorian Eye and Ear Hospital, University of Melbourne Position: Principal investigator retinal gene therapy, vitreoretinal surgeon Location: Melbourne Years in the profession: 12

WITH THE APPROVAL OF LUXTURNA TO TREAT LEBER’S CONGENITAL AMAUROSIS – AND 40 CLINICAL TRIALS FOR VARIOUS CONDITIONS UNDER WAY GLOBALLY – IT’S AN EXCITING TIME.

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