Insight December 2023

DEC 2023

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975 DECEMBER 2023

OPTOMETRY SCOPE How our nation can become a more desirable destination for overseas-trained practitioners

RANZCO RECAP: 2023 CONGRESS COVERAGE The latest from Australian ophthalmology's main event in Perth

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INDEPENDENT REVIEW CONSIDERING ENHANCED ROLE FOR PROFESSION

THE LESS CONVENTIONAL ROUTE The unique vantage point of optometrists who became ophthalmologists

You’d look good in Specsavers Ranked as one of Australia’s Best Workplaces for 2023.

DEC 2023

AUSTRALIA’S LEADING OPHTHALMIC MAGAZINE SINCE 1975

OPTOMETRY SCOPE IN SPOTLIGHT AMID INDEPENDENT FEDERAL GOVERNMENT REVIEW Australian optometrists face “various funding, regulatory, technological, cultural, and inter-professional barriers” preventing them from practising to their fullest scope, Optometry Australia (OA) has told an independent review, while calling for a detailed comparison of health professionals in other countries to identify opportunities for further scope enhancements.

Representing around 6,700 optometrists, the peak body also highlighted examples of health systems where prescribing of oral medications and intravitreal injections – which Australian optometrists are prohibited from performing – are done by non-ophthalmologists, and how one of the biggest hurdles is the scaling of collaborative care models already established in parts of the country.

The details are contained in OA’s submission to the ‘Unleashing the Potential of our Health Workforce’ independent review led by Australian National University health workforce expert Professor Mark Cormack.

mean that Australian optometrists with equivalent qualifications that are duly recognised in New Zealand are unable to practise in Australia to the same scope as their counterparts across the Tasman,” she said.

The review will identify opportunities to remove the barriers stopping health professionals working to their full scope-of-practice. It will also look for examples of multi-disciplinary teams working at the top of their scope to deliver best practice primary care.

“Optometrists face various funding, regulatory, technological, cultural, and inter-professional barriers to maximising the utilisation of their professional skills and qualifications.

OA strongly supports the process, which it said “is of vital interest to the optometrist profession”. However, in the past, calls to increase the optometry scope have failed to convince ophthalmology bodies like RANZCO and the Australian

Allowing prescribing of oral medication is a focus of Optometry Australia's advocacy.

Society of Ophthalmologists (ASO) who both cite patient safety as key barriers to optometrists prescribing and administering oral and intravitreal injection therapies.

But in the submission, OA CEO Ms Skye Cappuccio said the optometry scope in Australia is more limited than in comparable countries like New Zealand, the UK, US and Canada. “[These] are noteworthy as they

"These barriers can prevent optometrists from providing comprehensive treatment and support to their patients and make it more difficult to work collaboratively with other health professionals managing chronic eye health conditions. Despite these hurdles, optometrists have demonstrated their willingness continued page 8

UNTANGLING RED TAPE TO EASE WORKFORCE PRESSURES To make Australia a more attractive destination for overseas-trained practitioners, Ahpra and the National Boards are considering two additional changes to English language skills (ELS) requirements that could see the bar lowered for writing proficiency and the list of “recognised countries” significantly expanded.

The two new proposals follow an independent review, led by Ms Robyn Kruk, to cut the red tape and costs for qualified overseas-trained practitioners wanting to work in the Australian health system. If introduced, the measures could alleviate workforce shortages in regional areas that have struggled especially when it comes to specialist eyecare services.

According to a 2018 workforce report, ophthalmology welcomes around

12 overseas trained new fellows each year.

The Kruk review recommends measures to immediately boost the health workforce and ensure Australia is a competitive destination for the global health workforce, while weighing these against quality and safety.

According to the report, employers and health practitioners say Australia’s registration and immigration processes are often slower, more complex and expensive than other countries. For example, recruiting an overseas GP can take up to 21 months and cost more than $25,000 even for cohorts from fast-tracked countries, while nurses can pay over $20,000 and take 35 months to get their qualifications recognised.

“Only applicants with qualifications from a small number of countries and professions are eligible for the streamlined pathways,” Kruk said.

“The requirements are particularly inflexible for experienced health practitioners that specialise over their career. Regulatory responsibilities are highly fragmented, with roles spread across multiple parties and legislation with little coordination.

Some employers no longer consider applicants from countries without expedited registration pathways as the process is too hard and outcomes uncertain. Australia is often no longer the country of choice for the health workers we want and need.”

One significant proposal raised continued page 8

BACKING AUSTRALIAN INDEPENDENTS German ophthalmic lens manufacturer Rodenstock has made a significant investment in its Australian business by establishing new fitting labs in Brisbane and Melbourne, improving the service to independent practices. page 18

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IN THIS ISSUE

DECEMBER 2023

EDITORIAL

FEATURES

A ROAD LESS TRAVELLED Part of the prestige of becoming an ophthalmologist is the highly competitive selection process to get on the trainee program.

To put it in perspective, there are as many as 1,100 ophthalmologists servicing 25 million people (equating to a population prevalence of 0.0044%), with 46 trainees graduating to become RANZCO fellows this year.

It’s no secret that applicants work to amass an exemplary academic record, coupled with experience, just in the hope to stand out. Then, once selected, the hard work really begins.

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BUY-IN PARTNERS As more optometrists retire, George & Matilda has made succession a priority.

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IOL INNOVATION Where the IC-8 IOL and its small aperture technology shines for two Australian surgeons.

It’s an imperfect process with vulnerablities, but RANZCO is working on ways to diversify its selection progress – and thereby the ophthalmology workforce – through different pathways, including those with a First Nations and/ or a regional background. It’s also recognising the need to target medical school graduates earlier.

Interestingly, there is a handful of ophthalmologists who have taken a more unconventional route to their vocation by practising as optometrists first. In this issue, we interview two eye doctors who discuss how their grassroots experience as an optometrist helped set them apart.

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2023 REFLECTIONS A look back on the key issues and events that shaped the Australian ophthalmic sector.

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CAREER LONGEVITY Countering the high prevalence of musculoskeletal pain in the ophthalmic sector.

EVERY ISSUE 07 UPFRONT

55 MANAGEMENT

09 NEWS THIS MONTH

56 SOAPBOX

53 OPTICAL DISPENSING

57 CLASSIFIEDS/CALENDAR

54 ORTHOPTICS AUSTRALIA

58 PEOPLE ON THE MOVE

The issue of ophthalmology workforce was also a major focus at the RANZCO Congress at Perth, which Insight attended in October. It was interesting to see college’s work to build on the Indigenous ophthalmology workforce in Australia – which stands at just one. Through scholarships and waived application costs, among other measures, it expects to have more Indigenous trainees next year (more can be found on page 23). While there’s a long way to go, it’s clearly an issue that is front of mind for the college, and can only be positive for First Nations eyecare.

But ultimately the ophthalmology workforce remains constrained by the number of training posts in public hospitals, which sits at around 40.

While at the congress, it was heartening to hear RANZCO’s proactive work in this space. With its new Vision 2030 plan, the college knows if it doesn’t look out for ophthalmology’s interests, then no one will. And no one will be there to advocate against key issues like funding for public ophthalmology training and services in Australia.

MYLES HUME Editor

INSIGHT December 2023

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UPFRONT Just as Insight went to print, the ACT CIVIL AND ADMINISTRATIVE TRIBUNAL has banned a doctor for 12 months after a landmark ruling over discriminatory and offensive behaviour towards Australia's sole Indigenous ophthalmologist A/Prof Kris Rallah-Baker, a Yuggera, Warangoo and Wiradjuri man. The Medical Board of Australia referred the now-retired ACT doctor to the tribunal over an offensive email sent to Rallah-Baker,

WEIRD When recovering from acute vision loss after an accident, eyesight rehabilitation involves individually training various parts of the visual field, but German researchers believe they have “cracked the code” to rehab larger portions of vision more efficiently. In contrast to traditional methods, study participants explored visual stimuli through movement of their eyes. As a result, their perceptual capacities not only improved in the target area, but to other untrained sections of their visual field.

which included "insulting and culturally unsafe comments". IN OTHER NEWS, the Optical Distributors and Manufacturers Association (ODMA) is disappointed a Free Trade Agreement with the EU has broken down. After a 5% tariff was unexpectedly imposed on eyewear imports in 2022/23, suppliers were pinning their hopes on the deal.

“ODMA’s immediate action is to again write to border force, explaining what a ridiculous situation this is, and we will copy in the Home Affairs Minister and the Shadow Affairs Ministers in

the hope they will be interested and take any positive actions to resolve the matter,” CEO Ms Amanda Trotman said.

FINALLY, the Centre for Eye Research Australia (CERA) and the World Health Organization (WHO) have developed an app to increase access to vision tests.

Launched by WHO director-general Dr Tedros Adhanom Ghebreyesus, WHOEyes allows anybody with a smartphone to test their vision and learn about protecting their eyes. It’s hoped the app will improve outcomes for people in rural and remote communities.

QUOTE

WACKY Smart glasses that use a technique similar to a bat’s echolocation could help blind and low-vision people navigate their surroundings. The technology that translates visual information into distinct sound icons has been developed by a Sydney research team. “Acoustic touch technology sonifies objects, creating unique sound representations as they enter the device’s field of view. For example, the sound of rustling leaves might signify a plant, or a buzzing sound might represent a mobile phone,” Professor Chin-Teng Lin, from UTS, said.

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WONDERFUL Vision Australia has released the final instalment of its Big Visions series, Dressed for Success, which follows the story of Ms Nikki Hind, Australia’s first blind fashion designer. Based on the lives of remarkable Australians living with blindness or low vision, each book in the series aims to alter people’s expectations of what a person with disability is capable of, while also creating inspiring role models for children of all abilities.

insightnews.com.au

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CHANGE FROM WITHIN “After 10 years of trying to reform the system, I realised we had to completely transform it. And what better way to do that than leading by example,” – Mr Shaun Tatipata on establishing Australia’s first Aboriginal-owned eyecare and optical provider. Page 29

WHAT'S ON

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The Asia-Pacific Vitreo-Retina Society conference in Hong Kong is a platform for vitreo-retinal specialists to meet and keep abreast of the latest developments.

One of Germany’s leading events for optics and design, OPTI2024 is returning to the Munich Fairgrounds.

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INSIGHT December 2023

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NEWS

NO QUESTION OVER CO-MANAGEMENT POTENTIAL continued from page 3

to embrace enhancements to their scope-ofpractice and an ability to develop innovative models of collaborative care to address unmet eye health needs.”

One of the challenges for optometrists and professional organisations like OA is the ability to scale successful collaborative care initiatives in the mainstream health system, OA said.

The organisation believed it was vital the review recommends meaningful changes that would benefit patient outcomes and the overall productivity of the health system long term.

To do this effectively, OA is encouraging the review to focus on addressing “structural and systemic impediments”.

These include incompatibilities between the federal and state/territory health systems (and between the public and private systems) regarding funding and remuneration, regulatory requirements, clinical and organisational obligations, and the handling of patient data.

OA also highlighted discrepancies in the ability of various health professions to access MBS items despite performing the same clinical tasks; traditional patient gatekeeper arrangements and referral pathways that engrain treatment siloes and prevent timely care; disincentives to use the most cost-effective and accessible care options; and a lack of incentives to encourage health professionals to maximise available technologies to enhance access and enable multidisciplinary care.

Drawing on the optometry experience, Cappuccio said OA believed there would be value in undertaking a detailed comparison of the current scope-of-practice of individual health professions in Australia with similar

overseas health systems, identifying possible scope enhancements that could benefit patients and the overall productivity of Australia’s health system.

Examples of optometry scope-of-practice enhancement •O ral therapeutic prescribing – In New Zealand, therapeutically-endorsed optometrists can prescribe oral medications for eye conditions such as bacterial and viral infections, inflammatory conditions, and ocular allergies.

In terms of lessons learned and areas of future opportunity, the review will consider innovative practices in rural and remote contexts.

“Optometry Australia strongly supports this element of the review,” OA stated. “In eye health, some of the most innovative approaches are in rural and remote locations, including the Pilbara in Western Australia, where optometrists and ophthalmologists have developed co-management models of care that are making a marked difference to the eye health of First Nations Peoples through a combination of practising to full scope and utilising digital technologies to enhance patient access and interprofessional collaboration.”

• I ntravitreal Injections – in the UK, US and New Zealand, non-ophthalmologists are playing an enhanced role with intravitreal injection access. OA believes there is a ready opportunity for optometrist to be more effectively utilised in treatment planning and implementation.

Examples of optometry’s involvement in collaborative care • Centre for Eye Health – Intermediate tier care model in NSW; and glaucoma management clinic as a branch of the Prince of Wales Hospital.

OPHTHALMOLOGY POSITION In response to OA’s submission, ASO president Dr Peter Sumich said the organisation always welcomed optometry co-management and assistance with disease screening. However, he said the ASO, RANZCO and Australian Medical Association remained “implacably opposed” to optometry scope increases that involve surgical entry into eyes such as intravitreal injections.

“In the US, the State Governor Gavin Newsome, of California, banned optometrists from performing this invasive procedure. In other US states, despite there being greater laxity in safety regulations, it remains almost unheard of for optometrist injections to occur due to severe medicolegal risks,” he said.

“Despite the routine success of intravitreal injections, even in expert hands we see things go wrong sometimes. When it happens, it happens fast and severely and is challenging even for

• Queensland Children’s Hospital Paediatric Optometry Alignment Program – enabling participating optometrists to examine and treat children’s eyes more confidently.

• Lions Outback Vision in remote Western Australia – providing teleophthalmology services to rural and remote communities since 2011 that connect patients in real time with optometrists and ophthalmologists.

Source: Optometry Australia submission to Unleashing the Potential of our Health Workforce independent review

ophthalmic surgeons. It’s a numbers game – do enough and it will happen. It’s not an if, but a when. In those circumstances it would not be advisable to be without ophthalmic surgical expertise to recognise the issue, solve it and appear medicolegally sound.”

NEW MINIMUM REQUIREMENTS FOR ENGLISH TEST continued from page 3

early on in the consultation was to remove South Africa from the list of English-speaking “recognised countries”. This classification typically offers a smoother path to registration if practitioners have completed their education and qualifications there. This is because of inconsistencies in English language standards across health professions in South Africa, with some substantially below the equivalent Australian entry requirement.

Ahpra also considered making Hong Kong, Malaysia or Singapore recognised countries, but could not find sufficient evidence to do so. If South Africa is removed, the remaining recognised countries would be Australia,

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INSIGHT December 2023

Canada, New Zealand, the Republic of Ireland, UK and US. But the Kruk report noted that often practitioners from countries with similar regulatory systems to Australia must sit exams or undertake further training to qualify, adding costs and delays. Many are also subject to long periods of supervision despite having extensive clinical experience.

Now, Ahpra and National Boards are considering expanding the list of recognised countries after a review indicated opportunities to expand the recognised country list to better align with UK and NZ. There are 24 countries on the proposed list, many of which are Commonwealth countries

or self-governing British Crown dependencies such as Jamacia, Barbados, Guernsey, Isle of Man, Jamaica and Malta.

English language proficiency is vital to practise in Australia.

In another move focused on English language proficiency, the regulator is also considering setting the minimum requirements for the writing component of an English language test from seven to 6.5 IELTS equivalent and seven in each of the other three components (reading, speaking and listening) with an overall score requirements of seven.

According to Kruk, this change could improve the success rate from 26% to 40% of test takers, saving candidates time, costs and the need to sit multiple tests. It could also led to an additional 2,750 health practitionerd registered over five years.

OPTOMETRIST WAREHOUSE OPENS FIRST NSW STORE

IN BRIEF GLAUCOMA REBRAND Glaucoma Australia has revealed the new name of its patient support program. SiGHTWiSE, the new brand identity, signals a brighter future for people diagnosed with glaucoma and their families, the organisation says.

“SiGHTWiSE really is the perfect articulation for our program. We aim to support glaucoma patients throughout their treatment journey by arming them with the knowledge to confidently face a future living with glaucoma. With wisdom comes confidence and confidence is the foundation of success,” Glaucoma Australia CEO Mr Richard Wylie said.

Through one-on-one emotional and practical support delivered by qualified orthoptist educators and health counsellors, SiGHTWiSE helps patients manage the anxiety of receiving a glaucoma diagnosis and supports them with their ongoing challenges.

Optometrist Warehouse has opened in Campbelltown.

OCT HONOURED The trio who invented the OCT imaging technique have been awarded America’s highest technological honour by president Mr Joe Biden. In a ceremony in the White House on 24 October, Dr James Fujimoto and Dr Eric Swanson, of Massachusetts Institute of Technology (MIT), and Dr David Huang, of Oregon Health and Science University (OHSU), were presented with the National Medal of Technology and Innovation by President Biden. They were among 12 recipients.

Since its inception in 1991, OCT has revolutionised ophthalmic care and disease management. Huang, Fujimoto and Swanson developed the technology in the early 1990s when Huang was an MD/PhD student in Fujimoto’s MIT lab.

The store is the second to open in Australia, accompanying the Optometrist Warehouse that opened on Glenferrie Road in the Melbourne suburb of Malvern in February 2023 to much fanfare.

The Marketfair store opened on 5 October 2023 with a three-day grand opening affair cutting across Optometrist Warehouse, Chemist Warehouse and Ultra Beauty.

Spanning 2000 sqm, joint managing director Mr Charles Hornor said the “three pillars” format ensured a broad health and wellness customer experience.

“The format directly connects the optometry team with its pharmacy peers to zero in on conditions where direct collaboration can make an immediate difference,” he said.

EDUCATION PRECINCT The Royal Victorian Eye and Ear Hospital (Eye and Ear) has unveiled a state-of-the-art education precinct as part of its latest redevelopment. The facilities include a surgical skills lab, which is equipped with nine cutting-edge microscopes, as well as a simulation centre featuring a Virtual Simulation Room, which trains medical staff in surgical techniques using simulators, and the Clinical Simulation Room, designed for delivering practical and theoretical skills training. However, the flagship of its education precinct is the Martin Family Auditorium that has capacity for large lectures with 128 seats and additional break-out spaces. The Ronald Lowe Library, established in 1954, remains in place, housing the largest collection of ophthalmology and otolaryngology resources in Australia.

New Chemist Warehouse-backed optometry venture Optometrist Warehouse has opened its first NSW store. Located in the Marketfair Campbelltown shopping centre, the practice is situated in a “diabetes hot spot”, fitting with the network’s aim to eliminate blindness associated with the disease.

“For example, with diabetes, the pharmacy team has embraced reminding people with diabetes prescriptions of the need for a regular

diabetes eye check and – if they choose to visit Optometrist Warehouse – they can do so while waiting to have their script filled.”

Hornor said that the Marketfair Optometrist Warehouse optimises patient outcomes through its holistic care model.

“Sharing case reports directly with the pharmacists, our optometrists are already demonstrating the impact that this sort of intervention is delivering, with significant sight-saving disease detection and referral to local ophthalmology,” he said.

“This creates an enhanced patient experience, especially for those whose conditions may have been missed or undetected, as well as a broader involvement in holistic care for the pharmacist and optometrists involved."

Hornor addeed: “As a diabetes hot-spot, Campbelltown was a targeted choice for Sydney’s first Optometrist Warehouse.

While our business purpose is to connect optometrists with pharmacists and other health professionals to deliver better health outcomes, our core mission is to work together to eliminate diabetes as the leading cause of avoidable blindness in each community we serve."

GEORGE & MATILDA STRENGTHENS VICTORIAN PRESENCE George & Matilda (G&M) Eyecare has expanded its network in more than 100 communities with Joyce Optometrists, in the Melbourne suburb of Balwyn, becoming its latest partnership.

The Joyce Optometrists team.

Ms Sue and Mr John Joyce have operated the practice for 43 years and are well known for their comprehensive vision care and quality eyewear. Sue has been practising optometry for more than 50 years, following in the footsteps of her optometrist grandfather.

According to a statement, the Joyce Optometrists practice has served the local community for more than 80 years and is respected for delivering high quality clinical and optical outcomes for patients. The business prioritises a collaborative team approach, aligning with G&M’s own values.

Sue said partnering with G&M was a good fit for the practice.

“Joining G&M allows our team, Monica, Diana, Leah, Catherine and Senuri, to stay together and our patients to experience

business as usual in terms of independent care,” she said.

“At the same time, we can now enjoy all the benefits of being part of a larger, all-Australian entity that provides strong support across multiple functions, including access to wonderful new eyewear ranges.”

G&M said the partnership formed part of its broader expansion plans, but also underscored its dedication to bringing together like-minded professionals who share a vision of raising eyecare standards across Australia.

G&M has a pipeline of potential partnerships and anticipates more announcements soon.

“George & Matilda Eyecare continues to be at the forefront of providing exceptional eyecare services to over 100 communities across Australia. This expansion further cements our position as a leading eyecare provider, dedicated to delivering the highest level of service and care for our patients,” the company said.

INSIGHT December 2023

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NEWS

SPECSAVERS UNVEILS 2023 DOUG AND MARY PERKINS MEDAL WINNERS

NEW MDFA-TERRYWHITE PARTNERSHIP FOR EARLY DETECTION OF AMD Macular Disease Foundation Australia (MDFA) has teamed up with pharmacy chain TerryWhite Chemmart to raise awareness Around 25% of macular about the importance disease remains of monitoring changes undiagnosed in Australia. in vision for early detection of macular disease.

Specsavers has announced the recipients of the Doug Perkins Medal and Dame Mary Perkins Awards for 2023 at the annual Specsavers Clinical Conference (SCC) in Sydney in October.

The Doug Perkins Medal for Clinical Excellence, introduced in 2018, is awarded to the respective Australian and New Zealand store that consistently upholds the highest standards of clinical excellence.

Meanwhile, the Dame Mary Perkins Award for Outstanding Patient care, introduced in 2021, is awarded to one Australian and one New Zealand recipient who has demonstrated exceptional commitment to patient care in the last 12 months.

Despite the high prevalence of macular disease in Australia, 25% of cases remain undiagnosed. To address this issue, MDFA and TerryWhite Chemmart are providing people over the age of 50 with a fast and easy way to understand and assess their risk factors for macular disease.

This year’s Doug Perkins Medal winners were Specsavers Beaudesert and Specsavers Masterton on New Zealand’s North Island.

“Our partnership with Macular Disease Foundation Australia has helped us to start conversations with patients and get these important tools into their hands,” Mr Brenton Hart, chief pharmacist at TerryWhite Chemmart, said.

“To select the finalists and winners, we analyse nationwide data collected through our clinical reporting, combining this information with patient feedback and health outcome data,” Specsavers head of clinical performance Mr Nick Gidas said.

“We look to raise awareness of these tools including the Check My Macula online quiz. In less than one minute, a TerryWhite Chemmart customer can learn about their risk of developing age-related macular degeneration and diabetic eye disease and then promptly schedule an eye test with their local optometrist.”

“We are delighted to crown Specsavers Beaudesert and Specsavers Masterton with this year’s award in recognition of their exceptional commitment to clinical care throughout the year.”

The Dame Mary Perkins Awards for Outstanding Patient were judged by industry professionals, Ms Skye Cappuccio, CEO of Optometry Australia,

In addition to the risk assessment quiz, MDFA has provided the TerryWhite Chemmart pharmacy network with Amsler grids, which patients can collect for free at their local pharmacy. The grid is an essential home monitoring tool for people over 50 years of age to spot changes in their vision between eye exams.

Patients are encouraged to place the Amsler grid on their fridge and check their vision at home on a weekly basis. If any changes are noticed, the organisations recommend booking an appointment with a local eye health professional immediately.

Pharmacists also have a valuable role to play in early detection and reducing the impact of macular disease in the community. This is fundamental to the collaboration between TerryWhite Chemmart and MDFA, added Dr Kathy Chapman, CEO of MDFA.

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With the Doug Perkins Medal, Specsavers director of clinical services Dr Ben Ashby (from left), Specsavers Beaudesert optometrist partner Millicent Healy, Specsavers Masterton optometrist partner Helen Haslett and Nick Gidas, head of clinical performance.

With the Dame Mary Perkins Award, director of clinical services Dr Ben Ashby (from left), Specsavers Salamander Bay’s Laura Hou, Specsavers Hornby optometry partner Lachlan Martin (accepting on behalf of Alice Jackson), and Cindy Nguyen, head of professional services.

Ms Carly Iles, CEO of Vision 2020 Australia, and Mr John Mulka, the co-chair of Eye Health Aotearoa.

This year’s recipients were Ms Laura Hou from Specsavers Salamander Bay and Ms Alice Jackson from Specsavers Hornby.

OPTIMED LAUNCHES NEW EDUCATION PLATFORM Ophthalmic equipment distributor OptiMed has launched its own education portal, kicking off with a series of OCT interpretational videos by UK optometrist Mr Jason Higginbotham.

The portal will feature local key opinion leader optometrists.

In the videos, Higginbotham talks through a series of scans acquired using the Optopol REVO OCT and provides insights on how to interpret results of various pathological diseases.

He also provides helpful tips about using the software. The site contains a series of short tutorial videos on how to perform basic and manual REVO OCT scans.

the company is offering to customers who have purchased REVO OCTs and Canon OCT from the company.

OptiMed will be working with local key opinion leader (KOL) optometrists to further develop content too.

It also plans to include some tutorials on Optopol visual fields and the Thermaeye Plus IPL to assist clinicians who have purchased this equipment to get the best from their investment, and will launch CPD learning material in the near future.

The site is free to register but limited to ANZ customers only and requires The OptiMed education portal is a service validation prior to gaining access.

INSIGHT December 2023

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COMPANY

HP-OCT INTEGRATES WITH NEW MYOPIA RISK INDICATOR SOFTWARE

APELLIS ISSUES SAFETY UPDATE AMID RARE RETINAL VASCULITIS REPORTS

Australian hyperparallel OCT (HP-OCT) manufacturer Cylite has entered an agreement to integrate the recently launched PreMO myopia app into its software.

An investigation into rare events of retinal vasculitis linked to Apellis Pharmaceutical’s new therapy, SYFOVRE, The company also for geographic atrophy welcomed positive (GA) has identified 24-month data. “internal structural variations” in a 19-gauge filter needle used to withdraw treatment from the vial.

The company has since asked practitioners to immediately stop using injection kits that contain the 19-gauge filter needle and only use those with an 18-gauge filter needle.

Apellis created history early in 2023 with SYFOVRE when it became the first and only FDA-approved treatment for GA secondary to age-related macular degeneration (AMD).

Also referred to as pegcetacoplan, the therapy is not yet approved in Australia.

In the latest update on 5 October 2023, Apellis said in total, there have been 10 confirmed cases of retinal vasculitis (seven occlusive, three non-occlusive) and two suspected cases. Of the confirmed cases, six have recovered vision either fully or partially, three have severe vision impairment that is unlikely to be resolved, and one outcome was pending. Visual outcomes in both suspected cases were pending.

In the OAKS trial at 24 moths, SYFOVRE administered monthly and everyother-month slowed GA lesion growth by 22% and 18%, respectively, compared with sham.

At 24 months in the DERBY study, SYFOVRE administered monthly and every-other-month slowed GA lesion growth by 19% and 16%, respectively, compared with sham.

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INSIGHT December 2023

The app uses spherical equivalent refraction, axial length and parental myopia status to stratify future risk of myopia and can be used by clinicians in combination with their professional judgement to select evidence-based management options.

technology, each axial length measurement is based upon information from hundreds of individual beamlets which can be used to track axial length growth in children over time.”

“This is a welcome addition to the HP-OCT software and makes full use of the fact that the device measures axial length with such precision,” Cylite said.

“Given its utilisation of hyperparallel OCT

According to Cylite, the PreMO software performance, based on the refractive progression of children in Northern Ireland monitored over nine years, has been verified with independent prospective data taken from an ethnically-diverse sample of children in Birmingham, UK, and an East Asian sample of children in Hong Kong.

“We are very excited about adding the PreMO software to the HP-OCT and expect that it will add another important application to its already long list,” the company said.

Cylite expects PreMO to be integrated with HP-OCT software sometime in 2024.

POSITIVE DATA FOR PAEDIATRIC MYOPIA CONTROL CONTACT LENS

The company reported the GALE study – (n=792) is a Phase 3 extension study to evaluate te long-term efficacy and safety – at 30 months showed the safety profile of SYFOVRE continued to be consistent with previously reported Phase 3 data.

Meanwhile, the company welcomed “positive” 24-month data published in The Lancet, demonstrating “that SYFOVRE is a clinically meaningful treatment” for GA.

The PreMO myopia app uses several measures to stratify future risk of myopia.

According to Cylite, PreMO presents axial length for individual patients (including any input past data) against predictive growth curves, as well as predicting at what age they will become myopic and how fast they will progress. This informs discussions on the need for treatment and once treated, its effectiveness, even though the eye continues to grow. And finally, the information can be sent to a patient via email.

The safety of SYFOVRE has been in the spotlight after reports of retinal vasculitis reported in real-world treatment.

“The estimated real-world rate of retinal vasculitis remains rare, at 0.01% per injection,” Apellis stated.

Developed by Professor James Wolffsohn and colleagues at Aston and Ulster Universities, PreMO (predicting myopia onset and progression) is described as an evidence-based myopia risk indicator software.

The lenses showed a treatment effect of 59% for axial length.

Visioneering Technologies Inc (VTI) has announced positive interim one-year data from the PROTECT clinical trial of its paediatric myopia progression control contact lenses.

The results, announced at the American Academy of Optometry Annual Meeting in October 2023, confirm the safety and efficacy of its NaturalVue Multifocal 1 Day contact lenses, the company announced.

According to VTI, which is listed on the ASX, the lenses have demonstrated the highest scientific standards for myopia management in children with a treatment effect of 69% for refractive error and 59% for axial length versus control group.

The multi-centre, randomised, double-masked clinical trial has

participating investigators in Canada, the US, Hong Kong, and Singapore.

Dubbed PROTECT, it is a three-year study with interim analyses planned after the one-year and two-year subject follow-ups.

One-year data from studies of similar design to PROTECT have been predictive of the three-year results.

“This data release signals the beginning of a new chapter for VTI as we secure our place on the global map as a positive intervention option in myopia management.

The new interim results are outstanding and may support imminent partnering opportunities and commercial growth in key markets throughout Asia and Europe,” VTI CEO and executive director Dr Juan Carlos Aragón, said.

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OPTOMETRY

SMOOTH

succession

Ken Ingram became a buy-in partner at G&M for Greg Bowyer Optical in Brisbane in 2021.

With many original partner optometrists moving on to a well-earned retirement, George & Matilda Eyecare is overseeing succession to a new generation of buy-in partners across its network.

W

hen Mr Ken Ingram owned pure-play independent optometry practices, he had a lot on this plate. After a long day seeing patients, there were times he’d need to stay back until 8pm for administrative tasks – and then came the arrival of his son with a disability.

You would be forgiven for thinking something had to give, but after doing his research, Ingram came across the George & Matilda (G&M) Eyecare model and realised he could have the best of both worlds – time with his family and the self-actualisation of running a practice he had equity in.

“Although I was initially attracted to the practice itself – George & Matilda Eyecare for Greg Bowyer Optical – due to its heritage and boutique, high-end positioning, in general I thought G&M was a good option because I could see they were acquiring really solid practices run by great practitioners,” he says.

“I did a fair bit of due diligence, in fact, I worked as an optometrist in the network for three years before becoming a buy-in partner. The investment was reasonably modest, nothing like establishing a new practice, and the model is set up in a way so that I have skin in the game to keep me interested and sharp, while also providing that support structure around you. Given my circumstances, it suited me nicely.”

Ingram is among the next generation of optometrist partners emerging through G&M. Since its foundation in 2016, the network has acquired several practices with owner optometrists in the twilight of their careers.

Many of these practices are part of the fabric of their community, so finding suitable, long-term successors has been a priority in recent years.

Ingram – who in 2021 took the reins of G&M for Greg Bowyer Optical in the Brisbane suburb of Kenmore – is one of those who have taken on partnership of a practice after the original partner has retired or left the business, which G&M refers to as buy-in partners.

The benefits of becoming a buy-in partner are similar those enjoyed by original partners, including clinical autonomy, back office support for business functions like recruitment, marketing and payroll, as well as flexible models that ensure the buy-in partner has a vested interest in the practice’s commercial success.

Prior to joining G&M, Ingram had a varied career, spanning from independent ownership, to drawing a salary as a corporate optometrist.

“Private practice ownership became challenging for me in terms of time and flexibility plus, like a lot of people, I had to mortgage the family home to finance it. So for a couple of reasons, I sold my two practices in the early 2000s,” he says.

“When I went into corporate practice, it had some advantages. It had that collegiate feel, as opposed to the more isolated feel of independent optometry. On the flip side, I tended to get frustrated with some of the constraints put on professional practices, which is only natural when you come from private practice.”

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OPTOMETRY

and comfortable dialogue with patients by blending humour into my examinations and building meaningful bonds, and G&M allows me to do that.”

G&M for Optique has a rich history spanning over 25 years. Nestled between Edgecliff and Rose Bay, it is located in an affluent hot property suburb. The last major owner was Ms Sue Green who left the business two years ago, with the practice overseen in a caretaking capacity by local optometrist Ms Eva Freeman and practice manager Ms Lynne Abrahamson.

Now under Mrocki’s remit, he is excited to lead the practice in his own way.

“I’ve always been a hands on individual and professional. My unofficial mantra is if you want something done correctly, you most likely have to do it yourself – and I’ve seen firsthand the advantages of running your own business and creating something you can be proud of,” he says.

“I’ve also seen the shortcomings of having no one else to rely on so it’s quite the dichotomy, but the G&M partnership model is advantageous, with a blend of freedom, guidance and support structures to help an eager, ambitious, young optometrist like myself to find their entrepreneurial feet.”

Mrocki says the transition would not have been possible without the support of G&M’s head office. Beer and Bradford have always been just a phone call away, and whether it’s the merchandising or IT department, his feedback has been welcomed with open ears.

Double Bay buy-in partner and optometrist Marshall Mrocki.

Although G&M’s practices aren’t independent in the strictest sense, he says G&M for Greg Bowyer Optical operated like one – and still does in many ways, controlling its own frames range and, importantly, allowing Ingram to stamp his mark on the way he executes his clinical skills.

This has seen him diversify the eyewear offering that was predominantly boutique and high end in the past, but was calling out for options to cater for longstanding patients who had become more budget conscious in their older age. With an interest in orthokeratology, myopia control and rigid lenses for keratoconus, he’s also added a specialty contact lens service.

“Becoming a buy-in partner means I’m invested in my own success and treat it as my own practice,” he says.

“For me and my family, there’s far less risk financially, I can sleep better at night because there’s not so much on the line. Because I know I’ve got good people around me who will look after things, I don’t have to stay back till 8pm each night doing the books, ordering stock or payroll. It gives me my time, gives me my family back – while still having skin in the game.”

‘THROW ME IN THE DEEP END, I CAN HANDLE IT’ At the time Mr Marshall Mrocki spoke with Insight about becoming a buy-in partner at George & Matilda Eyecare for Optique, in Double Bay, a ritzy harbourside suburb in Sydney, he had only been in the role five weeks. But it had been some time in the making, after several proposals to G&M head office to express his interest in partnership.

“When I found out Double Bay was available, I leapt at the opportunity, and didn’t stop nagging CEO Chris Beer and COO Matt Bradford – I told them to throw me in the deep end, I can handle it,” the 33-year-old says.

Indeed, it’s a steep learning curve, especially when you consider he graduated from The University of Melbourne in 2021. But when you speak with Mrocki, one can tell he is a capable operator. He’s also been primed by recent experience as the principal optometrist at G&M’s George St location, one of the network’s flagship practices in Sydney’s CBD. “I was working for an optical retailer on the NSW Central Coast in 2022 when I originally received a message from G&M. They told me what they were about – basically a network of independents supporting each other,” he says.

“I was yearning at the time for greater freedom to establish relationships with patients and autonomy to apply a patient-first principle way of practising. For me, it’s really important to establish a pleasurable

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Abrahamson, who has long been with G&M, has familiarised Mrocki with the practice’s processes. Some have been refined already, such as a new shared cloud with local ophthalmologists to improve the flow of diagnostic images, without the need for Mrocki’s involvement.

“In other areas, we’re working to streamline the products that we’re offering to make it laser focused on what the people are asking for, with boutique brand appeal,” he adds.

“All in all, the message I have for younger optometrists wanting to dip their toes into partnership or seeking more control over their optometry activities is to look at what G&M are offering because from my experience, it’s an ideal blend of support alongside day-to-day operational freedom that I haven’t seen at other larger groups.

“The deal that was offered to me aligned well with my career objectives … now that I am a partner, it’s lighting a fire under me to ensure G&M for Optique in Double Bay remains the best place for eyecare and eyewear fashion.”

A 10-MINUTE COMMUTE It’s fair to say nothing can fully prepare an optometrist for their first foray into practice partnership, but the experiences Ms Antigone Kordas had during her first five years out of university had her well-equipped for the demands of becoming a buy-in partner.

Her first job as a fully-fledged optometrist was at George & Matilda (G&M) Eyecare for Maroubra Optometrists in Sydney – under the guidance of optometrist partner Mr Kyriacos (Kyri) Mavrolefteros. She was swiftly elevated to the role of principal optometrist and saw the bulk of the patients, while helping coordinate an outback eyecare program and supervising final-year Deakin and UNSW optometry students, among other roles. It was a significant responsibility.

“I DON’T FEEL ANY PRESSURE TO DO THINGS IN A PARTICULAR WAY, I JUST HAVE TO DO THE BEST BY MY PATIENT, AND MY HOPE IS THAT BY TAKING THIS APPROACH WE WILL NATURALLY GROW THE BUSINESS.” ANTIGONE KORDAS G&M FOR OPTOMETRIST MENAI

So when a partnership opportunity emerged at George & Matilda Eyecare for Optometrist Menai, a G&M area eyecare manager put Kordas’ name forward. The stars aligned and wheels were set in motion for her to become the new buy-in partner on 31 July 2023. What’s more, the practice is only a 10-minute drive from her house, a major drawcard for Kordas who used to commute more than an hour daily.

“Practice ownership or partnership was always something I had thought about but I didn’t know quite how quickly that would eventuate,” she says.

“Working at G&M Maroubra provided great exposure for me in terms of my responsibilities and the way practice was run. I first started working there as an assistant when it was independently owned by Kyri, and then when I first became an optometrist that was when G&M entered the picture. Even so, it was still very much run like an independent practice.”

Now Kordas is a buy-in partner, this is what she appreciates most about the business model – the benefits of clinical autonomy and leading the practice in her own way, without feeling like she’s doing it on her own.

G&M was even able to work around her wedding and honeymoon plans before bringing her on as a partner.

She’s also been able to adapt her schedule to align one of her days off with her husband’s (a paediatrician) off-day.

“Now that I’m here, all I need to do is focus on my patients while G&M takes care of the rest whether that be advertising, recalls, the building etc. It means I can focus on recommending the best options for my patients and I

Optometrist and buy-in partner Antigone Kordas (centre) with her new team at new G&M for Optometrist Menai, Sydney.

think people can see that too,” she says.

“I don’t feel any pressure to do things in a particular way, I just have to do the best by my patient, and my hope is that by taking this approach we will naturally grow the business side of things. I’m not hugely KPI-focused; if people are happy, it’ll grow and it’s already started to show.”

Quantify brain waves associated with human sensitivity to provide effective visual clarity and comfort

LENSES

Rodenstock

Jen Forrest, customer service, and Andy Poole, lab manager, fulfilling orders in Rodenstock’s new Melbourne lens edging and fitting lab.

BACKS AUSTRALIAN INDEPENDENTS By opening new lens fitting labs in Victoria and Queensland in 2023, Rodenstock isn't only making a substantial investment in itself, but in independent optometry too.

I

n recent years, Rodenstock found itself at an important juncture in its Australian operations. As an increasing number of independent optical practices were opening accounts with the German lens manufacturer, it was becoming increasingly important to sustain its level of service as far as lens orders were concerned.

“Rodenstock has amazing products, but working with Rodenstock in the past wasn’t always the easiest,” Rodenstock Australia general manager Mr Tim McCann says.

“People love the product, so they have been willing to persevere, but this wasn’t ideal. We wanted to serve the independent market to the best of our ability, which meant re-examining our supply lines and changing them to improve the accessibility to our products.”

Rodenstock HQ in Munich, Germany, agreed, and has made a significant investment so Rodenstock Australia could establish new lens fitting labs in Brisbane and Melbourne. The project has also seen several experienced optical industry figures join the business, with former CR Surfacing commercial director Mr Sasha Sergejew appointed to assist with the rollout.

Previously, Rodenstock’s only Australian fitting lab was in Sydney, so McCann says independent practice customers in Queensland and Victoria can soon expect faster turnaround times. Customers can also call on the expertise of their local labs for troubleshooting and general inquiries, allowing for a more personalised service.

“The other major change we have implemented is moving the production and surfacing from Europe to Bangkok. Once the lenses are produced, it means we can bring them much faster into Australia on an overnight flight.

Customs is also easier to clear in Thailand, so we have a lot more consistency of supply into Australia,” McCann says.

“Establishing new fitting labs in Brisbane and Melbourne is about being closer to the customer. We didn’t want to become a large, impersonal lab. So, on the one hand we’re bringing the manufacturing closer to Australia – with all the benefits of a large international company in terms of consistency, quality of product and the benefits of scale – alongside a more localised fitting service.

For many customers, it also means they will no longer be shipping frames long

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distances across the country, ultimately leading to faster turnaround times.”

Rodenstock’s lens lab expansion is against industry norms, in a time when many lens makers are consolidating and centralising their fitting services. But McCann says the approach makes sense when you consider the handcraft involved, and the fact that high quality product and services are the hallmarks of successful independent practices in Australia.

SETTING UP THE LABS Rodenstock’s new Brisbane lab came at an opportune time. The owners of independent lens fitting firm C&S Optical – which provided a service for some of the major lens manufacturers – were seeking a partnership, so Rodenstock Australia acquired the business and its experienced employees. Originally located in the inner northern suburb of Windsor, Rodenstock has moved the lab to Banyo.

“Our Brisbane lab is close to the airport, which is great for bringing lenses into Brisbane and also dispatching to regional Queensland,” McCann adds.

The Melbourne lab was a greenfield project, set up in the south-eastern suburb of Mount Waverley. It is centrally located within a spread of Rodenstock customers and close to the Monash Freeway for easy courier access via National Optical Distribution who can drop into the site for delivery and pick up as many as three times a day.

The Melbourne lab is equipped with an edging machine manufactured by Italian company MEI – considered a global leader in this space.

“But our machines are just tools at the end of the day. We need to have the right people and I’m very happy with the calibre of staff we have in our labs. All

“ESTABLISHING NEW FITTING LABS IN BRISBANE AND MELBOURNE IS ABOUT BEING CLOSER TO THE CUSTOMER. WE DIDN’T WANT TO BECOME A LARGE, IMPERSONAL LAB.” TIM McCANN RODENSTOCK AUSTRALIA

Rodenstock has invested in an edging machine manufactured

by Italian company MEI – a global leader in this space.

of our staff are trained dispensers and mechanics, and if they’re not, we are putting them through the Certificate IV in Optical Dispensing,” McCann says.

“Effectively every single job that comes into the lab is bespoke. There is a very clear science when it comes to manufacturing the lenses but when fitting them into frames, it’s more of an artform, understanding how the job is going to finish before you start to ensure you get the best possible outcome. And we need people who are skilled in this area.”

A LENS LAB TO LEAN ON One of the biggest gains to emerge from the growth of Rodenstock’s Australian lab network is the addition of Sergejew to the business, with his 42 years of optics industry experience. Roles at OPSM Laboratories, SOLA Optical and CR Surfacing are all listed on his CV. In particular, during his 16 years at CR he spent time developing the business, before an opportunity came up with Rodenstock in the early part of 2023.

“I keep my ear pretty close to the ground about what’s going on in the Australian optical market and have good relationships with customers all over,” he says. “I could see the direction that Rodenstock was headed and I was impressed. The quality and technologies Rodenstock produces is out of this world and, for a lens nerd like me, to now be involved is exciting.”

Sergejew has history setting up labs in Australia and New Zealand, so he was the ideal candidate to assist in the planning, design and execution of the new Brisbane and Melbourne sites.

It didn’t take long before he got a glimpse into the way Rodnestock goes about its business in classic German fashion: strategic, methodical, and considered.

“It’s been very interesting working with HQ. They’ve got lens labs all over the world and understand the optimal floorspace for a certain number of jobs and the configuration required so they can run efficiently,” he says.

“I drew a mud map on an A4 page and next thing it comes back from the head engineers as a 3D diagram. I’ve learned some swear words in Rodenstock are ‘shortcut’, ‘give it a crack’ or ‘winging it’. They’re very strategic, everything gets planned and tested.”

Rodenstock’s lens manufacturing site in Thailand where lenses are now being produced for the Australian market.

“Independent practices are finding it increasingly difficult to find highly skilled dispensers, so the lens lab is someone you should lean on. We get to see many jobs every day and some of those that are outside the box might only be seen by a practice once a month. I’m really proud of the team we have got here.”

HERE TO STAY Looking at the big picture, the investment could be interpreted as a sign of the value Rodenstock HQ places on the Australian market. It’s expected more labs will follow in future, which can only bode well for independents operating in the premium space.

McCann says the Rodenstock brand is a powerhouse in Europe, and there’s no reason this couldn’t be replicated in Australia which is home to a comparable market.

Sergejew is excited about the value the new lens labs can deliver for Rodenstock customers. Each lab is employing people with around 100 years of collective experience.

“We have a premium product that’s suited perfectly to the independent market. The two aims we have for practices are, firstly, for their patients to be happier with a demonstratable difference in their Rodenstock lenses. And secondly, we support independent practices to become more profitable.

If we can do those two things, then we will have a strong position in the marketplace,” he says.

“In Melbourne we’ve got people like Andy Poole and Jen Forrest who have been on the phones to assist customers in Victoria for the last 10 years.

Andy in his last role, in particular, was handling ‘specials’, which are the more unconventional jobs. We have a philosophy that we don’t ring with a problem, we ring with a solution and that’s a luxury you can have only through years of experience,” he says.

“We know there’s an increase in consolidators and corporatisation, meaning there’s very little choice left for practices seeking premium lens manufacturing from an international supplier with an independent focus. We see an opportunity to do that and believe the market is there – and if we can meet our customers with timeframes, pricing and product quality, we can help set them apart, and all are winners.”

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CATARACT

Through a recent acquisition, Bausch + Lomb has added the IC-8 IOL to its portfolio, featuring small aperture intraocular technology that Australian ophthalmologists say is addressing unmet needs in various scenarios.

Small aper ture, BIG RESULTS

I

t’s one of the great paradoxes of modern-day ophthalmology. The fact cataract surgeons have access to an expanding suite of advanced intraocular lens (IOL) designs, one would expect their job has never been easier. Yet, there has never been greater demands on their technique and technical knowledge, partially driven by more patients seeking spectacle independence – regardless of their ocular physiology.

More sophisticated multifocal and extended depth of focus (EDOF) IOLs have made it possible to satisfy an increasing desire for presbyopia correction. But the ophthalmologist still needs to consider multiple variables and manage the patient’s expectations before the final IOL is selected.

For instance, cases of corneal irregularity may render some patients ineligible for certain traditional premium lenses featuring complex optics that split, shift or stretch light to achieve clear vision at more than one focal point.

Or on the other hand, myopic cataract patients may baulk at the thought of losing excellent unaided near vision they’ve enjoyed for most of their adult life, if offered with a monofocal IOL. The IC-8 IOL – adopting small aperture intraocular technology – is one lens working to address several unmet needs in eyecare, as several Australian ophthalmologists are attesting to. The IOL was originally developed and commercialised by AcuFocus but was acquired by Bausch + Lomb earlier in 2023.

The IC-8 IOL was first launched in the Australian market in 2015 for cataract patients seeking near, intermediate and distance vision with increased spectacle independence. And in July 2022, it became the first and only small aperture non-toric EDOF IOL of its kind approved in the US. It is recommended for unilateral implantation in the non-dominant eye with an aspheric monofocal or toric monofocal IOL in the dominant eye. All in all, it can provide over 2.00D of extended depth of focus, tolerate up to 1.00 D deviation from the target manifest refraction spherical equivalent, and accommodate as much as 1.50 D of corneal astigmatism.

Sydney ophthalmologist Associate Professor Chameen Samarawickrama – an expert in complex corneal disease – says the IC-8’s unique design has also garnered impressive results in several of his patients with irregular corneas such as keratoconus, pellucid marginal degeneration, corneal dystrophies, and those with a history of corneal trauma or herpetic eye disease”.

“This is because of its ability to address irregular astigmatism, making it the most optimal lens on the market currently that can do so”, he says.

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INSIGHT December 2023

“We know these patients can’t obtain good vision from glasses and the same happens with a standard IOL – they end up 6/7.5, 6/9 or worse and sometimes contact lenses are the only way to improve their vision [postoperatively].

“What the IC-8 does better than any other lens, is neutralises the irregular astigmatism component of their cornea through its pinhole technology. I’ve had patients who historically have never been better than 6/9 in glasses achieve 6/6 or 6/7.5, once implanted with the IC-8. Many remark they’ve never seen this well in their life. Those with more mild corneal disease can achieve remarkably good distance, intermediate and near vision too. The classic example is a mild keratoconus patient where it’s not uncommon to achieve 6/6 for distance, and N6, N7 or N8 for near unaided vision.”

Crucial to this, says Samarawickrama, is the embedded FilterRing Component in the IC-8 design, which blocks scattered, defocused and aberrated peripheral light, but allows the passage of paraxial, central light rays.

“But it also has an elongated interval of Sturm and, because of this, the lens is able to achieve greater depth of focus and range of vision as a result,” he says.

Samarawickrama says it’s also important to point out the IC-8 addresses regular astigmatism in his patients too. And in cases of residual regular astigmatism, he has implanted a piggyback cylindrical IOL in the sulcus to achieved 6/6 unaided vision when they have historically never been able to do so before.

He has audited his IC-8 cases in patients with irregular astigmatism, which

“WHAT THE IC-8 DOES BETTER THAN ANY OTHER LENS, IS NEUTRALISES THE IRREGULAR ASTIGMATISM COMPONENT OF THEIR CORNEA THROUGH ITS PINHOLE TECHNOLOGY.” A/PROF CHAMEEN SAMARAWICKRAMA SYDNEY OPHTHALMOLOGIST

LEFT: The IC-8 IOL adopts small aperture intraocular technology. ABOVE: Targeting -0.75 D in the non-dominant eye, the IC-8 IOL eye works to deliver monofocal-like distance, while improving intermediate through to near.1

he presented at the RANZCO Congress in Perth in October 2023. This was rounded off with a case report on a severe keratoconus patient with -6.00 D of astigmatism. The patient was contact lens dependent and only saw 6/18 in glasses, but was developing cataracts that dropped her vision further.

Ultimately, he implanted the IC-8 that – while being able to tolerate up to -1.50D of corneal astigmatism – managed to neutralise a surprising -4.00 D of cylinder in this patient.

“This was followed with a piggyback cylindrical lens in the sulcus leaving her 6/5 for distance and surprisingly N5 for near, all unaided,” he says.

For fellow ophthalmologists considering the IC-8 in their patients, Samarawickrama says it’s important to note the IOL only comes in spherical powers. With a pinhole design allowing less light to the retina, some patients may also report slight reduction in the visual field, and a longer time adapting from light to dark environments.

“But in patients with abnormal corneas, the improved visual acuity is so dramatic, that they don’t even notice any of the other symptoms,” he says.

Other surgeons have noted IC-8’s reputation as a forgiving lens, tolerating up to 1.00 D deviation from the target manifest refraction spherical equivalent.

“I would agree it’s a forgiving lens,” he says. “Instead of a pinpoint target, the calculations gives you a higher and a lower anticipated zone, providing a soft landing, which is very comforting as a surgeon,” Samarawickrama says. “For those starting out, the keratoconus patient is ideal because invariably there is more irregular astigmatism and spherical aberration present, and these patients will achieve improved quality of vision, which they will thank you for.”

OVERCOMING THE INTOLERANCES OF MYOPIC CATARACT PATIENTS Since the advent of presbyopia-correcting IOLs, Melbourne corneal and cataract surgeon Dr Alex Poon has made it a priority to discuss these with every patient.

“But I think it’s about targeting certain lenses for certain individuals,” he says.

When he first became aware of the IC-8 around five years ago, he saw its suitability in patients with irregular corneas. But he was also excited about its potential in myopic cataract patients. In his experience, this patient group didn’t always respond well to multifocal IOLs because of reduced contrast compared to their original vision.

In his experience, these patients also have high expectations, largely due to the fact many have good unaided near vision prior to needing cataract surgery.

“For example, a -3.00 D myope has a focal point of around 30cm, meaning

“IT’S QUITE EASY TO CONVINCE PATIENTS TO CONSIDER THIS IOL, BECAUSE IN THE CLINIC WE CAN ALL DEMONSTRATE TO PATIENTS HOW THEIR SHORT SIGHTEDNESS CAN BE CORRECTED WITH A PINHOLE.” DR ALEX POON MELBOURNE OPHTHALMOLOGIST they can read quite well. So if they have inferior near vision post cataract surgery with a monofocal IOL, they will often complain about why their vision is worse, if they weren’t warned about it.”

To understand this in greater detail, Poon conducted a retrospective study of 25 myopic cataract patients implanted with the IC-8, from his private clinic. This was published in the Hong Kong Journal of Ophthalmology.

All had myopia (≥-0.25 D) in both eyes and astigmatism (≤-2.50 D) in the non-dominant eye and were assessed after six months. Patients had a monofocal IOL targeting plano in the dominant eye and the IC-8 in the nondominant eye targeting -1.00D to -1.25D. Binocularly, 92% of patients achieved uncorrected distance of logMAR 0 or better, 64% recorded uncorrected intermediate vision of logMAR 0 or better, and 100% logMAR 0.20 (N5) or better for near vision.

Ultimately, he was able to show the IC-8 can extend the depth of focus and is a good option for patients with myopia who can tolerate monovision. It also provides good binocular uncorrected distance, intermediate, and near visual acuity when used in conjunction with a monofocal IOL in the dominant eye.

Poon did note that some patients may experience dysphotopsia symptoms, but the symptoms are not frequent, severe, or bothering.

For patients who might not be as tolerant of traditional monovison, he believes the IC-8 is advantageous because it provides depth of focus in the non-dominant eye, potentially decreasing the sensation of blur and improving stereopsis for distance, besides providing for unaided near vision.

“It’s quite easy to convince patients to consider this IOL, because in the clinic we can all demonstrate to patients how their short sightedness can be corrected with a pinhole. When you explain we can incorporate this principle into the IOL, the IC-8, it’s simple for them to understand,” he says.

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CATARACT

“But with all lenses it’s important to warn patients about any potential disadvantages.

Some things I mention is the potential for poorer vision in dim light (24% of patients in the study were dissatisfied with vision in dim light compared to 4% in bright light), and when driving at night they may experience some starbursts and halos. And, in my study, the laser capsulotomy rate was higher with this lens than a monofocal IOL (72% vs 48%).”

STRENGTHENING PORTFOLIO For B+L, the IC-8 is playing an important role in its premium IOL portfolio, which today also includes the LuxSmart, an IOL offering an extended range of vision launched earlier in 2022. The global premium cataract IOL market is projected to grow at a compounded annual growth rate of 13% between 2022 and 20272.

Both Poon and Samarawickrama are pleased to see a company of Bausch + Lomb’s size and reputation bring IC-8 into its sphere, potentially broadening its availability.

“With the addition of the IC-8 lens, Bausch + Lomb continues to expand its premium IOL portfolio offering,” said Ms Marion Bastier, head of global IOL strategy and international director of marketing at Bausch + Lomb Surgical.

REFERENCES: 1. Food and Drug Administration. (2002). IC-8 Apthera Intraocular Lens (IOL) - P210005: FDA Summary of Safety and Effectiveness Data. Accessed April 27, 2023. https://www.accessdata.fda.gov/cdrh_docs/ pdf21/P210005B.pdf.

2. Market Scope. 2022 IOL Market Report (April 2022).

Frame R7136 A

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EVENT

Dr Neil Miller, a global expert on neuroophthalmology, flew in from the US to deliver his presentation.

RANZCO RECAP

Highlights from the congress RANZCO has rounded off its jam-packed annual congress in Perth by inducting 46 new fellows, recognising Australia’s top performing eye doctors and outlining its workforce blueprint. The event was also punctuated with a high-powered speaker line up, featuring heroic tales and insightful updates on glaucoma, neuro-ophthalmology and more.

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he 2023 RANZCO Congress speaker sessions started with an incredibly tough act to follow. Dr Craig Challen, a retired veterinarian and cave diver from a town just 40km north of where this year’s conference was held, recounted his involvement in the famous 2018 Thai cave rescue of 12 boys, sharing bizarre and miraculous insights from the event that changed his life forever.

While it soon became apparent that cave divers would hold the key to the rescue, in the Opening Lecture at the Perth Convention and Exhibition Centre, Challen told delegates of the extreme measures people entertained to try save the boys, including the use of drill rigs, the search of alternative cave entrances, pumps to reduce the water table and locals using picks and pipe upstream to divert water away from the cave.

“There were also other plans you might say that were verging on the bizarre, not least of which was Elon Musk who turned up on site with his so-called submarine,” he said.

Challen’s keynote speech was a gripping way to kick off this year’s RANZCO Congress that welcomed around 1,500 in-person delegates alongside 243 online attendees. The event kicked off in a big way on Friday

20 October when a record 170 people attended the Global Eye Health Workshop, followed by the morning of Saturday 21 October when more than 660 delegates turned up to the morning session, which included Challen’s Opening Lecture.

Discussing the proposed use of a submarine for the Thai cave rescue, Challen said it was an impressive piece of equipment, but would have been impossible for cave divers to manoeuvre into the cave where the boys would then climb inside and been pulled to safety.

“But there were a couple of technical problems with this plan. The first was there didn’t seem to be any sort of life support system and, by this stage, we had a pretty good idea that it was going to take about three hours to swim out from chamber nine where they were located,” he said.

“The second thing was this device was made from super high-tech alloy of lithium and aluminium and weighs next to nothing, which isn’t so good for diving [which requires a weight belt] … but unfortunately, the one outstanding difficulty was that this was too big to fit through some of the restricted areas in the cave.”

It was going to be down to cave diving experts, including Challen and fellow INSIGHT December 2023

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EVENT

Dr Craig Challen talking about his involvement in the 2018 Thai cave rescue of 12 young boys.

“We must also meet the additional challenge of navigating a complex, fragmented funding environment, rife with cost-shifting and lacking in governance and accountability, our current cost of living crisis, a widening income gap, and a low rate of private health insurance.”

Notably, she pointed to the “stagnant” funding of public eyecare, with just 13% of services delivered in the public setting, insufficient accredited training post opportunities, longer waiting lists, and the threat of closure of public eye departments.

Part of the solution, Bell said, could be an atlas of healthcare delivery standards to define what services need to be delivered where, and the mandatory reporting of outpatient waitlist data. She also called for greater collaboration across the eye health sector, including a consensus on the roles and scope of each “craft group” i.e. optometry, so the sector can go to government united in its approach, led by ophthalmology.

Meanwhile, Kennedy updated fellows on the activities of the Australian and New Zealand Eye Foundation (ANZEF) – RANZCO’s philanthropic arm – with a major focus on increasing the First Nations ophthalmology workforce, which currently stands at one (A/Prof Kristopher Rallah-Baker).

Australian Mr Richard Harris, a trained anaesthetist; both would become the joint 2019 Australian of the Year for their heroics.

Both had a unique skillset that would set them up for the next part of the outlandish rescue plan – to render the boys unconscious with a formulation containing ketamine. Some of the boys didn’t know how to swim, and diving can be a disconcerting experience for first-timers, especially in 10cm visibility.

“If they started panicking and thrashing around in the cave underwater, they were certainly going to kill themselves and quite likely take a diver out with them,” Challen said.

Then came another challenge. The anaesthetic would only last for 45 minutes, so the non-medical members of the dive team were given a crash course so they could administering the drug through a thigh injection mid-rescue.

Fifteen days after the boys went missing, the rescue commenced, and the gravity of the situation began to weigh on Challen. “To be perfectly frank, we had no hope at all that we were going to get all of these kids out alive, we fully expected casualties – and to be honest – if we lost a whole lot of them, I wouldn’t have been all that surprised,” he said.

Miraculously, every boy was returned to their family alive. Challen says if confronted with the same situation today, he would be just as daunted by the prospect. But out the other side, the situation has taught him some life lessons.

“All of us are going to face a test in our lives which can come in many different forms. It might be difficulties in your professional life, financial or health problems. You might be caught in a war or natural disaster, which in one way you’re completely unprepared for,” he said. “But in another way, we’ve been preparing our whole lives for these moments, and it’s behoved upon all of us to take the opportunities we’re presented with.”

THE LATEST FROM THE COLLEGE Immediately after Challen came the RANZCO Plenary Lecture, offering a glimpse into the college’s activities and priorities. The session was chaired by president Dr Grant Raymond, and featured Dr Kristin Bell, Dr Justin Mora, Dr John Kennedy and Professor Nitin Verma.

Bell, a Tasmanian ophthalmologist, delivered an update on some of the biggest issues facing the ophthalmology workforce and access to eyecare in Australia. This was against a backdrop of growing demand for healthcare (now growing faster than the rate of GDP), inadequate funding of preventative health and poor coordination and funding of chronic diseases.

“In this challenging funding environment – where healthcare strategy and funding largely remain focused on acute disease presentation and inpatient services – ophthalmology, which in large part is an outpatient and elective surgeries specialty, is a canary in the coalmine,” she said.

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INSIGHT December 2023

Quoting the late Professor Fred Hollows, he acknowledged that “to close the gap, you have to put Aboriginal health in Aboriginal hands”.

Current barriers to First Nations participation in the ophthalmology workforce include the $50,000-$60,000 cost over five years for registrars to cover RANZCO’s Vocational Training Program (VTP) and exams.

“Now of course, registrar’s are well-paid, but this is a large amount of money for a young person, particularly if you come from a financially challenged background and are away from home and family for the duration of your training,” Kennedy said.

To counter this, ANZEF is providing $30,000 scholarships to Aboriginal and Torres Strait Islander RANZCO trainees, comprising $10,000 towards the first year, and $5,000 for every year after. Plus, the $1,800 application fee for the VTP has been waived for all First Nations applicants.

Currently, Kennedy said two Indigenous trainees started receiving the $30,000 scholarship last year (in WA and Victoria), while a Sydney trainee began receiving the funding this year and another trainee is expected to in Melbourne next year.

“Soon we will have four indigenous trainees in our scheme,” he added.

Finally, the ANZEF Indigenous Award in Ophthalmology at UNSW is offering two Indigenous students $10,000 each to undertake research in the fourth year of medical studies to provide exposure to ophthalmology. This will be overseen by the Prince of Wales Hospital ophthalmology department, Prof Tina Wong delivered the glaucoma update, focusing on overcoming the imperfections of blebs in trabeculectomy.

The trade hall was a hive of activity, with product demonstrations and meaningful connections made between the industry and eyecare practitioners.

including outreach clinics, and the UNSW Faculty of Health and Medicine.

“And if this is successful, we hope to replicate this at other universities. This program is also fully funded for the next three years,” Kennedy said.

Next, Kennedy provided an update on the ANZEF’s 2023 grants round where projects can receive up to $50,000 where they promote eye health equity and access. This year ANZEF was “swamped” with 40 applications from RANZCO members and affiliates. Six projects were selected totalling $185,000. These were: • The Western Murrumbidgee LHD Indigenous eyecare project, led by A/Prof Geoffrey Painter, Dr Dominic McCall and Mrs Kerrie Legg.

• Bad sugars, bad eyes – a culturally appropriate diabetic retinopathy screening campaign in the Kimberley, led by A/Prof Angus Turner, Lions Eye Institute • Expansion of support for the Global Eye Health Workshop at RANZCO Congress, led by Prof Mark Radford, Queensland Eye Institute • Mentoring workshop in Auckland for Maori and Pacifika applicants to the VTP, led by Dr Justin Mora • Lions InReach Vision: improving eyecare for Indigenous Australians, refugees, and asylum seekers in Perth’s metropolitan regions, led by Dr Marcel Nejatian andA/Prof Hessom Razavi, Lions Eye Institute • Sponsorship of Pacific Islands participants for microsurgical skills training, led by A/Prof Graham Wilson, A/Prof Con Petsoglou and Dr Yves Kerdraon.

MAKE BLEBS GREAT AGAIN In the Glaucoma Update Lecture, delegates heard from the Singapore National Eye Centre’s Professor Tina Wong who provided a thoughtprovoking and entertaining update on glaucoma and trabeculectomies.

She focused on the downside of bleb forming surgeries, namely unpredictable scarring and the potential for loss of function, stating the industry has been waging a 60-year war on this issue – that’s yet to be entirely resolved.

Wong said modern trabeculectomy was first described in the 1960s. Then, several years later when the adjunctive use of 5-Fluorouracil (5FU) and Mitomycin C (MMC) were first introduced to address wound healing and improve surgical outcomes, the industry thought it had addressed the problem.

“But after a while things started to go a little bit south. There was

more understanding of other factors which could lead to failure of our trabeculectomies that may be out of our control, such as ethnicity and racial differences, but also data from David Broadway’s work showed the adverse effects of topical anti-glaucoma medications that not only causes problems with compliance, but also on how the patient will scar when we perform surgery on them.”

Thus, the quest continues for a Holy Grail approach. Fundamentally, Wong believes trabeculectomies work, but she says it’s important to think of blebs as a “surgically-created living organism” that is in constant change and evolution.

“It’s like you’ve given birth to a new child. At the beginning, everyone’s delighted and commenting how cute they are, and as you go through the years, they start having tantrums, they don’t behave the way you want them to, and you have to chastise them,” she said.

“And then after a while, they rebel as they grow older. And this is exactly what happens with the bleb, they can either remain perfect or become something that you don’t recognise anymore, or they are a major disappointment.”

When looking to future strategies to avoid scarring, Wong said it’s time to search beyond the inhibition of fibrosis.

Firstly, this includes harnessing the immune system. Secondly, there needs to be a focus on the restoration of normal tissue health and architecture: “This is the absolute cornerstone of a healthy functioning bleb, you want near normal conjunctival vascularity. I’m obsessed with conjunctival vascularity and the appearance of blebs post-op, because that’s the only way to overcome the wound healing response post-op and strive to get long term healthy bleb function and better control of disease progression.”

On the issue of harnessing the immune system, Wong presented a study she co-authored showing that oral ibuprofen prescribed in the weeks following treatment is associated with a reduced likelihood of early bleb failure after trabeculectomy in high risk patients.

In terms of restoration of normal healthy tissue, she said it is the quality, not the quantity, of collagen that matters most. But what approaches exist to modulate collagen? Valproic acid has been used since the 1960s to prevent seizures, but has widely been shown to have anti-inflammatory and anti-fibrotic effects. Wong’s team was among the first to interrogate it’s potential in the eye, culminating in more than 10 years’ work.

INSIGHT December 2023

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EVENT

RANZCO was a chance for companies like Alcon to present their latest microscope technology.

Delegates checking out the Eye Museum on the trade floor.

ophthalmology at the Johns Hopkins University School of Medicine.

In his jam-packed presentation, he promised key takeaways that delegates could begin implementing tomorrow – and he delivered, offering new and important insights for acute optic neuritis [as well as chronic relapsing inflammatory optic neuritis (CRION)], visual snow syndrome and idiopathic intracranial hypertension.

Starting with acute optic neuritis, Miller urged delegates to avoid thinking of the disease in “typical vs atypical” terms. Previously, the main aetiologies were broken into idiopathic, multiple sclerosis (MS)-related, systemic infections like syphilis and Lyme disease, or drug or vaccine related. In the absence of a systemic infection or history of potential causative medication, the usual assumption was either idiopathic or MS. But Miller warned of new evidence showing that acute optic neuritis can also be associated with anti-AQP4 antibodies or anti-MOG antibodies – an important factor that alters the treatment approach.

She reported that valproic acid in combination with low dose MCC has been shown to reduce collagen maturation (and reduce tube shunt obstruction), and preserve conjunctival tissue while maintaining bleb function. It’s also important to remember that cross talk between the Tenons fibroblasts – the main cells involved in wound healing and scarring after a trabeculectomy – with resident and circulating inflammatory cells, heavily influences the wound healing outcome – and it’s important both are targeted for long term success.

“I encourage everybody to remember blebs are a living organism that are surgically created by us. It’s in a constant change of evolution, so we need to know how to look after them,” she said.

“Collagen still remains the main target and cornerstone in anti-fibrotic drug development. I believe the future direction of targeting collagen remodelling will help us to achieve that long awaited, perfect, long-term healthy bleb that we’re all striving to give to our patients.”

RETHINKING NEURO-OPHTHALMOLOGY CASES One of the major drawcards of the speaker program was Dr Neil Miller who flew in from the US where he works as the global authority on neuro-

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INSIGHT December 2023

For example, acute optic neuritis associated with anti-AQP4 antibodies requires emergency treatment with systemic steroids, opposed to the idiopathic variety where patients are advised steroids will help speed recovery, but ultimately they will reach the same point in their recovery. In addition, the use of MS drugs in so-called “neuromyeliis optia”-related optic neuritis can make the condition worse, highlighting the importance of testing for this aetiology.

Meanwhile, as far as anti-MOG antibody-related cases are concerned, these can be easily confused with idiopathic acute optic neuritis, but, again, the urgency of steroid treatment followed, if needed, by plasmapheresis is crucial to the prognosis, he said.

Starting immediately, Miller urged delegates to consider performing assays for both anti-AQP4 and anti-MOG antibodies in all patients with acute optic neuritis – even though it can take up to one week to receive results – and to treat all presentations with systemic steroids, unless there is evidence of an infectious cause.

In the case of CRION, Miller said it is now known that in most cases this is a form of MOG antibody-positive optic neuritis. Therefore, patients suspected with CRION should be assessed for MOG antibodies and treated accordingly.

“What does this mean for your practice? If you have a patient with chronic

relapsing recurrent optic neuritis that is steroid sensitive and dependent, and you haven’t done so, check that patient for MOG antibodies. Those patients shouldn’t be treated with a steroid each time they have an episode but rather with some type of immunosuppressive such as rituximab,” he said.

In his next update, Miller delivered the latest findings on IIH, also known as primary pseudotumor cerebri.

In many cases, the condition can be managed with acetazolamide (Diamox) and weight loss, but Miller said acetazolamide has been shown to reduce intercranial pressure (ICP) more effectively than weight loss alone.

Previously, patients were started with 1gm/day divided doses, with the belief that the maximum tolerated dose was 2gm/day – and if there was no improvement or intolerance, surgery was often considered.

But the Idiopathic Intracranial Hypertension Treatment Trial out of the US showed there was an acceptable safety profile of up to 4mg/day.

“So if you are managing a patient with pseudotumor cerebri and they are tolerating, but not improving, on Diamox 1-2mg/day, don’t be afraid to increase the dose slowly up to a maximum of 4mg/day, and in many cases that will take care of the problem,” he said, adding they should be warned about side effects.

In the case of weight loss, Miller said this was one of the mainstays of IIH treatment, with a loss of 7-10% found to be highly effective. But ultimately sticking to a formal program of exercise and diet has proven difficult for many patients.

The randomised Idiopathic Intracranial Hypertension Weight Trial enrolled 64 women with active IIH and a body mass index consistent with obesity in the UK and assessed ICP at 12 months.

“Patients were separated into those receiving bariatric surgery, and those enrolled in a community weight loss program. What was found was that bariatric surgery was far better than a weight loss program – and the effects were continued for at least two years,” he said.

Overall, the study found weight loss of 24% was associated with complete disease remission that was unlikely to be achieved without bariatric surgery.

“What’s your change and practice tomorrow? For patients with mild-to-moderate papilledema – without optic neuropathy and not requiring emergency surgery – at the beginning of your management, discuss not just the importance of weight loss, but the potential weight loss obtained by bariatric surgery,” he said.

“The other thing that’s useful is if you have a practice that sees patients with [IIH], try to collaborate with colleagues who deal with weight loss, so that if you have a patient who needs surgery, either at the beginning or later, then they can be fast-tracked for treatment because it’s not a simple thing – they have to undergo psychological testing etc.”

Miller rounded off his presentation on the topic of visual snow syndrome – a condition he emphasised is an organic condition. Patients describe their vision as if looking through snow or static, even though their examiation findings are completely normal.

“I have to admit, I used to think all these people were nuts … and I’m embarrassed about that because it turns out this is an organic condition,” he said.

“These patients have normal retinal structure on OCT, but they have abnormal electrophysiology, compared to control patients. There’s an increased b-wave and flicker amplitude on the ERG and there’s increased sensitivity of both the rods and the cones.”

Miller urged ophthalmologists seeing these patients to emphasise to them that no permanent damage has be found in their eyes and to reassure them that what they are seeing is a “real but benign” condition that won’t lead to blindness.

“Some patients respond to lifestyle modification, using dull paper, tinted glasses, lowering the ambient brightness in the room, and some respond to various medications that the neurologist can prescribe, but it’s very inconsistent,” he said.

Alcon's Hamish Buddle with WA ophthalmologist Dr Frederick Nagle.

A QUICK GLANCE AT RANZCO 2023 • Delegates – 1,491 in-person, 243 online •E xhibition – 141 booths, 60 exhibitors 2023 COLLEGE AWARD WINNERS •C ollege Medal – Prof Nitin Verma •C ollege Medal – A/Prof Alex Hunyor istinguished Service Award – Dr Ross Littlewood •D •D istinguished Service Award – Dr Richard Rawson •D istinguished Service award for service to Aboriginal and Torres Strait Islander eye health – Prof Hugh Taylor •F ederal Meritorious Service Award – Prof Nigel Morlet 2023 TRAINERS OF EXCELLENCE •D r Krishna Tumuluri, Sydney Eye Hospital •D r Tim Henderson, South Australia •D r Alexandra Crawford, New Zealand •D r Elsie Chan, Victoria •D r Antony Clark, Western Australia •D r Guy Bylsma, Regionally Enhanced Training Network •D r Fraser Imrie, Queensland •D r Kimberley Tan, Prince of Wales Hospital, Sydney The Filipic-Greer Medal (for overall excellence in the RANZCO Ophthalmic Pathology Examination) •S emester 1, 2020 – Dr Shivesh Varma •S emester 2, 2021 – Dr Neeranjali Jain A total of 46 new fellows were admitted to the college at the Graduation and Awards Ceremony & President’s Reception.

INSIGHT December 2023

27

Are you a people person?

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Jessica Early Career Optometrist

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PROFILE

a t a p i t a T n u a Sh A VISIONARY FOR COMMUNITY HEALTH AND LEADERSHIP

SHAUN TATIPATA was never meant to be a bystander. As the pioneer of Australia’s first Aboriginal-owned optical and eyecare provider, his work has seen a radical shift in the eyecare services provided to his local community.

D

uring his time as an Aboriginal Health Practitioner in 2001, Mr Shaun Tatipata’s encounter with one patient would ultimately cement his career in eye health. An older gentleman came to the local Aboriginal Medical Service for help with his vision and Tatipata – working alongside an ophthalmologist – was tasked with post-operative care.

When the man first came into their care, he was blind as a result of a cataract surgery complication. The only option was a corneal graft. Later down the track, their paths crossed again. The patient was animated after re-capturing his old life.

“His whole personality had changed, and I felt a sense of great pride in what we had achieved. He was able to get his driver's licence back and become independent from then on. His family then moved back out on to

Shaun Tatipata convened the Deadly Cup Rugby League Carnival in 2020 in support of Indigenous eye health.

their ancestral homelands where he was able to practise and teach his culture. He was able to support his family and really play that key role model for his community,” Tatipata says.

He cites this as a formative moment that would set him on the path to establishing the first Aboriginal-owned eyecare and optical provider, the Deadly Vision Centre, in 2020. The centre works to deliver culturally safe and socially responsive eyecare, access to affordable, appropriate and fashionable (Deadly) eyewear and helps Aboriginal and Torres Strait Island people navigate the eye health system.

“After 10 years of trying to reform the system, I realised we had to completely transform it. And what better way to do that than leading by example,” he says.

Tatipata grew up on Larrakia Country in Darwin and is of Wuthathi and Ngarrindjeri descent.

His interest in Indigenous health can be traced to the ailments of immediate and extended family members growing up. This meant he was exposed to the health system early and quickly became familiar with the value of Aboriginal Health Practitioners.

So, when there were calls for expressions of interest for traineeships for Aboriginal Health Practitioners at the local Aboriginal Medical Service in 2000, Tatipata interpreted this as divine timing and took it as an opportunity to contribute in his own way.

The role of an Aboriginal Health Practitioner is a revered community position and was understandably daunting for Tatipata when he applied.

However, with an eagerness to contribute, he was accepted.

In this role, he was first exposed to eyecare with a Federal Government initiative, driven by Professor Hugh Taylor, that saw the funding of Regional Eye Health Coordinator positions in Aboriginal Medical Services across the country. Tatipata supported the visiting ophthalmologists to deliver eyecare in his local service and remote communities across the Top End. It was during this time that his world collided with the elderly gentleman.

INSIGHT December 2023

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PROFILE

A local health system that’s Aboriginal-led is key to improving eye health outcomes for Indigenous Australians.

community members and 25 sponsors driving awareness of Indigenous eye health.

“Two weeks later we had some donated and secondhand equipment.

We had volunteer optometrists working alongside of us to deliver eyecare to mob. Organisations like the Brien Holden Foundation and the Optical Superstore came to the party, and they provided us with some equipment and access to their optometrists to start delivering services.”

Tatipata says the Deadly Vision Centre relies on self-generated funds and sector support. The practice marks an important milestone in Indigenous eye health, and according to Tatipata, sets the scene for success in this space.

“At the moment, it's all self-funded. We sell T-shirts, sunglasses and we're trying to leverage the Medicare system; whatever we can do to fund the much-needed eyecare in my community,” he says.

“We've got some very generous and supportive sector members. The sector and the industry are getting behind us by donating equipment, old and damaged stock, and offering advice and guidance. We take pre-loved glasses from practices around Australia, and we can provide them to people where cost remains a barrier to good vision.”

TRANSFORM, NOT REFORM Transformation begins with an eyecare pathway where Aboriginal and Torres Strait Islander people are supported by Aboriginal people every step of the way. A local health system that’s Aboriginal-led is key to improving eye health outcomes for Indigenous Australians.

He was tasked with follow up appointments that saw him visit the patient three times a day to administer eye drops while working with his family to educate them about his condition, treatment and support he required.

“And from there, I've kept wanting to do more. I could see the potential for the visiting specialist services and to support them to get out into more communities and places where mob live and work,” he says.

PAY IT FORWARD An important stint in Tatipata’s career would see him adopt a hands-on, proactive and national role to improve eyecare access. Much of his work was dedicated to establishing and running outreach programs with local Aboriginal Medical Services, but a highlight was his appointment at The Fred Hollows Foundation in 2011.

When the Australian Institute of Health and Welfare (AIHW) released the Indigenous Eye Health Measure report in 2017, Tatipata used this to quantify the coverage of eyecare services for Indigenous people against the projected needs.

“In my own community, I realised we were falling well short of the eyecare services that were needed and we were only delivering something like a third of the cataract surgeries required. We were only just scratching the surface of diabetic retinopathy,” Tatipata says.

“All my fellow community members, including my own family members, weren't receiving the services that they needed, nor what they deserved.

The current service providers didn't necessarily have the capacity or the capability to address the needs of the Aboriginal and Torres Strait Islander community. The ophthalmology department, as passionate about the cause as they were, just didn't have the capacity.”

With insufficient resources and consideration from governments, and with the knowledge he had accumulated during his time at The Fred Hollows Foundation, Tatipata took up the challenge of transforming the eye care landscape for his community.

He mobilised a network of likeminded people and organisations to establish the Deadly Vision Centre.

“Out of the sheer determination to give my community the best possible vision; that's what prompted me to set up the Deadly Vision Centre,” Tatipata says.

To raise awareness and support for the service, Tatipata established the Deadly Cup Rugby League Carnival in September 2020 as part of NAIDOC week. The event featured 80 volunteers, close to 300 players, 2,500

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INSIGHT December 2023

Cultural safety can play a major part in ensuring that people respond to their own health needs. Thus, Deadly Vision Centre’s rates of failure to attend are better than that of public hospitals or public eyecare services, Tatipata says.

“IT’S MORE THAN JUST PROVIDING EYE CHECKS; WE'RE TRYING TO CREATE AN ECOSYSTEM WHICH ALLOWS US TO TRAIN AND SUPPORT MOB AND ULTIMATELY INCREASE REPRESENTATION IN THE EYE HEALTH AND VISION CARE SECTOR – PARTICULARLY IN THE LEADERSHIP SPACE.” The collaborative care model at Deadly Vision Centre is an example of this Aboriginal led system. Here, the Aboriginal Health Practitioner is the initial point of contact for patients and facilitates access to eyecare services.

“We have the Aboriginal Health Practitioner-led pathway here and so the patient will come in and then they'll see the Aboriginal Health Practitioner, and then they see the optometrist and ophthalmologist,” Tatipata says.

“Communities value these roles and so we empower them to lead the service. The optometrists and specialists know that they’re fundamental to ensuring cultural safety and really embrace their role in supporting our Aboriginal Health Workforce.”

He explains that Indigenous eye health outcomes are better through organisations that have Aboriginal and Torres Strait Islander leadership.

Thus, education and training are key determinants in eye health success and promote greater representation. Tatipata’s overarching goal is for the eye health and vision sector to realise its full potential in this space.

EMPOWERMENT IS THE CORNERSTONE OF SUCCESS Beyond Deadly Vision Centre, Tatipata contributes in other ways, namely through the Indigenous Eye Health Unit at The University of Melbourne. There, he is engaged as an academic specialist, assessing and strengthening Indigenous leadership, lobbying governments and contributing to the organisation’s advocacy programs, including greater representation in leadership for improved cultural safety.

“We're thinking about how we can strengthen education and training pathways that create opportunities because we know that's going to lead to better employment and life outcomes overall. And we’re impacting other parts of the community as well. It’s more than just providing eye checks; we're trying to create an ecosystem which allows us to train and support

mob and ultimately increase representation in the eye health and vision care sector – particularly in the leadership space,” Tatipata says.

In the Vision 2030 report that Tatipata co-authored, the need for First Nations communities to lead the development of health promotion and health interventions was outlined. He says empowerment is the cornerstone of success in the eye health sector as well as championing the next generation of Aboriginal and Torres Strait Islander eye health professionals and Aboriginal Health Practitioners.

Shaun Tatipata (right) was nominated for the NT Australian of the Year Award in 2022.

“It's more than just simply being measured against our non-Indigenous community members, in terms of eye health outcomes. It's about hearing what our communities want, what our aspirations are, and what our measures of success are. And the best way to do that is to ask, so we did that. Being able to articulate those aspirations, and then support the communities to achieve them is quite powerful,” Tatipata says.

The future looks bright for Indigenous eyecare, with the introduction of ophthalmology services to the Deadly Vision Centre which will cut down surgical wait times in half. Tatipata hopes to see a dedicated surgery list and laser services at the clinic soon.

He's also expanding the Deadly Eyewear range that helps to fund the operations of the clinic.

“We've got our own finishing lab where we make glasses and train other Aboriginal community members how to make and fix glasses. There’s opportunity for us to expand that support to other communities around the Northern Territory, as well as Australia,” he says.

Tatipata acknowledges the invaluable support he has received from institutions nation-wide.

“The University of Western Australia's optometry school provides an incredible amount of support to the Deadly Vision Centre, enabling us to

have increased capacity to deliver services in my community,” he says.

“I am extremely grateful for the support of The Fred Hollows Foundation, Indigenous Eye Health Unit at the University of Melbourne, the Australian and New Zealand Eye Foundation and the optometry schools at Flinders and Deakin Universities; the support has been incredible. The majority of our equipment in here has been donated by industry supporters and that's given us a huge amount of additional capacity to do more in the community.”

CAREER

WHEN AN OPTOMETRIST BECOMES

an ophthalmologist

Ophthalmology has one of the most competitive selection processes in the Australian medical training workforce. There are many pathways, but some choose to practise as optometrists before taking the leap into medicine.

Wales. There, he was among one of the first cohorts to graduate with ocular therapeutic training in 2011.

T

His stint as an optometrist in a country practice, saw him work closely with the local ophthalmologist. This provided him with insight into comprehensive patient care, including management, monitoring and referral. With this experience, he wanted to be there for the final patient outcomes.

With insider knowledge in both spheres, these individuals emphasise the importance of collaborative care models and how bridging communication gaps can optimise patient outcomes.

“I just wanted that extra little bit of a challenge to provide care from the very

he unconventional transition from optometry to ophthalmology is marked by a unique set of skills. The few that have made this journey say their time as primary eyecare providers has set them up for success, with a deeper understanding of the eye health ecosystem.

To explore the intersect of these professions, Insight has spoken to two ophthalmologists who have come from optometry.

BEST OF BOTH WORLDS Dr Rajeev Naidu’s pursuit of optometry came with a stroke of serendipity. His early academic career saw him initially study commerce at the University of Sydney. However, it became evident early on that this was not his calling.

So, when Naidu visited the optometry clinic his family frequented, he left with an eye exam and a new ambition, having been convinced to pursue optometry by the optometrist.

After a year of commerce studies, Naidu switched to a combined Bachelor and Master of Optometry and Vision Science at the University of New South

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In his first two years as a graduate optometrist, Naidu worked in regional clinics, including Albury-Wodonga. His return to Sydney marked a full circle moment, where he worked part-time with Barry Clennar in Parramatta, the optometrist who guided him into the field.

“IF I HAD NOT BEEN AN OPTOMETRIST PRIOR TO STARTING MEDICINE, OR OPHTHALMOLOGY TRAINING, LIFE WOULD HAVE BEEN INFINITELY HARDER AS AN OPHTHALMOLOGY REGISTRAR.” DR RAJEEV NAIDU SYDNEY EYE HOSPITAL

start to the very end,” says Naidu, who is now a second-year ophthalmology registrar at Sydney Eye Hospital.

He continued his part-time work at Clennar’s practice while studying medicine at the University of Sydney. In his final year of medical school, Naidu worked in Dubbo and as a rural locum for OPSM. These optometric skills facilitated his success as an ophthalmology registrar.

With no backup plan or second priority medical specialty, he revels in the fact that he was accepted by RANZCO on his second admission attempt.

“If I had not been an optometrist prior to starting medicine, or ophthalmology training, life would have been infinitely harder as an ophthalmology registrar,” he says.

“From my experience as an optometrist, I have gained the skills of ocular examination, knowing patient follow up and knowing how patients perceive their eye health and the impact that eye disease has on them.

And I believe that’s made me a little more insightful during my training as an ophthalmology registrar.

“I think that optometrists really do make good ophthalmologist because they have an idea of what is involved in patient community eyecare from the very ground level. I think that's probably the biggest difference to someone who doesn't have an optometry background.”

Currently, Naidu has plans for a paediatric fellowship once he finishes his training. He hopes to complete an overseas fellowship in either the UK or Canada.

As one of the few optometrists in ophthalmology, he says the transition has provided an opportunity to elevate the collaboration between both professions and highlights the importance of the relationship.

“I think the handful of us are able to make a bit of a difference to foster the collaboration between optometry and ophthalmology for the future,” he says.

Evidently, these individuals with their unique academic and professional backgrounds help strengthen that relationship between optometry and ophthalmology for the best possible patient outcomes.

This uncommon career transition involves two very different, yet essential facets of patient eyecare, expanding the scope of eyecare practice with the amalgamation of two distinct skillsets.

‘OPTOMETRY HAS HELPED ME GREATLY’ For Dr Nicholas Toalster, some advice from a school counsellor led to him undertaking a bachelor’s degree in optometry. Upon graduation from the Queensland University of Technology in 2002, he completed six months in general optometry and a paediatric optometry practice.

During this time, a visit from the manager of a local ophthalmology practice marked the beginning of a notable career shift for Toalster. An offer of employment saw him work as a clinical optometrist for Gold Coast Ophthalmologists Dr Darryl Gregor and Dr Peter Heiner for several years.

Toalster had a yearning to practise beyond the scope of optometry. That’s when Heiner suggested he pursue medicine.

Toalster held his optometry registration through his medical studies by working at the clinic one day a week. After graduation, he worked as a junior medical officer in the Royal Brisbane and Women’s Hospital.

Initially assuming ophthalmology was too competitive for admission, he considered training as a general physician or rheumatologist. However, he made an application to RANZCO and was accepted, and completed his training at Sydney Eye Hospital where he was offered a fellowship as a corneal sub specialist.

Toalster’s career shift was not an isolated event, with some of his classmates in his medical cohort on a similar trajectory.

“There were at least four or five optometrists in my cohort, and I think three of those have gone on to become ophthalmologists,” he says.

Toalster completed a further fellowship in glaucoma sub-specialty training at the Royal Victorian Eye and Ear Hospital and then returning to the Royal Brisbane and Women’s Hospital in 2019 where he has remained since.

BECOMING AN OPHTHALMOLOGIST Ophthalmology is a highly competitive specialty among trainees, with around 135 applications each year. There are about 40 training posts available in 2023/2024 intake.

Requirements: · A medical degree with full registration to practise medicine in either Australia or New Zealand · Completion of a minimum of two years full time post graduate pre-vocational experience (including the intern year) when entering the VTP, which must include a minimum of 18 months of broad experience in medical, clinical and surgical settings other than ophthalmology Selection is a two-step process: Step 1: applicants apply to RANZCO and, through a rigorous selection process, suitability to join the training program is confirmed. CV review, referee reports, situational judgement test and mini multiple interviews form part of this process.

Step 2: Individual Training Networks in Austalia and New Zealand then assess and select the best trainees for their network from this shortlist and make them an offer of employment in a training post.

He describes his shift from optometry to ophthalmology as advantageous, citing that his unique skillset distinguishes him from others within the field. Integrating his expertise in both areas ensures the best possible outcomes by collaborating with optometrists.

“They're both very different degrees, optometry and medicine. Back when I did optometry, it was very didactic and proscriptive compared to medicine, which was a bit more investigative where you had to work things out for yourself,” he says.

Dr Nicholas Toalster, OKKO Eye Specialist

“Optometry has helped me greatly Centre, Queensland. because I have insight into how optometrists practise. Whereas most doctors don't know how a general community optometry practice in a shopping centre works. But the reverse is true as well. Optometrists often haven't had the experience of working in a hospital doing after hours on call for example. Bridging those gaps has been a big part of what's useful.”

Toalster notes the importance of his transferrable skills and their relevance to the RANZCO Collaborative Care for Glaucoma program where optometrists and ophthalmologists adopt a shared care arrangement for lower risk glaucoma patients.

“What could be done is bridge those gaps between what the two different professions experience, and the knowledge they bring to the table,” Toalster says.

In his clinic, there are professionals with a similar mindset but have not transitioned from optometry to ophthalmology just yet.

“In our practice we have a number of optometrists. They are drawn to working in ophthalmic practices, often after having done a placement with us, due to the increased scope-of-practice and clinical variety they see.”

Toalster believes that an expansion of the scope in optometry in recent years might see a reduction in career shifts, with incorporation of more therapeutic options including contact lens prescription and myopia management into optometry practice.

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LEARNING OBJECTIVES:

CPD

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At the completion of this CPD activity, optometrists will understand the clinical utility of optical coherence tomography angiography (OCT-A) ...

CLINICAL CPD HOURS This activity meets the OBA registration standards for CPD

Including: • Discern the benefits of OCT-A change analysis over time as a tool for earlier diagnosis of pathology of the retina and optic nerve.

• Recognise common conditions where OCT-A imaging is clinically beneficial.

• Understand the importance of choosing the appropriate OCT-A scan protocol and retinal layer appropriate to the suspected pathology.

PEARLS FOR EXPANDING USE OF OCT-A IN OPTOMETRIC PRACTICE OCT angiography has emerged as a pivotal imaging technology but despite its utility for detailed assessment of the retinal and disc microvasculature, many optometrists have been slow to adopt it. With optometrists well placed to use it for early diagnosis and disease monitoring, DR GEORGINA CLARK shares practical tips for performing OCT-A scans.

O

ptical coherence tomography angiography (OCT-A) is a useful imaging tool that has become widespread in hospitals and private ophthalmology practices since its introduction in 2016. Uptake in optometry practices, however, has been slower, with research suggesting that optometry practices consider OCT-A less applicable to their practices than other imaging technologies.1 This isn’t surprising, given that initially, OCT-A was viewed as an alternative to fundus fluorescein angiograms (FFA) – tests traditionally performed by ophthalmologists.

Over the last five years, clinical research, driven by data science enhanced with artificial intelligence analysis, has expanded the clinical applications of OCT-A. There are now many valuable opportunities for optometrists to use OCT-A as a diagnostic and monitoring tool for many eye conditions. OCT- A can be used to identify eye pathology earlier and, in some cases, even before permanent vision loss occurs.2 No longer just an alternative to FFA, OCT-A can now be used to assess for various forms of optic neuropathy; from glaucomatous optic neuropathy to non-arteritic ischaemic optic neuropathy and even

ABOUT THE AUTHOR: Dr Georgina Clark

BA MA MBBS (Hons) FRANZCO Sydney at Mosman Eye Centre and Bondi Eye Doctors

arteritic ischemic optic neuropathy.

OCT-A is used to identify cases of age-related macular degeneration (AMD) that are at high risk of transformation from ‘dry’ to exudative neovascular AMD. Additionally, OCT- A is used to identify ‘quiescent’ choroidal neovascularisation age-related macular degeneration (CNV ARMD), a new sub type of the neovascular AMD (nAMD) not identifiable with FFA or regular OCT. In short, the applications of this technology are wide and significant.

ADVANTAGES AND DISADVANTAGES OF OCT-A OCT-A is easy to use and fast. Optometrists and their staff can perform the tests without need for nursing or medical staff. Also, it is a safe, non-invasive test, especially when compared to FFA and the associated risk of allergy and anaphylaxis. Also, compared to FFA, OCT-A is a relatively low-cost investigation, both for the patient and the medical system.

One drawback of OCT-A is that the process of learning the skill of interpreting OCT-A can be daunting, especially outside of a formal teaching program (most retinal fellowships now include dedicated teaching on the interpretation of OCT-A as well as FFA).

Figure 1. Angiography analysis screen shows the layers of the retina and choroid. By clicking on the appropriate layer on the left, the en face OCT-A image can be viewed along with the associated B scan view, including representation of blood flow in red. Note, the purple lines on the B scan image indicate the level of the retina analysed. These can be manually moved and manipulated.

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By virtue of its digital nature, the OCT-A gathers a lot of data.

This, in turn, means that the clinician needs to make a series of informed decisions about what data to collect and analyse. OCT-A is most useful when the clinician has a particular disease in mind, and then performs the appropriate scans to look for that condition.

Figure 2. A 3 x 3 mm image of the macular centred on the fovea. The B scan shows the superficial capillary plexus, and deep capillary plexus. The Angio image confirms an enlarged irregular foveal avascular zone (FAZ). The widened contour of the FAZ is also evident on the B scan.

Figures 3A and 3B. The circularity of the FAZ can also be measured using the FAZ Parameters on Angioplex scans.

In the same patient, the circularity index was reduced at 0.61, with 0 (irregular) and 1 (regular).

Figure 4B. Branch retinal vein occlusion right eye as seen on the superfial angioplex. The darker areas of the peripheral retina are ischaemic at risk for retinal neovascularisation.

representation can be rendered.

Figure 4A. BRVO with peripheral non perfusion.

HOW OCT-A WORKS OCT-A enables capture of retinal and choroidal microvasculature images. OCT-A technology uses laser light reflectance of the surface of moving red blood cells to accurately depict vessels in different layers of the eye. The same tissue area is repeatedly imaged and differences are analysed. Differences in ‘scatter’, due to movement of red blood cells, allow imaging of the vasculature. OCT-A technology is used to provide insight about blood flow through the eye's structures, picking up abnormalities such as reduced blood perfusion, or new abnormal vessels.

OCT-A provides high-resolution detail and also shows the vertical relationship between the vessels and the surrounding tissue architecture through the B-scan slice. Traditional FFA shows the superficial capillary plexus whereas OCT-A can show the deeper vascular layers right down to the choriocapillaris.

THE APPROPRIATE SCAN PROTOCOL: WHERE TO LOOK FOR SUSPECTED PATHOLOGY There is a lot of information gathered and presented on the OCT-A device. The clinician can elect to scan the following regions of the eye: fundus, macular and disc. Acquisition sizes range from 3 x 3 mm to 12 x 12 mm and even wider field using montage functions up to 50 degrees. Additionally, macular cubes with 3D

When scanning the retina, it’s advisable to start your assessment by going to scan ‘Acquire’, and then the ‘Angiography Analysis Screen’, as pictured in Figure 1.† In Figure 1, the following layers are imaged: •V RI (vitreoretinal interface) •R etina •D eep capillary plexus •S uperficial capillary plexus •C horiocapillaris •C horoid •R PE-RPE best fit •O RCC (outer retina choriocapillaris) The clinician clicks on the layer of the retina he or she wants to assess. As such, the OCT-A is largely driven by pattern recognition in the layer of the retina in which the clinician expects to find pathology.

It's critical to choose the appropriate scan protocol depending on the indication and likely pathology.

For example, for a suspected CNV in a patient with AMD, a macular scan of 3 x 3 mm can help detect smaller lesions and segmentation can be more finely tuned. However, for diabetic retinopathy assessment, montage or wide field scans of 12 x 12 mm provide a better view of peripheral retinal ischaemia, and will show capillary non-perfusion and neovascularisation.

CASE 1. ENLARGED FOVEAL AVASCULAR ZONE In Figures 2-3, this is the case of a 56-year-old male with type one diabetes who presented with blurry vision, worse in the right eye. Physical exam of the

PRACTICAL TIPS FOR THE USE OF OCT-A IN THE CLINIC •C hoose the appropriate scan protocol depending on the indication and likely pathology.

The suspected pathology determines the appropriate site, size and depth of scan to help you best locate abnormal blood flow or vasculature. Focus your analysis on pattern recognition of the pathology you are seeking to rule in or out, at the level of retina it is expected to occur. Don’t get distracted by data or patterns in other layers.

• Capture baseline scans during initial consults.

These are an invaluable reference point.

• Scan as frequently as is clinically useful. The scans are quick and the more data points you have for a patient, the more likely you will be able detect pathological changes early.

Also, the more you scan and the more normal conditions you see, the easier it will be to detect abnormal conditions.

• Employ the OCT-A Change Analysis tool to look for changes between visits. The software is loaded with nomograms and algorithms designed to facilitate the easy identification of abnormalities.

• Make use of the education resources available - Online education and videos provided by many OCT-A manufacturers (for example: ZEISS school) - Conferences and publications • Don’t hesitate to refer to an ophthalmologist if something doesn’t look right.

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Figures 5A-5C. Quiescent or non-exudative choroidal neovascular membrane in a myopic patient.

Figure 5A. Structural OCT shows the macula is dry but with evidence of increased flow in the sub-RPE space. Figure 5B. Normal superficial capillary plexus on OCT-A. Figure 5C. A small neovascular lesion is seen in the avascular and RPE-fit layer of the OCT-A

patient was unremarkable. There was no refractive error change; best- corrected visual acuity right eye was 6/9 and left eye is 6/7.5. There were no lens changes. On dilated fundus exam, mild NPDR was noted in both eyes, but no diabetic macular oedema.

Without an alternative explanation for his reduced vision, in this patient you may suspect capillary perfusion at the macular secondary to diabetes. This would appear as enlargement of the foveal avascular zone (FAZ), with irregular margins.

Studies have demonstrated that, compared with fluroscein angiogram, OCT-A allows better discrimination of the central and parafoveal macular microvasculature, especially for FAZ disruption and capillary dropout.3 To identify enlargement of the FAZ, it’s important to scan the macula in the highest resolution possible on your device. Enlargement of the FAZ (increased area of non perfusion at the fovea), with increased irregularity of the border, can be seen on the level of the superficial capillary plexus and the deep capillary plexus. Sometimes, relatively smaller spotty areas of non perfusion can also be identified in the choriocapillaris.

It is a valuable to also employ the change analysis software to look for change over time. Having a baseline scan in patients such as this can prove extremely useful down the track. Also, frequent imaging allows for pathology to picked up earlier, especially where the change analysis software is employed.

There is also an argument for scanning often as part of the education process. That is, the more scans of normal FAZ a clinician looks at, the more likely that clinician is to pick up the abnormal scans.

CASE 2: BRANCH RETINAL VEIN OCCLUSION This is the case of a 70-year-old female. She is known to have suffered a right branch retinal vein occlusion nine months ago. Her best corrected visual acuity is 6/24. Her optometrist is concerned about possible ischaemia.

An OCT-A scan of her retina in performed. The imaging options at this visit were 6 x 6 mm, 8 x 8 mm, and Montage (which offers up to 50-degree field of view). The Montage images are shown in Figure 4. These reveal regions of peripheral ischaemia and peripheral capillary drop out. This patient was referred for consideration of sectoral argon retinal laser to reduce risk of neovascularisation. This fast

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and efficient scan can help pick up patients at risk of complication.

Figure 4B demonstrates BRVO in another patient.

This patient has peripheral retinal ischaemia with ‘drop out ‘ of vascular flow in the periphery. In addition, OCTA at the level of the superficial capillary plexus shows vascular tortuosity, dilation, telangiectasia and decreased vascular density.

CASE 3: QUIESCENT nAMD An 85-year-old male presented has known nAMD. An OCT-A scan reveals a ‘quiescent CNV’ in the fellow eye.

The role of OCT-A in the imaging and diagnosis of nAMD is now familiar to both optometrists and ophthalmologists alike. More recently, research has identified a new entity which is named ‘quiescent’ CNV. These are lesions detectable on OCT-A as abnormal vascular networks above Bruch’s membrane. However, they show no evidence of leakage (intraretinal fluid/subretinal fluid) on OCT – or FFA. As such, it’s a pre-clinical CNV that is only diagnosable using OCT-A.4 This is relevant in patients with history of nAMD one eye. For these patients, the risk of conversion to exudative or active disease at one year was 15 times higher than those without subclinical lesions.5 Closer follow up and patient counselling for symptoms is recommended in this cohort.

It’s noteworthy that this patient’s CNV is most visible in the RPE – RPE Fit layer in Figure 5C. The RPE- to-RPE fit analysis compares the Anterior RPE border (interdigitation zone) to posterior RPE border.

In healthy eyes, this is close to parallel. An increasing deviation between the anterior and posterior border is suggestive of developing pathology. Thus, this is a useful tool in monitoring those at risk of transitioning to an exudative CNV.6

FUTURE TRENDS Overall, advancements in OCT and OCT-A technology are an active area of research. The digital nature of these images lend themselves to prospective and retrospective research. The image data sets can be stored and assessed by data scientists for subtle signals and trends that will help with the earlier diagnosis of disease.

Additionally, artificial intelligence is now actively employed in the segmentation and interpretation of images both for clinical and research purposes.

This research is powering trends towards earlier identification of disease. and at risk individuals. This,

in turn, increases the scope for closer monitoring in those patients. At this time, OCT-A clinical guidelines based on that research are being developed by the American Academy of Ophthalmology and the United Kingdom’s NICE guidelines group.

SUMMARY The applications of OCT-A technology are expanding rapidly. OCT- A can be used to identify eye pathology earlier, and, in some cases, even before permanent vision loss occurs.

As the first point of contact for many patients seeking eyecare, early consideration of disease has long been an inherent part of optometric practice. OCT-A can, and does, nicely complement that aspect of optometry as a useful tool in the early diagnosis and monitoring of eye pathology.

In coming years, this exciting field of research will be increasingly streamlined with practical clinical guidelines in development by ophthalmology colleges around the world.

NOTE: † This articlecontains ZEISS images and nomenclature. However, equivalent analysis screens are applicable in other makes of OCT-A. REFERENCES: 1. Cheung R, Ho S, Ly A. Optometrists’ attitudes toward using OCT angiography lag behind other retinal imaging types. Ophthalmic Physiol Opt. 2023 Jul;43(4):905-915. doi: 10.1111/opo.13149. Epub 2023 Apr 21. PMID: 37082888.

2. Miguel, A.I.M., A.B. Silva, and L.F. Azevedo, Diagnostic performance of optical coherence tomography angiography in glaucoma: a systematic review and meta-analysis. Br J Ophthalmol, 2019.

3. Soares M, Neves C, Marques IP, et al. Comparison of diabetic retinopathy classification using fluorescein angiography and optical coherence tomography angiography. British Journal of Ophthalmology 2017;101:62-68.

4. Carnevali A, Cicinelli MV, Capuano V et al (2016) Optical coherence tomography angiography: a useful tool for diagnosis of treatment-naïve quiescent choroidal neovascularization. Am J Ophthalmol 169: 189–198 5. de Oliveira Dias JR, Zhang Q, Garcia JMB, et al. Natural History of Subclinical Neovascularization in Nonexudative Age-Related Macular Degeneration Using Swept-Source OCT Angiography.

Ophthalmology 2018; 125: 255–266.

6. Parravano M, Borrelli E, Sacconi R, Costanzo E, Marchese A, Manca D, Varano M, Bandello F, Querques G. A Comparison Among Different Automatically Segmented Slabs to Assess Neovascular AMD using Swept Source OCT Angiography. Transl Vis Sci Technol. 2019 Mar 27; 8 (2):8. doi: 10.1167/tvst.8.2.8. PMID: 30941265; PMCID: PMC6438244.

NOTE: Insight readers can scan the QR code or visit insightnews.com.au/cpd/ to access a link to this article to include in their own CPD log book.

CPD

LEARNING OBJECTIVES:

Including:

At the completion of this article, the reader should be able to improve their management of keratoconus ...

• Review surgical and non-surgical treatment and management options

• Understand clinical signs and symptoms of keratoconus

• Identify the demographic groups at risk for keratoconus • Understand the critical importance of early identification, especially with imaging, of keratoconus patients and suspects

CLINICAL CPD HOURS This activity meets the OBA registration standards for CPD

• Feel confident investigating or referring suspicious cases.

KERATOCONUS: A FRANK DISCUSSION The pathogenesis of keratoconus is not well understood but it is a condition that can be practically managed to prevent visual deterioration and stabilise the condition. Delayed diagnosis results in lost vision, which is why early identification through patient history, eye exams and especially corneal imaging is so critical, writes ABI TENEN.

U

nderstanding, diagnosing and managing keratoconus seems to be confusing for many, but why? Probably because nobody really knows for sure what causes it, how common it is and the best way to treat it.

It can present as very mild thinning or corneal asymmetry with normal vision. It can also present as severe corneal collapse with scarring and corneal blindness, or it could be anywhere in between these two extremes.

Perhaps the condition seems tricky because it’s not a single disease entity but rather a consequence of various pathologies. This idea could mean that the corneal ectasia we see in keratoconus is a consequence of various disease processes in the same way that inflammatory arthritis is the consequence of various autoimmune diseases. Like arthritis, keratoconus could be the ‘effect’ rather than the ‘cause’. It’s interesting to ponder this possibility and the topic is open to debate.

The patients with mild corneal thinning or steepening may not fit the classic diagnostic criteria of keratoconus but they are arguably on the spectrum. These are the patients who may be deemed suitable for surface laser treatments such as PRK but not deeper corneal procedures such as LASIK. It’s not uncommon to find keratoconus among family members of a PRK patient who presents with these milder findings.

Certainly, keratoconus presents along a spectrum.

Keratoconus also has ‘clinical cousins’: pellucid marginal degeneration and post-LASIK ectasia

ABOUT THE AUTHOR: A/Prof Abi Tenen MBBS(Hons) FRANZCO Vision Eye Institute

are variations which essentially fall under the same disease category but follow distinctly different patterns.

COMPLEX GENETICS New information is constantly being offered up as research projects delve deep and diagnostic technology advances, which is all very exciting.

But we are only at the tip of the iceberg in terms of unravelling the vastly complex underlying genetic associations with one gene location on chromosome 11 showing consistent relevance,1 however, genome-wide analysis has found significant association between 36 gene locations and keratoconus.

Needless to say, the genetics are complex.

Results of genetic studies also suggest ‘pleiotropy’, which means that some disease mechanisms are genetically shared with other corneal conditions such as Fuch’s dystrophy. 2 This is interesting because, clinically, these two diseases are unrelated, except that they both involve the cornea.

There’s a lot we don’t know yet, but we do have enough information to deal with keratoconus practically in a clinical setting. To boil it down: what matters is detecting keratoconus, stabilising it and correcting the vision. The earlier this is achieved, the better. That’s the take home message.

Despite the gaps in our knowledge, there’s a lot we do know about the condition, so let’s look at the topic in more detail.

Figure 1. Corneal maps validate the diagnosis of keratoconus despite weak clinical signs.

CLINICAL SIGNS AND SYMPTOMS Keratoconus presents as a progressive thinning and bulging (ectasia) of the cornea which is bilateral but usually asymmetrical. It tends to present with increasing visual impairment mostly due to unstable INSIGHT December 2023

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Figure 2. Corneal maps reveal keratoconus with significant asymmetry.

refractive error (astigmatism is key) and debilitating symptoms such as glare, ghosting or diplopia. In more advanced cases hydrops, scarring and even perforation may result.

WHO IS AT RISK? Most patients present at a younger age (10-30 years) although progressive disease has been reported in older decades all the way up to 77 years.3 It isn’t an uncommon condition; there is a global prevalence of about one in 500, however, the numbers are uncertain and are very likely higher with one recent report suggesting prevalence of one in 84.4 There are hot spots for keratoconus in some communities – it’s more common in the Middle East, parts of India and among the Māori population in New Zealand; Australia has quite a high incidence of keratoconus, mostly among people who originate in above listed regions. Consanguinity is a contributing risk factor in the genetic analysis of highly affected populations.

Keratoconus is also associated with conditions such as Down Syndrome and Marfan Syndrome, which highlights the genetic component to the disease.

THINGS THAT EXACERBATE THE CONDITION Mechanical, pro-inflammatory stimuli such as eye rubbing or poorly-fitted contact lenses can progress keratoconus. This, alongside more recent findings, supports the theory that keratoconus is an immune-mediated inflammatory degenerative process, although in the past it has been widely categorised as a non-inflammatory process.5 TREATMENT AND MANAGEMENT OPTIONS Collagen cross-linking (CXL) is commonly used to prevent progression of keratoconus and, in younger patients, plays a prophylactic role in terms of preventing early vision loss. Various protocols exist and for the classic epithelium-off technique, minimal corneal pachymetry of 400 microns is recommended.

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Vision correction can be offered using non-surgical methods including spectacles (sometimes with specialised technology such as wavefront treated lenses), soft contact lenses, rigid gas permeable lenses or specialised lenses (piggy-back, hybrid, miniscleral and scleral). Making sure that the ocular surface is well lubricated and paying attention to allergies with, for instance, antihistamine or mast cell stabilising eye drops can also assist visual quality and patient comfort.

Surgical management, aside from CXL, may include: intracorneal ring segments such as Keraring; CAIRS (corneal allogenic intrastromal ring segments); topography guided surface excimer laser ablations; and corneal grafting techniques, usually deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty (PK).

•c hanging refraction and particularly astigmatism • f amily history of keratoconus A young patient with rapidly-changing refraction, particularly with astigmatism, in addition to any of the known risk factors is highly suspicious. These patients need corneal imaging straight away or at the very least, look for distorted mires.

TOPOGRAPHIC DIAGNOSES Imaging is the most reliable way to objectively find keratoconus and it doesn’t really matter which type of topographer or tomographer is used, they will all pick up corneal steepening and thinning.

Scheimflug imaging and elegant anterior OCT devices with features such as epithelial mapping provide valuable information, but for the purposes of detecting keratoconus and referring

“WHAT MATTERS IS DETECTING KERATOCONUS, STABILISING IT AND CORRECTING THE VISION. THE EARLIER THIS IS ACHIEVED, THE BETTER. THAT’S THE TAKE HOME MESSAGE.” PK or full thickness corneal transplant is now uncommonly performed for keratoconus and would be indicated in situations such as post hydrops.

Thankfully, corneal grafting as a whole is rarely required since the advent of CXL, which really can be thought of as not just a stabilising procedure but a graft preventing procedure. Of course, not every cross-linked patient will escape progression and the need for an eventual graft, especially if they continue to enthusiastically rub their eyes.

THE IMPORTANCE OF EARLY IDENTIFICATION OF PATIENTS AND SUSPECTS Detection of keratoconus will partly depend on access to diagnostic equipment, but everybody can check the following: • history of changing vision • history of eye rubbing and allergy

to ophthalmology, suspicious corneal shape and thinning pachymetry are more than enough to raise alarm.

Fortunately, the reduced cost and increasing availability of topographers means that more optometry practices than ever now have the ability to make a topographic diagnosis. Don’t wait until you’re confident that you’re seeing a scissor reflex, Fleischer rings, Voigt’s striae, oil droplet sign or Munson’s sign – by then the disease may be significantly progressed and the patient could lose the opportunity to be stabilised with CXL. Also, don’t wait until you’ve documented several refractive shifts with deteriorating best corrected visual acuity. Again, the patient misses out on the opportunity to be stabilised early with the chance of holding on to better vision.

WHEN IS THE BEST TIME TO IMAGE? Suspicion of keratoconus is enough to justify imaging, it’s a non-invasive test that can be done quickly with definitive results. The earlier this is done the better – and then the patient can be assessed for CXL.

Keratoconus could be considered a consequence of various pathologies, rather than a single disease entity.

Any young patients with keratoconus or older patients with evidence of progressive keratoconus should be referred to an ophthalmologist who performs cross-linking. Likewise, any patients with suspicion of keratoconus and/or who requires corneal imaging that may not be available to the referring optometrist, should be referred too.

Identifying the risk factor of eye rubbing and advice against it, along with management of any ocular allergy symptoms, should also be tended to without delay. Of course, spectacle and contact lens prescription closes the loop of the detection/ stabilisation/vision correction triad.

INFORMED REFERRAL AND PATIENT CO-MANAGEMENT Bear in mind that if your patient is likely to require CXL soon, then their refraction will most likely fluctuate and change after the treatment while the cornea is remodelling and stabilising. This means that any vision correction prescribed during the stabilisation period is unlikely to be useful for very long and will need to be updated regularly. If you are planning contact lenses for a patient referred to CXL, it may be worth waiting until a few months post-op before considering the high-tech lens options but, of course, this would need to be assessed on an individual basis.

Likewise, if the patient is to be considered for any of the other keratoconic corneal surgeries, it makes sense to understand the timeframe and pathway to surgical treatment before a prescription is actioned to the relevant eye. Ask the doctor directly when the patient should see you for a new prescription and tell them what you are planning to do.

Open communication in both directions is important so that patients receive the optimal treatment at the optimal time. Patients appreciate smooth co-management, and nobody likes wasted time and resources which tends to result when practitioners aren’t ‘on the same page’.

IMAGING THE CORNEA Ophthalmologists managing keratoconus are generally very happy to assess if there’s doubt about the diagnosis. Sometimes what looks like keratoconus clinically is just high regular corneal astigmatism and sometimes what doesn’t look like keratoconus clinically is actually early cone.

Imaging the cornea takes the guesswork out of the equation.

Here are a couple of examples where corneal maps evidently demonstrate the diagnosis of keratoconus, making management decisions straightforward, whereas history and clinical findings did not clearly raise suspicion.

CASE 1 This 30-year-old patient (Figure 1) only had 1.75 D of cylinder in their glasses and good BCVA, so

the maps seem surprising. They had been wearing spectacles for 15 years and were rubbing their eyes with gradual visual decline over recent years but no significant symptoms or slit lamp signs. (The left and right corneas looked similar on imaging).

be unverified or inaccurate, this means that they are generally aware of current medical treatments and sometimes present for professional help already self-diagnosed. This can be either helpful or problematic. Don’t be deterred and stick to your plan.

CASE 2 This 39-year-old patient (Figure 2) presented with normal vision in the left eye and poor vision in the right.

Corneal maps show keratoconus with significant asymmetry. The patient hadn’t really noticed visual difficulty as the left eye was compensating for the right. Sometimes these cases are misdiagnosed as unilateral amblyopia if the cornea is not properly examined and/or imaged. The right cornea at presentation was too advanced for CXL and was booked for deep anterior lamellar keratoplasty (DALK). The left cornea looked almost normal and observation with serial imaging was planned. It will possibly require CXL in future if deterioration is detected. The patient does not rub their eyes.

Finally, patients and/or parents and carers of patients always appreciate a practitioner who takes the time to thoroughly discuss with empathy what can be a frightening diagnosis. A good ‘bedside manner’ not only gives patients reassurance and confidence, but it can also actually result in better clinical outcomes as practitioner attitude and demeanour can have a positive placebo effect, particularly in terms of reducing patient anxiety.

CONCLUSION In many ways, with the prevalence of keratoconus showing itself to be much higher than once thought, the clinical decision to only observe (i.e., watch the patient deteriorate without offering active treatment) is no longer enough. Patients will only be upset if they find out later that they’ve had keratoconus all along and they weren’t given the opportunity to stabilise it.

Remember that children with keratoconus can progress very rapidly, leading to devastating visual decline, so refer these patients urgently. Sometimes this may seem like an inconvenience to parents and carers, particularly if the patient needs to travel from rural areas to the nearest city. Spending time to explain the relevance of urgent medical review is an important first step in what will be a lifelong journey for the patient.

It's worth noting that patients often self-educate online and although their information sources may

REFERENCES: 1. McComish BJ, Sahebjada S, Bykhovskaya Y, [...], Tenen A, et al. Association of genetic variation with keratoconus.

JAMA Ophthalmol. 2020; 138(2): 174–181. (Published online) doi:10.1001/jamaophthalmol.2019.5293.

2. Hardcastle AJ, Liskova J, [...] Tenen A, et al. A multi-ethnic genome-wide association study implicates collagen matrix integrity and cell differentiation pathways in keratoconus.

Commun Biol. 2021; 4 (1): 1–13. (Published online) doi:10.1038/ s42003-021-01784-0.

3. Burton O, Tenen A and Hodge C. First presentation of keratoconus in a geriatric patient: diagnosis and treatment of late progression. JCRS Online Case Reports. 2019; 7(4): 65–70.

(Published online) doi:10.1016/j.jcro.2019.09.004.

4. Chan E, Et Al. Prevalence of Keratoconus Based on Scheimpflug Imaging: The Raine Study. Ophthalmology. 2021 Apr; 128 (4): 515-521.

5. Shetty R, Khamar P, Kundu G, Ghosh A, Sethu S. Inflammation in Keratoconus. In Keratoconus 2023 Jan 1 (pp. 159-168). Elsevier.

NOTE: Insight readers can scan the QR code or visit insightnews.com.au/cpd/ to access a link to this article to include in their own CPD log book.

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2023 REVIEW

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1-6

YEAR IN REVIEW -

2023

How do you think the year of 2023 will be remembered in the ophthalmic sector? Insight reflects on the key industry issues that shaped the past 12 months.

W

hen the ophthalmic sector of the future looks back on 2023, it will be remembered as the year that many seeds were sown.

Five to 10 years from now, the industry will likely be bearing the fruits of its labour, with this period considered a turning point in some respects.

With an aging population and expanding cohort of progressing myopes, there are increasing demands on the ophthalmic industry. As such, the sector is ripe for innovation, and 2023 was no exception with major business deals, personnel changes and breakthrough products that will shape the Australian ophthalmic sector in years to come.

In fact, if you’re reading this article many years from now, it’s likely Chemist Warehouse’s foray into optometry is in full swing with a national rollout across Australia. Corporate optometry would have strengthened its market grip, and more networks may have embedded additional allied health streams to diversify their businesses.

KEY BUSINESS HIGHLIGHTS Without a doubt, the biggest announcement to drop in 2023 was Chemist Warehouse’s entry into the optometry market. In fact, it was Insight’s most-read story of the year. The pharmacy giant’s Optometrist Warehouse venture began by opening its first store in the Melbourne suburb of Malvern in February, followed by the first NSW store in Cambelltown in October.

Like intraocular lenes, there will also probably be a multitude of myopia management options for practitioners to choose from and individualise for their patients, while more groundbreaking solutions like red light therapy may have become more mainstream. Eye researchers would have discovered ways to harness the power of gene therapy to tackle the most common eye diseases too.

And, in all likelihood, the use of artificial intelligence (AI) will be the norm eye clinics, with many practitioners wondering what they were initially so worried about.

Eventually, it’s expected there will be “a mass network rollout which will FROM TOP LEFT CLOCKWISE: Eyerising International announces TGA approval of its red light myopia therapy; Optometrist Warehouse opens a second store in Campbelltown, Sydney; O=MEGA23 returns in Melbourne, held with the 4th World Congress of Optometry; Vision Eye Institute partners with Western Eye Specialists to create the largest private ophthalmology clinic in Melbourne.

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see Optometrist Warehouse become a household name and the go-to optometry service provider within the Australian market”.

It’s a bold plan, but Chemist Warehouse isn’t mucking around. It has appointed prominent industry figure Mr Peter Larsen as its managing director, as well as Mr Charles Hornor, to run the show. Both were instrumental in bringing Specsavers into Australia around 15 years ago, and in several events attended by Insight, there was a lot of curiosity about corporate optometry’s newest player.

In other changes to the optometry scene, George & Matilda Eyecare – now supporting more than 100 communities – revealed its blueprint for a rollout of audiology that promises to offer hearing care services beyond industry norms. This began in May 2023 via a pilot at George & Matilda Eyecare for Antonello Palmisani Optometrist, the company’s Leichhardt practice in Sydney.

The network also welcomed new additions including Mr Ian Brigden’s Nelson Bay practice in northern NSW, Wand Optometrists in Toukley on the Central Coast of NSW, and Joyce Optometrists in Melbourne.

Meanwhile, Vision Eye Institute (VEI) continued its expansion amid a leadership change in June that saw Ms Amanda Cranage, a long-standing member of the organisation, replace Mr James Thiedeman after 5.5 years of service.

Australia’s larger provider of private ophthalmology also partnered with Western Eye Specialists to create the largest private ophthalmology clinic in Melbourne. Taking effect from 1 July, all patients of Western Eye Specialists’ Maribyrnong location are now being seen at VEI’s state-of-the-art Footscray clinic, while patients attending Western Eye Specialists clinics in St Albans and East Melbourne will continue to have appointments at those locations.

VEI then announced in August that Boroondara Day Surgery in Victoria would join its Vision Hospital Group business, bringing the number of day surgeries it operates across Australia to 11.

In other acquisitions, it was a big year for ophthalmic industry giant Bausch + Lomb. The company in July confirmed the purchase of Blink eye and contact lens drops from Johnson & Johnson Vision for US$106 million (AU$155 m).

It came hot on the heels of a separate deal to take over the Xiidra prescription dry eye drug from Novartis. And earlier in the year, B+L brought AcuFocus into its fold, a privately held ophthalmic medical device company that has developed a small aperture extended depth of focus (EDOF) IOL, IC-8 (more about this on page 20).

WORKFORCE In a bid to shine a light on the harsh reality facing the optometry workforce, Specsavers released its second Deloitte Access Economics report showing that, on the current trajectory, Australia will have a shortfall of 1,102 full time equivalent (FTE) optometrists by 2042.

Queensland is expected to be the hardest-hit state. Unsurprisingly, the deficit is expected to impact rural areas most, with an approximate shortage of 799 FTE optometrists over the next two decades. In urban areas the shortage will be less significant, totalling 303 FTE optometrists. It’s a concerning trend, the company says, especially considering that within its own network around 40% of Australian locations currently have an unfilled optometry vacancy.

Meanwhile, the supply and demand of ophthalmic professionals influences wages, and the latest data from the Australian Tax Office shows that male ophthalmologists again reported the largest annual taxable income out of all occupations in Australia ($703,700).

In the latest available data (from the 2020-21 financial year), the figures showed that female ophthalmologists earn $346,100 on average, while the average taxable income for optometrists (both men and women) was $106,800, optical dispensers $45,500, orthoptists $68,200 and practice managers $80,800.

Elsewhere in August, Specsavers was named one of Australia’s Best Workplaces for 2023 by Great Place To Work, a global authority on

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workplace culture. The optometry provider was ranked 8th in the Best Workplaces in Australia list in the large (1,000-plus employees) category, featuring alongside companies like Cisco, Hilton, DHL Express and Marriott International Australia.

KEY DECISIONS AND POLICIES Tariff pain experienced by eyewear wholesales continued this year.

An Australian Border Force (ABF) decision in 2022 to impose a 5% border tax on acetate eyewear – which blindsided the industry and was triggered by Port Macquarie manufacturer Optex Australia – was upgraded to also cover metal frames in 2023.

After learning of the AFB’s decision to cover both metal and acetate frames, Safilo Asia Pacific senior director Mr David Pearson said at the time it was “a very poor decision and will only result in putting additional costs on consumers and pressure on the industry”.

Eyewear suppliers have been pinning their hopes on a 2024 free trade agreement with the European Union – where the majority of imports come from – but this now appears dead in the water after Trade Minister Mr Don Farrell said on 30 October that both sides have been unable to make progress.

In one of the most-read stories of 2023, the National Health Practitioner Ombudsman (NHPO) announced it was reviewing the way Australian Health Practitioner Regulation Agency (Ahpra) handles vexatious complaints.

The Australian Society of Ophthalmologists supported the Australian Medical Association’s position that the handling of vexatious complaints – and the notification process broadly – must be improved. The body said it was imperative Ahpra addressed growing distrust of the regulator, and cases where people can make a false complaint and face no repercussions regardless of the impact on the doctor’s life.

In a win for ophthalmic surgeons, a new law was passed in September restricting use of the ‘surgeon’ title. Prior to this, any registered medical practitioner could refer to themselves as a ‘surgeon’ without completing specialist surgery training or being registered in a surgical specialty, a loophole that was being exploited by rogue operators in the cosmetic industry.

From now on, ophthalmology, obstetrics and gynaecology are the only specialities that can now refer to themselves surgeons, with those found misusing the title facing potential criminal prosecution with a maximum fine of $60,000- or three-years’ imprisonment, or both.

Globally, one of the biggest health stories of the year was the contaminated eye drops saga in the US that saw 14 patients suffer vision loss, an additional four requiring enucleation (surgical removal of the eye), and four deaths, in the latest data. The outbreak of a lethal drug-resistant bacteria strain has been linked to an alleged eye drop manufacturing breakdown at Global Pharma Healthcare in India.

PEOPLE AND LEADERSHIP Legendary Western Australian ophthalmologist Professor Graham Barrett received another accolade in 2023 when he was inducted into inaugural Ophthalmologist Power List Hall of Fame. Barrett is perhaps best known as ophthalmic innovator, helping develop the world’s first foldable IOL implanted in 1983, the Barrett Toric Formula and Calculator, as well as the Rayner RayOne EMV, the first and only available IOL optimised for use with monovision.

The Ophthalmologist magazine’s new initiative honours ophthalmologists and scientists whose impact on the field will last beyond their lifetimes. Barrett was the only Australian and among 10 recipients to make the inaugural list. Each year from now will see five new figures inducted.

But Barrett wasn’t the only Australian ophthalmologist recognised by The Ophthalmologist magazine in 2023. The publication also compiles an annual Power List featuring the world’s top 100 eye doctors. Featuring this year was South Australian Dr Ben LaHood for the first time who, at 39-years-old, was the youngest Aussie to make the list. Others included were Sydney’s Professor Stephanie Watson, WA ophthalmologist

FEBRUARY

Professor David Mackey, Professor Mingguang He, who has affiliations with the Centre for Eye Research Australia (CERA) and The University of Melbourne, and New Zealand’s Professor Helen Danesh-Meyer who made the top 20.

Optometrist Warehouse enters optometry market.

The Australian ophthalmic sector never has a shortage of honourees in the King’s Birthday Honours (previously Queen’s Birthday Honours). This year there were 10, with the most notable being posthumous recognition of Mr Richard Grills – a former ODMA board chair and founder of Designs For Vision who passed away in July 2022.

He was awarded Member (AM) in the General Division, alongside other industry recipients: Clinical Associate Professor at The University of Sydney Dr Andrew Chang (AM), Distinguished Professor Justine Smith (AM) from Flinders University, oculoplastic reconstructive and cosmetic surgeon at St Vincent’s Private Hospital Sydney and Mater Hospital Dr Brett O’Donnell who was awarded Medal (OAM) in the General Division, UNSW Scientia Professor Fiona Stapleton awarded Officer (AO) in the General Division, chief scientist innovation officer at BHVI Conjoint Professor Arthur Ho (AM), the Lions Eye Institute’s Dr Margaret Crowley (AM), CERA research fellow and clinical orthoptist Dr Sandra Staffieri (AO), Scientia Professor Rebecca Ivers (AM) who is an epidemiologist and former optometrist at UNSW, and Professor Alice Pébay (AM) from The University of Melbourne.

APRIL Optical Dispensers Australia hosts inaugural national conference.

MAY George & Matilda launches audiology service.

This year also marked several high profile leadership changes.

Australia’s Professor Peter Hendicott ended his term as president of the World Council of Optometry, replaced by American Dr Sandra Block.

There were changes to the Vision 2020 Australia Board too, with CEO of Guide Dogs NSW/ACT Mr Dale Cleaver and Melbourne optometrist and former Optometry Australia president Mr Murray Smith joining the fray, and former Orthoptics Australia president Ms Jane Schuller elected as deputy chair.

Elsewhere, Oculo co-founder and former CEO Dr Kate Taylor started a new position within iCare as vice president of strategy and business development. This came about after Finnish company Revenio – which supplies ophthalmic devices under the iCare brand – acquired the Oculo e-referral platform in 2021.

THERAPIES AND EQUIPMENT Myopia management dominated headlines as far as the latest ophthalmic technology is concerned.

JUNE Ten industry professionals recognised in King’s Birthday honours.

JULY Eyewear imports tariff extended to metal frames.

Of most interest was the new Eyerising Myopia Management Device

by Australian-based firm Eyerising International. A new approach, the technology is based on repeated-low level red-light (RLRL) that gently stimulates blood flow in the retina, helping to slow the elongation of axial length and control myopia progression. The company reports that studies have demonstrated children who undergo RLRL for three minutes twice a day, five days a week, experience a significant reduction in myopia progression over a 12-month period, with a 69.4% efficacy in controlling axial length elongation and a 76.6% efficacy in managing myopia progression.

In October, the company addressed questions over the safety of the device, following two case reports on a probable “super responder” who experienced afterimages and vision loss, but ultimately made a full recovery. The patient is among five cases of significant adverse side effects reported among the 80,000 daily users of the device in China. At a rate of 1:20,000, the company reported that side effects with RLRL are extremely rare.

Spectacle lens myopia control interventions were also a hot topic in 2022 and the trend continued this year. Rodenstock and ZEISS Vision Care became the latest to launch lenses in this space with the respective MyCon and MyoCare lenses. What’s interesting about MyoCare is that it’s an age-related solution comprising two lens design options, depending on whether the child is under the age of 10, or 10 and older.

HOYA also continued its leadership in this space, with two new sun lens options for its MiYOSMART range: MiYOSMART Chameleon – photochromic spectacle lenses, offering an all-in-one solution, and MiYOSMART Sunbird – polarised spectacle lenses that complement

SEPTEMBER Prof Graham Barrett inducted into inaugural Ophthalmologist Power List Hall of Fame.

OCTOBER RANZCO Congress takes place in Perth, with almost 1,500 in-person delegates.

NOVEMBER Specsavers report reaffirms major optometry shortage in future.

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addition to MiYOSMART clear spectacle lenses.

It was a milestone year for the macular disease community too after the US approved the first-ever therapy for geographic atrophy (GA) in February. Developed by Apellis Pharmaceuticals – and not yet available in Australia – SYFOVRE (pegcetacoplan injection) targets complement C3 and was heralded as the most important event in retinal ophthalmology in more than a decade.

The approval was followed by a second GA therapy approval in the US in August, with Iveric Bio’s IZERVAY (avacincaptad pegol intravitreal solution) – a complement C5 inhibitor – cleared following the GATHER1 and GATHER2 Phase 3 clinical trials.

In dry eye, Australian practitioners welcomed a new treatment approach from InMode – a provider of medical aesthetic devices – which entered the local ophthalmic scene with its Envision platform, featuring three devices encompassing radio frequency and intense pulsed light technologies.

KEY EVENTS AND TRADE SHOWS The return of O=MEGA23, this time in combination with the 4th World Congress of Optometry, after four years was the highlight on the ophthalmic event calendar. It was a chance to present the Australian optical industry to the globe and it didn’t disappoint, with more than 3,500 people attending, including 200 international visitors.

The RANZCO Congress is always a highlight – and this year it headed to Perth where almost 1,500 delegtes heard the latest updates from a high-powered speaker line-up, including neuro-ophthalmology global authority Professor Neil Miller.

Insight also headed to Sydney four times to attended the inaugural Optical Dispensers Australia national conference and Specsavers Partner Seminar – both in April – the Ophthalmology Updates! conference in August, and Specsavers Clinical Conference in October.

RESEARCH One of the most interesting papers of 2023 was on the topic of artificial intelligence (AI) by researchers at the Centre for Eye Health, School of Optometry and Vision Science, UNSW Sydney, including - PhD candidate Ms Sharon Ho, Associate Professor Gordon Doig and senior lecturer Dr Angelica Ly. Their myth-busting work found, on average, that Australian optometrists had positive attitudes towards using AI as a tool to aid the diagnosis of retinal disease. Participants surveyed also agreed there will be an overall need for AI in primary eyecare and were excited by future increased use.

“This is promising for the future implementation of AI clinical decision support systems into clinical practice as it suggests that optometrists’ attitudes will not be a major limiting factor,” the researchers noted.

It could be argued the debate around blue light blocking lenses was put to bed by a group of University of Melbourne researchers in 2023.

Associate Professor Andrew Anderson and Associate Professor Laura Downie presented their work at O=MEGA23, comprising a review of several randomised controlled trials that found these lenses probably make no difference to eye strain caused by computer use or to sleep quality. Nor did the study find any evidence that blue-light filtering lenses protect against damage to the retina.

Finally, in a world first, Flinders University’s Professor Jamie Craig will lead a trial on the use of selective laser trabeculoplasty (SLT) as a preventative measure in high risk glaucoma patients. With $1.7 million in funding, the study will determine the effectiveness and suitability of SLT laser as an early intervention to prevent the onset of visual loss from glaucoma.

REPORT

F ighting fit LONGEVITY IN AN OPHTHALMIC CAREER

Take note of your posture as you read this: startling new statistics show the vast majority of eyecare professionals, including ophthalmologists, optometrists and orthoptists, suffer from musculoskeletal pain and injuries.

New statistics show the majority of eyecare professionals suffer from some form of musculoskeletal pain or injury.

he physical demands of ophthalmology and other eyecare professions may seem minor to more labour-intensive careers on the face of it. But repetitive stress due to compromised body positions during precise tasks can culminate in insidious injuries to the neck, lower or upper back, wrist and hand.

T

and ophthalmologist. I got to the point where I couldn’t operate without having pins and needles in my left hand and intense pain in my elbow and eventually some weakness as well,” he says.

Duty of care and accommodating the needs of the patient are the cornerstones of any health profession. Unfortunately, in these instances, the practitioner’s needs are often overlooked.

Raising awareness of sustainable ergonomic setups is essential for maintaining quality-of-life. There’s also duty of care considerations for patients; it’s vital musculoskeletal fatigue does not impact results.

This is reflected in a recent study by Taison et al. (2023), published in Cureus, which found that up to 66.7% of eyecare professionals experience musculoskeletal pain and injuries.

Beltz adds: “Stability during fine tasks is extremely important and can be compromised in the setting of discomfort. Most importantly though, injuries can lead to chronic problems such as headaches, musculoskeletal pain or neurological issues that not only can result in early end to careers, but in the worst cases, can reduce quality-of-life.”

It included 514 practising ophthalmologists, optometrists and orthoptists and, among the participants, 43.8% were younger than 30 years. More than half of ophthalmologists reported experiencing at least one type of pain, either in the lower back (39%) or neck (32.6%).

Furthermore, the study revealed the influence of age and gender, with 76.2% of women and 71.4% of those aged over 50 suffering from pain or injury and a high prevalence with existence of comorbidities – 92.2%.

These injuries are also associated with low productivity, with correlations between back pain and work stress.

These statistics speak to the importance of ergonomics, which industry figures say is generally not reinforced during training or in the workplace.

It also emphasises why correct posture and equipment setup shouldn’t be an oversight.

Melbourne-based ophthalmologist and director of educational platform GENEYE, Dr Jacqueline Beltz, is among the few eyecare professionals who have indoctrinated positive habits into their work routine. Having seen the majority of her colleagues suffer from musculoskeletal issues due to the demands of the profession, she uses her platform to drive awareness of the importance of ergonomics and physical health in her community.

“I personally know eight ophthalmologists that have needed to undergo neck surgery. Thankfully they are all doing well, and the injury or surgery has not been career-ending for any of them, but that number is extremely alarming,” Beltz says.

Ophthalmologist registrar Dr Rogan Fraser is among the many casualties of poor ergonomics. He recently underwent neck surgery to correct the cumulative impact of unaccommodating work environments.

“I had to have surgery on my cervical spine about halfway through last year, probably from a cumulative experience being both an optometrist

“I was left with this existential crisis of: can I continue doing the job that I love?”

RISK FACTORS Adelaide-based industrial physiotherapist Ms Lisa Harman has dedicated her career to physical longevity in the workplace through instilling manual handling principles into everyday life and works with eyecare professionals to ensure sustainable working conditions. Her ambitions as a physiotherapist are to identify her patients’ goals and help them to nurture that through targeted functional solutions. This includes working closely with eyecare professionals, where she optimises the way they work to ensure they employ neutral posture in their scope of daily tasks.

Key aggravating factors that contribute to musculoskeletal pain and injuries are sustained repetitive movement and awkward, or rigid positioning. These arise with continuous use of slit lamps, surgical microscopes, patient examinations and performing microsurgery.

“I PERSONALLY KNOW EIGHT OPHTHALMOLOGISTS THAT HAVE NEEDED TO UNDERGO NECK SURGERY. THANKFULLY THEY ARE ALL DOING WELL, AND THE INJURY OR SURGERY HAS NOT BEEN CAREER-ENDING FOR ANY OF THEM.” DR JACQUELINE BELTZ

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when the patient has musculoskeletal issues or discomfort,” she says.

“Whilst patient chair, doctor chair, table height and chin rest height are all adjustable, there are still some fixed variables and patients come in all shapes and sizes so sometimes we just have to be uncomfortable.”

The Cureus study showed that aggravating factors can include the number of consultations with patients, surgeries and laser treatment sessions. Others include how dynamic the surgeons are and if each specialisation requires sustained rigidity. Additionally, the type of equipment used in each specialisation, such as slit lamps and surgical microscopes, can be a contributing factor.

Of those who examined more than 150 patients per week, 72.4% experienced musculoskeletal pain and injuries, 85.7% of those performing more than 20 surgeries, and remarkably, 100% of those who performed more than 20 laser treatments.

Fraser cites laser eye surgery among the most notoriously strenuous procedures to perform in his discipline.

“The laser procedures are, personally for me, really awkward to perform.

I’ve spoken to some of my colleagues who have really awful neck and back pain because their hands are outstretched and at the end of its range. And you have to keep your hands still because you’ve got something touching the patient’s eye and then of course, you’re operating an ostensibly dangerous piece of equipment. So again, there’s a little bit of tension in everything else as well,” he says.

General ophthalmologists, cataract, cornea, refractive and glaucoma surgeons and medical retina sub-specialists are more at risk to have back pain than paediatric ophthalmologists, neuro-ophthalmologists, oculoplastic surgeons and retina surgeons, as the latter disciplines are more dynamic in the clinic.

“We have all been brought up on patient-centred care and of course the patient’s comfort comes before ours, but sometimes this does lead to me having neck or back pain at the end of a case,” Beltz says.

Dr Rogan Fraser had spinal surgery due to his cumulative experience as an eyecare professional.

“A lot of what they’re doing is with tools and with their hands, whether it might be using a slit lamp, changing lenses or operating on someone. This palm-down grip that they employ is leading to a lot of tennis elbow, and carpal tunnel injuries. They’re probably the more common injuries we tend to see in this population,” Harman says.

Neck and upper back issues can develop by looking through lenses or microscopes and not adjusting the height adequately to accommodate, resulting in forward neck posture.

“We’re also finding that people have musculoskeletal issues in their dominant shoulder from over reaching and we are finding they’re getting issues in their wrists from the repetitive wrist deviation when clicking different lenses. We definitely see a lot of forward head posture when they look into these lenses because there’s quite often a gap between the patient and the practitioner if the set up is not aligning to ergonomic principles,” Harman says.

The rigidity of clinical equipment contributes to the positioning of these items at incorrect height adjustments, so the worker’s posture is often altered to accommodate – instead of the equipment being suitable for the worker.

In Beltz’s experience, she finds correct posture more difficult to achieve at the slit lamp compared to the operating room.

“In general, in the operating room everything is adjustable and the first thing we do is set up the chair height, the table height and the microscope position and oculars to make sure that we can see well and stay steady, which basically correlates with being comfortable. But this can go wrong

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Fraser adds: “I remember a doctor said to me once, ‘If the patient is uncomfortable, that’s a moment of discomfort for the patient while you’re examining them versus potentially a lifetime of discomfort for you. You have to get it right’.”

PREVENTATIVE MEASURES – THE FIRST LINE TREATMENT “The best treatment is prevention,” Harman says.

Surgical procedures require extensive, tailored planning for the best possible patient outcomes. This should also include making a conscious effort to adopt proper positioning of oneself and the patient to improve durability and prevent fatigue.

According to Harman, maintaining neutrality is crucial in avoiding awkward posture and mitigating neck and back issues. When treating a patient, whether in the clinic or operating theatre, it’s advised ophthalmologists avoid leaning into the patient via stooping through their spine and over-reaching. Instead, shoulders should be relaxed, scapulae engaged, tilt the pelvis in the direction of the task to get closer to the patient whilst aiming for relaxed forearms.

Harman suggests adopting an anterior pelvic tilt for seated tasks which

“IF THE PATIENT IS UNCOMFORTABLE, THAT’S A MOMENT OF DISCOMFORT FOR THE PATIENT WHILE YOU’RE EXAMINING THEM VERSUS POTENTIALLY A LIFETIME OF DISCOMFORT FOR YOU. YOU HAVE TO GET IT RIGHT.” DR ROGAN FRASER

a lot of people do not incorporate into their normal range of motion.

This entails tilting the hips forward as opposed to planting hips and leaning forward with the upper back and neck – which is where she sees ‘stooping’ and unnecessary load bearing through the discs in the spine.

Saddle seats are useful in promoting and maintaining this position.

Neutrality in the upper neck can also be achieved by performing chin tucks, which involves retracting the chin back to the neck without tucking the chin to the chest.

In the operating room, Beltz says it’s important to have both feet firmly planted on the foot pedals to balance properly.

“If this means changing the table height; just take the time to do it. I also recommend using the brake on the operating stool as this reduces musculoskeletal load required to keep yourself still. Think about the position and support of your arms as well as the tilt of the eye pieces. In general, we want to have our neck slightly flexed into a chin-tuck position, rather than extended or chin forward,” she says.

Harman suggests the use of makeshift ergonomic arm rests to prevent unsupported forward reaching, which has been employed by a number of ophthalmologists to stabilise the ‘reaching’ arm when utilising a slit lamp.

“We’ve had a few ophthalmologists get a foam yoga block made to the height they require. And then they’ve been able to rest through the length of that and then it’s only their wrist that’s changing things. They’ve found it makes them feel a lot more comfortable as they have an additional base of support and there is less scapula stabilisation required,” Harman says.

Experts recommend incorporating preventative measures into routines when they are examining patients and performing surgery early in their careers. Incorporating movement into their regime is a key mitigating factor, according to the Cureus study findings, which showed 68.3% who don’t do running exercises suffer from injuries.

Systems like the Alcon NGenuity can improve posture. The surgeon wears 3D glasses and views the surgery on a high-definition screen instead of looking down a microscope.

As repetitive movements result in cumulative injuries, the key is to actively roster movement into the work schedules and break up the monotony of tasks to reduce likelihood of injury.

Beltz describes her movement regime: “I personally do physio-led Pilates as well as daily neck and back exercises to counteract the fixed postures that I employ during the day. I also see a myotherapist, have acupuncture and enjoy meditation and deliberate cold exposure.”

REPORT

movements during their most-performed tasks.

“We’ve had some great follow up from those conferences as well. We quite often get ophthalmologists emailing us for information and we’re giving them resources that make such an impact in their day-to-day function. And every year that tends to change a little because the more we can understand about their role and the changes that they’ve been making, the more questions they have,” Beltz says.

In addition to the ergonomics station, GENEYE 2023 featured a station run by Fujitsu. The station showcased the company’s digital twin technology that collects data from the real-world using cameras and sensors, reproduces the real world in a virtual space, and then carries out precise simulations to provide data that might improve practice.

Applications of this technology thus far include its use in the manufacturing industry to improve safety at work. At GENEYE 2023, the technology was used to assess posture while sitting at the slit lamp. This tool can be used to initiate important conversations about ergonomics.

“Something that we can all do is have this conversation with colleagues, especially those that are junior to us, and have reminders to look after ourselves,” Beltz says.

THE FUTURE OF ERGONOMICS FOR EYECARE PROFESSIONALS At GENEYE 2023, technology was used to hold practitioners accountable with their ergonomics. This included 3D surgical visualisation surgical systems and virtual reality simulation.

“PEOPLE HAVE MUSCULOSKELETAL ISSUES IN THEIR DOMINANT SHOULDER FROM OVER REACHING AND WE ARE FINDING THEY’RE GETTING ISSUES IN THEIR WRISTS FROM THE REPETITIVE WRIST DEVIATION WHEN CLICKING DIFFERENT LENSES.” LISA HARMON Rotating rosters is another strategy; injuries can be caused by completing clinical and operating work in succession, with no break in movement. Harman suggests reducing repetitive and sustained exposure through reduction of clinic and theatre shift times and alternating between the two to provide variation in movement.

“It’s not about not doing clinic and surgery work. It’s about rotating them as much as possible to avoid the exposure to prolonged levels of repetitive and sustained force,” Harman says.

THE GENEYE PROGRAM AND PROACTIVE ERGONOMICS GENEYE is an education platform that Beltz established on behalf of Eye and Ear Education in Melbourne 2019. The program uses modern educational strategies such as peer-to-peer learning, virtual reality simulation and coaching psychology for ophthalmologists striving for high performance, longevity, happiness and, consequently, excellent results.

It features an annual immersive workshop aimed at learners from all aspects of eye health. Topics vary each year, but always includes stations for surgical, mind and physical health training.

The immersive workshop in 2023 partnered with Harman, who guided the popular ergonomics station. It’s designed to educate on safe manual handling principles and ergonomics. Here, Harman and other expert physiotherapists, ergonomists and manual handling specialists demonstrated desk and slit lamp related strategies to prevent and manage musculoskeletal injuries, showing them sustainable posture and

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Technology, such as the Fujitsu digital twin, may one day start conversations, with Beltz and Fraser hoping that it will hold eyecare professionals accountable for their posture and positioning.

“Like how fitness trackers today remind us to get up and move, I would like to see slit lamps telling us to sort out our posture,” Beltz says.

Fraser adds: “What I’d love to see is slightly better technology. Whereby ergonomics can be more adaptable, certainly in the consulting room.

I even think there’s more scope to individualise the ergonomics in the operating theatre.”

In other developments, 3D surgical visualisation surgical systems can offer intraoperative views, and with advancements, that may provide ergonomic advantages in future. In these systems – like the Alcon NGenuity system and ZEISS Artevo 800 – the surgeon wears 3D glasses and views the surgery on a high-definition screen instead of looking down a microscope.

“So far, physical limitations limit the ergonomic advantages a little bit, but as they improve, I think we will see benefits,” Beltz says.

“As these operating systems improve and then become normalised, I would like to see them extending into the clinic as well. Visualisation is better with digital systems anyway and, ergonomically, the advantage is massive.”

Looking ahead, Beltz says it is necessary for ophthalmologists to instil good habits as early as possible before growing accustomed to a particular way of working.

“In the shorter term, I hope to see education continuing from day one of ophthalmology and optometry training. There’s a bit of a learning curve when you switch from flat to tilted eyepieces on your slit lamp, but it’s definitely worth it. If you do it from day one that learning curve becomes irrelevant,” she says.

The GENEYE 2024 workshop will feature similar ergonomics stations as per previous years, with physiotherapists present to provide group based and individual level preventative strategies, postural suggestions, exercises and support.

“We also look forward to seeing how Fujitsu progresses their technology over the next 12 months. The digital twin technology is really exciting, and we expect further improvements and the ability to analyse angles, postures and suggest corrections,” Beltz says.

“At GENEYE we like to say that we look after ourselves and each other, so that we can adequately serve our patients.”

MANAGEMENT

PRACTICE MANAGEMENT

Pearls

Good management is essential for the effective operation of complex workplaces like optometry and ophthalmology practices. Insight speaks to three leading practice managers about their philosophies and daily practices that set them up for success.

M

s Belinda Musitano owns and operates three independent optometry practices, a journey that began 18 years ago when she opened her first practice in Australind, Western Australia. Over time, her business has steadily expanded, with two more locations in Dalyellup and Falcon.

In addition to being the director of a three-practice business, Eyes @ Optometry, she doubles as an optical dispenser and practice manager. The ups and downs of independent practice ownership have armed her with a plethora of knowledge on how to manage successful businesses.

In this article, Musitano describes the unique skillset she has obtained during her time as a business owner and manager. Later, Ms Lara Sullivan and Ms Lucy Peters detail how they navigate specialised equipment requirements, patient expectations and scaling of their ophthalmology practices.

Musitano highlights the importance of rostering and monitoring the location of staff as one of the biggest challenges in managing several practices. Also, stock management, database maintenance and running effective and accurate marketing are other vital components, while ensuring recalls and record-keeping are properly managed.

According to Musitano, transitioning from single practice management to multiple practices requires a scalability plan, with plenty of due diligence about what is required for a particular set of practices.

“Things to be considered with scalability include choosing an on-site or remote database, setting up online appointments with ease of choosing location, rostering systems, purchasing stock in bulk and splitting to get

better discounts, and having certain practices ‘specialise’ in different eye health areas to meet needs,” she says.

In terms of rostering, Musitano was able to use an Excel spreadsheet to maintain and track staff. As the team grew, she moved across to Deputy which allows timesheet tracking, staff leave requests and rosters to be managed effectively and easily. She says that with expansion, business owners need to think laterally and find what works for their clinic dynamic.

“In terms of our rostering, we had a very basic rostering system when we had just the one practice,” Musitano says. “I transitioned to Deputy as it integrates with Xero and allows seamless exporting for timesheets and payroll, as well as leave being allocated correctly.”

“COMMUNICATION BETWEEN SPECIALISTS AND THEIR REFERRERS IS KEY TO ENSURING BEST QUALITY, CONTINUITY AND TIMELY PATIENT CARE.” LUCY PETERS GORDON EYE SURGERY

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Communication underpins everything at Gordon Eye Surgery, which has significantly expanded since its foundation in 1993.

“At O=MEGA23, I realised some practices also don’t utilise follow up SMS to patients, to check how their new glasses are going or regarding contact lens trials. They’re also not using categories to mark patients with dry eye, online database functions for new stock/lens codes and easy Medicare claiming for private billing practices, among others.”

In retrospect, Musitano says she would have been more proactive in capturing more patient data from the outset.

“I would have ensured that the team were getting email addresses, marking patient categories, adding in ‘source/referred from’ details for every single patient. This can then be used to re-market new clinical advances and products that were targeted to those patients. We now capture all that data,” she says.

More strategically, a major driver of her success is dedicating time to define her goals and establishing a formal marketing plan. That way, she doesn’t have to improvise throughout the year.

“It's always about taking time out to set goals. I set annual goals at the beginning of each year and then work out a quarterly plan to meet those goals. These are reviewed monthly and relayed to the team at a staff meeting,” Musitano says.

The next important step is staff engagement to ensure everyone is united and behind the business’ philosophy. This is especially important during the scale-up.

“It’s important to take time out of the practice or hold a management day where you're sitting down and actually writing down what you're hoping to achieve in that year and making a plan around that,” she says. “And when you're wanting to take a different approach, you’ve got to carefully communicate that to your team, so that nothing's missed.”

The cornerstone of any well-oiled practice is a comprehensive IT system that integrates the most important aspects of management into a single location. When Musitano selects software, she looks for its data capabilities and the type of information it can hold. Her practice management software, Optomate, has consulting, dispensing, reporting and marketing capabilities.

Accessibility, updating capabilities, and real-time reporting to determine how the practice is tracking against projected targets were among her most desired features.

In terms of patient communication, she says it’s about ensuring SMS and emailing capabilities are integrated with the main database, as well as with Medicare and health insurance providers.

One of the inevitable downsides of running an optometry practice is software failures. To mitigate this, Musitano backs up her clinics’ critical data every day and reverts to paper patient records if the system is not working that day. Her email database is exported to Mailchimp and the patient management system, HotDocs, is exported to maintain the ability to run recalls if systems are down.

She also advises other practice managers to become proficient with their software systems, noting there are often untapped features within the software than can enhance the user experience. She urges managers to stay informed about new integrations and functions and capitalise on these functions.

“Part of the problem is that software providers don't actually provide that much training. Once you figure out these extra, little functions, it can make your life much easier,” she says.

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MANAGING PATIENT EXPECTATIONS Sullivan, with a background in nursing and human resources, co-founded Bayside Eye Specialists ophthalmology practice with her husband, Dr Laurence Sullivan, 18 years ago. The Melbourne-based practice began with just the two of them and has since undergone significant expansion, adding 10 associate doctors and 22 staff.

Sullivan wanted to create a multidisciplinary practice that covers a wide range of sub-specialities within ophthalmology.

Managing an ophthalmology practice comes with its own specific set of challenges, says Sullivan, especially with the effects of the Melbourne lockdowns still lingering.

“We're still seeing a backlog of patients. We're seeing more advanced disease that we wouldn’t have normally seen, so consultations can take longer. Currently, we've got waiting lists for three to four months for most of our doctors, but obviously we'll always prioritise emergencies,” Sullivan says.

Ophthalmology, as a specialty, entails high overhead costs.

“Ophthalmology has the second highest overheads, with radiology being the only other discipline that beats us. The equipment that we use is very expensive and we have more clinical staff who support our doctors compared to someone like a dermatologist or orthopaedic surgeon. There are considerably more expenses involved,” she says.

Sullivan notes that staff retention is an ongoing industry issue. She therefore emphasises the importance of maintaining a positive workplace culture and to look beyond just the skillset during recruitment; this has contributed to a reduction in turnover in her practice.

“We've got a great culture in our organisation. We work hard to support our doctors, patients, and referrers, which are our optometrists and GPs, and to also support each other,” she says. “We have a flat management structure. I don't manage from the top down and everybody's input is taken into account.

“I will always recruit for attitude. I can teach people most things and I think a lot of specialist practices do themselves a disservice by only looking for someone with experience. If you've got someone with a fabulous attitude and they're willing to learn, and you give them an opportunity, they're going to be grateful and return it to you in spades.”

Sullivan’s practice focuses on patient triage, ensuring patients see the most suitable doctor for their condition. Post-operative consultations are grouped at the beginning of the session and she avoids booking new patients together.

At the same time, managing patient expectations is crucial, considering they may spend a long time in the clinic.

“For instance, undergoing scans and having your pupils dilated – all these things can take time. If we've managed to communicate that appropriately, then their expectations will be met,” she says. “I think managing expectations

is probably the single biggest issue in ophthalmology.”

Sullivan notes the platforms she uses for patient communication.

“We use Zedmed patient management software for admin and clinical, and are relatively paperless. Zedmed has an intra-mail component which links to the patient file which is great for documenting conversations or other notes.

We send SMS reminders from Zedmed to patients and use HotDoc for patients to complete their initial registration form which reduces the risk of errors in data input.”

As the director of a three-practice business, Belinda Musitano doubles as an optical dispenser and practice manager.

Given the unique needs of the specialty, Sullivan’s practice uses niche software that helps manage images and specialised equipment. However, managing large data storage can be challenging, which is mitigated by an efficient IT support system.

For example, the clinic has implemented ZEISS FORUM software that connects ophthalmic devices to provide access to all patient examination data.

“We're a ZEISS-heavy practice. We have the ZEISS visual field tester, IOL Master and OCT and, and with this being supported by the FORUM software, it allows the doctor to easily compare the visual fields and the OCTs to track what’s happening over time,” Sullivan says.

“We also export data from the IOL Master to a thumb drive which the surgeon can insert in the Callisto operating microscope which streamlines surgery.”

In retrospect, Sullivan would have built a more substantial practice from the beginning to accommodate expansions. Despite undergoing renovations, space is still a concern.

“I always say to younger ophthalmologists to allow for growth. The footprint for our equipment is significant,” she adds.

Finally, Sullivan says she’d like to see more collaboration among practice managers to strengthen the industry.

“I’d love to see more practice managers coming along to the RANZCO Practice Manager’s Conference. Running alongside RANZCO, it’s a fabulous program, and allows for practice managers to network with each other,” she says.

COLLABORATION AND COMMUNICATION Peters manages the NSW ophthalmology practices Gordon Eye Surgery (GES) and Lane Cove Eye Surgery (LCES) with business manager Ms Donna Glenn. Established in 1993, the practice has expanded from an initial two doctors in five rooms and two receptionists and orthoptists, to 22 doctors in 15 rooms with 40 support staff.

She emphasises the importance of communication across the business, while ensuring the team are familiar with the doctors' needs.

“This is to ensure that patients receive the best possible care and high-quality diagnostics and treatment; and continuing with ensuring patient expectations are managed expertly and with compassion, from their first contact throughout their visit and beyond,” Peters says.

The clinic uses technology, including an online manual and Practice Hub, for efficient management. Peters also organises monthly staff meetings and an annual staff symposium to keep everyone updated and provide perspective, with the final session led by a patient. Peters suggests scaling

“IF YOU'VE GOT SOMEONE WITH A FABULOUS ATTITUDE AND THEY'RE WILLING TO LEARN, AND YOU GIVE THEM AN OPPORTUNITY, THEY'RE GOING TO BE GRATEFUL FOR THAT AND THEY'RE GOING TO RETURN IT TO YOU IN SPADES.” LARA SULLIVAN BAYSIDE EYE SPECIALISTS

the practice according to doctor-to-staff ratios while ensuring key staff can spread the right message across the practice.

Streamlining the typing, checking and sending of reports has also been crucial to provide quick turnaround for communicating patient letters.

Dragon, Argus, Healthlink, GoFax, and off-site staff accessing their remote desktop using software setup by IT support, Solutions First, have all meant that letters are often received by health providers involved in a patient’s care the day after a consultation, if not on the day of consultation.

“This communication between specialists and their referrers is key to ensuring best quality, continuity and timely patient care, as well as collaborative relationships and improved patient satisfaction,” Peters says.

She says that space and support staff were primary challenges in scaling the practice. She would have introduced greater physical and digital storage capabilities early on as they have since had to double the consulting rooms to accommodate the growing number of doctors. Scalable servers and reliable IT support were essential to manage the large storage needs associated with digital records.

The transition to digital-only management has also been a complex and tedious task at times, as the clinic – like all health providers – is obliged to maintain physical records for seven years. Scanning and shredding services provided by Activscan have also been an ideal way to convert files from paper to electronic records since 2014, ensuring patient information is readily available – even in an emergency.

“We're just getting to the end of scanning the existing files and making sure all the patient files are accessible,” Peters says.

When choosing software, Peters emphasises the importance of security and cost-efficiency. Subscription-based software with fixed fees does not always align with the nature of its business, as fees are charged per head count. As some staff can only work one day per week or fortnight, this is largely cost-inefficient. She encourages vendors to offer full-time equivalent subscriptions for increased uptake.

GES uses an online platform for new patient registration by Aura Health that integrates with VIP.net to ensure patients are ready to be seen as soon as they arrive at clinic, significantly reducing the time and anxiety surrounding their initial interaction with ophthalmology. However, given many patients have ocular disease, text-based reminders are not always effective. The clinic also uses appointment cards but is exploring ways to improve accessibility.

Peters says much of the patient demographic are also unfamiliar with digital platforms. In fact, the majority of inbound phone calls are for appointment confirmation.

“We are exploring ways to improve the inherent accessibility issues with text-based communications, including making text size malleability prominent on our website and improving speech-to-text functionality,” she says.

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DISPENSER, OWNER AND A COMMUNITY CHAMPION DISPENSER DETAILS

Name: Bobby Bugden Position: Owner Location: Be Seen Eyewear Lismore and Ballina Years in industry: 3

What initially attracted you to a career in optical dispensing?

Through my father in-law Greg Hickey. He has 40 years’ experience as an optical dispenser and has built his two practices – Be Seen Eyewear – from the ground up. Through various conversations, Greg provided insights into the profession and what opportunities it presented individually, as well as for my broader family – continuing the legacy of an independent, family-run practice.

What are your main career highlights?

Although my optical career is relatively short, becoming a qualified optical dispenser through ACOD, which then led to shared partnership of Be Seen Eyewear in Lismore and Ballina are the two stand outs. The relationships with colleagues of the optical community as well as the patients is also a significant highlight.

What are your strengths as an optical dispenser, and what excites you?

I find it difficult giving myself praise, but my biggest strength is build trusting relationships with patients. What excites me is being able to aid patients in improving their quality-of-life by meeting their optical needs.

What advice would you give yourself at the beginning of your optical career?

To be a good dispenser it takes time, despite your best efforts you can’t learn everything at once and, in fact, you’ll never stop learning.

How do you ensure your skills and knowledge stay up to date and current in such a fast moving industry?

I stay up to date through conferences such as O=MEGA, our lab HOYA who organise training days, organisations such as ODA and ACOD through their resources such as webinars and training, as well as networking with people in the industry that are highly skilled and experienced.

Earlier this year, you won the Community Champion Award at the ODA National Excellence Awards. What actions led to this?

This related to the devastating floods in Lismore and the Northern Rivers in February 2022. I was flooded out myself for the initial day, but managed get through and eventually help out on the second day. I organised a garage full of donations for those that literally lost everything. Once I could get through to my hometown of Lismore, I dropped them to evacuation centres.

How your practice is faring since the Lismore floods?

My business partner Greg needs a lot of the credit for being proactive; he didn’t hesitate going all-in on the rebuild. Having a trade background, and with some help from friends and family, Greg and I rebuilt our shop and we managed to re-open eight weeks post-flood through hard work from the team and optical community.

Whether it be from EyeBenefit, suppliers, other practices, or optical industry friends, we were overwhelmed and humbled. The practice has bounced back remarkably. We are family-owned, local and independent and have always prioritised serving the community – and I believe that has helped us with the local community ultimately wanting to see us triumph.

Then, like so many others, I spent the next weeks organising help and working street-by-street cleaning out houses, stripping houses back to bare bones, clearing out businesses, including my own, and providing support wherever possible.

Why did you become a member of ODA, and what value do you see in the organisation?

I was introduced to ODA through ACOD when I was doing my Cert IV. ODA provides support for dispensers as well as an abundance of knowledge to help give you the best chance at reaching your potential.

Our practice in Lismore was completely inundated over the roof and we lost almost everything, while Ballina was shut due to flooding as well. Although devastating, we still had our homes and loved ones where many people weren’t as fortunate.

What would you say to others thinking of joining ODA? My advice to anyone on the fence about becoming a member would be that ODA will contribute to you doing your job well and progress your career in a positive way.

Bobby Bugden being awarded the Community Champion Award at the 2023 ODA National Excellence Awards.

What do you believe are the opportunities and challenges facing Australian optical dispensing?

I see opportunity in enhanced lens technology that can better meet an individual’s needs. There’s also opportunity for independents to provide a point-of-difference due to the large number of buy outs in recent years. The biggest challenge is a gap in experience. I have learnt from some great dispensers in the latter part of their careers, some with 40-plus years’ experience. While ACOD are doing an amazing job, you can’t replace that kind of experience overnight.

Founded in 2022, OPTICAL DISPENSERS AUSTRALIA’S mission is to transform the optical dispensing industry by creating a community where optical dispensers and their associates can feel supported and inspired through education, events, networking, and employment advice, plus more. Visit: www.odamembers.com.au

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DISPENSING

LOW VISION: INNOVATIONS FOR A BRIGHTER TOMORROW IN PART TWO OF HER SERIES ON ASSISTANCE TOOLS FOR LOW VISION PATIENTS, CONNIE ANGELI EXPLORES FOUR INNOVATIVE SOLUTIONS AND HOW THEY SERVE PEOPLE AT DIFFERENT STAGES OF THEIR LIFE.

L CONNIE ANGELI "SENIORS, STUDENTS, AND PROFESSIONALS ARE AMONG THE MANY PEOPLE IMPACTED BY LOW VISION, INFLUENCING THEIR QUALITY-OF-LIFE AND PRODUCTIVITY."

ow vision is a visual impairment that cannot be fully corrected by spectacles, contact lenses, or other forms of medical care. It affects many aspects of life, such as reading, working, and socialising. It can be caused by various eye diseases, such as age-related macular degeneration (AMD), diabetic retinopathy (DR), glaucoma, and cataracts. Different user groups face different needs and challenges when it comes to low vision.

•S eniors: As they age, seniors are more likely to develop eye diseases that impair their vision. This can limit their ability to perform daily activities, recognise faces, and enjoy hobbies. They may need devices that can magnify text, adjust contrast, and provide speech feedback.

•S tudents: Students with low vision may struggle to keep up with their academic demands. They may have difficulty reading textbooks, taking notes, and participating in class. They may need devices that can scan and read documents, display enlarged images, and record lectures.

•P rofessionals: Professionals with low vision may face barriers to their career advancement. They may have difficulty reading written materials, operating computers, or communicating with coworkers and customers. They may need devices that can connect to their computers, smartphones, or TVs, and provide high-definition magnification and text-to-speech.

To help patients overcome their challenges and regain their visual independence, there are various solutions available in the market. Some examples

are explorē 12, explorē 8, explorē 5, and Reveal 16i. These devices are designed to provide high-quality magnification, contrast enhancement, and speech output for people with low vision. They are portable, easy to use, and adaptable to different situations.

convenient access to enlarged text and images. It’s well-suited for seniors, students, and professionals with low vision.

INNOVATIVE SOLUTIONS explorē 12, explorē 8, explorē 5 and Reveal 16i are versatile assistive technologies designed to cater to the unique needs of people living with low vision.

Students: explorē 5 can help magnify printed texts in textbooks, class notes, and assignments, ensuring they don’t miss out on educational content.

explorē 12 This is a powerful electronic magnifier designed to assist seniors, students, and professionals alike. With a large 12-inch touchscreen display, it provides a wide range of magnification and contrast options, catering to specific needs of each user group.

Seniors: explorē 12 makes it simple for seniors to read books, newspapers, and prescription labels. These features enable them to continue managing daily duties independently.

Professionals: explorē 5 can assist in reading business documents, invoices, and contracts, ensuring they remain efficient in their work.

REVEAL 16I With its document scanning and text-to-speech capabilities, Reveal 16i is suitable for seniors, students, and professionals looking to convert printed materials into accessible content.

Seniors: It helps seniors regain their independence by allowing them to scan and listen to printed materials, from letters to recipe cards.

Students: explorē 12 is valuable for reading textbooks, taking notes, and accessing educational materials. Its portability makes it suitable for classroom use.

Students: Can scan textbooks and printed assignments, turning them into accessible audio content, making studying more manageable.

Professionals: Professionals can benefit from explorē 12’s large display and high-resolution magnification. It aids them in reading documents, taking notes, and maintaining their workflow.

Professionals: Professionals can scan business documents, articles, and reports, ensuring they stay on top of their professional responsibilities.

explorē 8 This is a compact and portable electronic magnifier, making it an ideal choice for seniors, students, and professionals who are always on the move.

Seniors: Can carry the explorē 8 with them, ensuring they can access printed materials wherever they go. This promotes independence and social engagement.

Students: The explorē 8 can help students remain engaged in the learning process by allowing them to magnify and read class materials effortlessly, whether in the classroom or at home.

Professionals: Professionals can stay productive with the explorē 8, using it to access documents, read reports, and manage their tasks efficiently, both in the office and during travel.

This explorē 8 is a compact and portable electronic magnifier, making it an ideal choice for people always on the move.

Seniors: explorē 5 can be easily carried and used for tasks like reading prescription labels, menus, and other printed materials, enhancing seniors’ daily living.

explorē 5 This is a cost-effective handheld electronic magnifier designed to offer quick and

Seniors, students, and professionals are among the many people impacted by low vision, influencing their quality-of-life and productivity. These user groups may regain their visual autonomy and experience a higher quality-of-life with the aforementioned technologies. These assistive devices fill a gap caused by low vision and the open door towards brighter futures by empowering users to read, work, and engage in daily activities with confidence.

As technology advances, the future for everyone with low vision appears more promising than ever.

CONNIE ANGELI has more than 34 years of experience as an optical dispenser, practice manager, educator, and assistive technology solution provider. She is HumanWare’s National Sales Manager for Australia and New Zealand and an Advisory Board Member for Optical Dispensers Australia.

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TIGHTER BONDS BETWEEN NDIS AND OPHTHALMOLOGY WHEN PARENTS ARE FACED WITH A MAJOR DIAGNOSIS FOR THEIR CHILD, IT CAN BE CONFRONTING AND RAW. DR SUE SILVEIRA SAYS EYECARE PROVIDERS PLAY AN INFLUENTIAL ROLE WHEN IT COMES TO ACCESSING APPROPRIATE FUNDING.

R DR SUE SILVEIRA

“AS THE NDIS NOW REPRESENTS THE MAIN SOURCE OF FUNDING FOR EARLY INTERVENTION AND LOW VISION SERVICES, EYE HEALTH PROFESSIONALS HAVE A RESPONSIBILITY TO UNDERSTAND THE SCHEME.”

aising a child with vision impairment impacts on every aspect of a family’s life. Beginning with a suspicion that child may not see in a typical way, followed by a significant eye or vision diagnosis, families have much to consider and adapt to. The life they had imagined for themselves, and their child, is often altered.

Much is expected of families at a time when they may be grieving and trying to navigate their “new normal”. Professionals once unknown to them now enter their world and become integral to their understanding and planning for the future.

There’s a sense of urgency once a child is suspected of vision impairment, even before a diagnosis is made. Because vision impairment impacts all areas of childhood development, early intervention becomes critical to ensuring the child stays on track and receives suitable support. During this time, families need to work closely with low vision service providers as well as ophthalmologists, optometrists and orthoptists. Families need sound advice about their eligibility and access to support funding through the National Disability Insurance Scheme (NDIS). The NDIS service charter outlines an approach which is “transparent, responsive and respectful”.

It aims to empower and enhance people’s lives by providing “reasonable and necessary supports” that encourage independence, and ultimately improve quality-of-life. Family participation in planning for services is also encouraged.

The NDIS approach recognises the needs of children. When a child is younger than six years and they have developmental delay, or when they are younger than nine years and have a disability, their support is considered under the NDIS’s “early childhood approach”.

Even without a diagnosis, the NDIS may fund access to essential strengths-based and family-centred early intervention.

However, the NDIS gate can be difficult to open and once through, the path can be tricky to navigate. So, professionals working with families should speak openly, ensuring families are aware of the scheme, providing them with links to the NDIS website while stressing the importance of early intervention and support for both their child but also themselves.

Ophthalmology reports are key to securing NDIS funding. Ophthalmologists should not delay reporting until a formal diagnosis has been reached. Instead,

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Because vision impairment impacts all areas of childhood development, early intervention becomes critical to ensuring they receive the right support.

including comments that indicate the child’s visual development is atypical and is impacting on general development are very helpful and usually understood by NDIS planners. When an overview of the child’s visual function has been established, comments that estimate the level of vision impairment –it is likely to be mild, moderate or severe – and the nature of the child’s vision impairment – it is likely to be lifelong or may change – can be helpful.

As part of the planning process, families are asked to consider their short- and long-term goals for their child at a time when everything may seem uncertain and they feel ill-equipped. Ophthalmologists may also be asked to recommend supports for the child. However, it will be challenging for ophthalmologists to achieve suitable, targeted advice from the outcome of a clinical assessment. Rather, ophthalmologists should encourage families to seek out and work closely with specialist service providers. These specialists will partner with the child and family to jointly reach recommendations drawn from functional, developmental, assistive technology and orientation and mobility assessments.

At times, for a variety of reasons, a child may be denied access to the NDIS. Families are fragile when this happens; they feel abandoned and begin to distrust the system. It is important that eye health professionals attempt to understand why

the child’s funding has been declined, to examine the nature of previous reporting and to change future approaches to reporting – don’t keep saying the same thing. It may be that the eye report has been too technical or clinical for the NDIS planner to understand.

As it is rare, childhood vision impairment is often incorrectly compared to vision loss in adulthood, with the impact on child development underestimated. As the NDIS now represents the main source of funding for early intervention and low vision services, eye health professionals have a responsibility to understand the scheme, to report clearly, and to question and advocate for children to ensure they receive NDIS funding to achieve their goals.

DR SUE SILVEIRA is the Course Director of the Master of Disability Studies, Macquarie University.

She is also a Research Fellow and Orthoptist with NextSense, a not-for-profit and registered NDIS providing support people with hearing or vision loss.

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

MANAGEMENT

ASSESSING FITNESS TO DRIVE – RESPONSIBLY WHEN AN EYECARE PROFESSIONAL BREAKS DIFFICULT NEWS TO A PATIENT ABOUT THEIR FITNESS TO DRIVE, IT CAN BE DIFFICULT, BUT THE PRACTITIONER NEEDS TO UNDERSTAND THEIR OBLIGATIONS, WRITES KAREN CROUCH.

A

n interesting case recently addressed in the Queensland Coroner’s court involved a 60-year-old veering off the road while driving his Landcruiser, colliding with gas bottles at the rear of a café which caused a fatal explosion, killing two and injuring 19 people inside the restaurant.

KAREN CROUCH

“A DOCTOR’S REPORTING OBLIGATIONS WITH PATIENTS’ FITNESS TO DRIVE IS DISCRETIONARY IN ALL JURISDICTIONS EXCEPT SOUTH AUSTRALIA AND THE NORTHERN TERRITORY.”

The driver had a history of epileptic seizures for a decade and had been admitted to hospital on three occasions for mental health assessment. He was advised by hospital doctors not to drive and was referred to his GP for follow-up care.

The court found that while all doctors have a clearly defined duty to their patient, they have a less clearly defined duty to act in the public interest, to ensure public safety. In this case, the coroner declared the patient-doctor relationship is defined by trust and doctors have an ethical and legal responsibility to preserve patient confidentiality. Consequently, the coroner did not recommend a mandatory duty on doctors to notify the transport department.

Such cases being to light the grey areas that exist around fitness to drive obligations in Australia. Nevertheless, there are several matters eyecare providers, in particular, need to be aware of.

As Australia’s population ages, so does the rise in motor accident rates, so it is timely to review this sensitive, sometimes life threatening, situation. Understandably, older people strive for independence and are keen to retain their driving licences, sometimes posing a potential risk to other unsuspecting drivers. Some older drivers, in a conscientious effort to ensure safe driving conditions, restrict their driving habits to daylight hours, while others limit the time or distance they are at the wheel.

However, as we age, health challenges may affect one’s ability to drive safely. To ensure the safety of other drivers and pedestrians, it is important elderly drivers regularly and honestly monitor their health and general ability to drive responsibly.

Older drivers may also find it difficult to handle challenges of increasing road rage.

Drivers who express road rage generally take greater risks, harbour more hostile, aggressive thoughts, and demonstrate more anxiety and impulsiveness, which poses a challenge to older drivers whose reaction times may not be sufficiently responsive.

Health professionals, including, GPs, specialists, optometrists, ophthalmologists

Many elderly people see their driver licence as the key to their independence.

and allied health professionals, should regularly review fitness levels of elderly patients to assess their ability to drive, particularly in light of an increasingly ageing population. If it is apparent a patient has a condition that may affect their ability to drive, the attending health professional should inform them of the potential impact of their driving efficiency on the lives of others. Healthcare providers should be ever alert to underlying health conditions older patients may suffer, including diseases like age-related macular degeneration, cataract, glaucoma, diabetic retinopathy, sleep disorders, neurological disorders and heart disease.

As a suggested starting point, it is advisable for a practitioner to advise a patient/driver who is deemed to be ‘unfit-to-drive’ of their obligation to report the matter to local state transport authorities. Naturally, health professionals should be aware of their responsibilities under relevant State Road Transport Acts.

Each state in Australia has specific regulations for assessing older Australians’ ability to drive. In all states and territories, vehicle licence holders have a statutory obligation to report any health conditions that may adversely affect a their ability to drive safely. In some circumstances wherein a patient/driver may be incapable of understanding – regardless of practitioner advice – and decides to continue driving, a health professional should consider reporting the matter to the relevant state transport authority.

Of course, such action may negatively impact the ongoing practitioner-patient relationship, so the practitioner should address the situation appropriately.

•d uty to protect third persons and/or the public from potential danger (and subsequent injury) that may be created as a result of a patient’s condition while driving.

A doctor’s reporting obligations with patients’ fitness to drive is discretionary in all jurisdictions except South Australia and the Northern Territory, where doctors have mandatory reporting obligations.

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

Admittedly, these obligations involve careful consideration and exercise of discretion in adopting the most appropriate course of action. Health practitioners have two conflicting responsibilities that must be weighed against each other: •d uty to protect confidentiality of information collected from a patient; and;

It is advisable that health practitioners who – having counselled a patient appropriately and recommended they report an impairment to the local state transport agency – become aware when the patient has not done so, and report the matter themselves.

Assessing Fitness to Drive 2022 contains Health standards for licensing and Clinical Management guidelines.

INSIGHT December 2023

55

SOAPBOX

A PEEK AT WHAT'S TO COME IN CATARACT SURGERY

BY A/PROF MICHAEL LAWLESS I was asked to talk at the recent Ophthalmology Updates! meeting in Sydney on the near future for cataract and refractive surgery. I began with a quote from William Gibson: “The future is already here; it’s just not very evenly distributed”. As part of that I reminded ophthalmologists that with cataract surgery, if they are comfortable with what they’re doing, then they probably need to look up, and look around, because somebody’s doing something better.

I concentrated firstly on EDOF intraocular lenses (IOLs) and urged ophthalmologists to look at the underlying optical principles behind the various lenses available and those coming to market. Some are truly innovative, others are simply modifications of multifocal IOLs and some are not even EDOF lenses at all; but if we understand the optical principles we can make sensible clinical decisions about which to use in our practice, and not be persuaded one way or the other by industry.

I also emphasised the dilemma

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INSIGHT December 2023

ophthalmologists have, for example, using the Vivity IOLs, which is probably the most widely used EDOF lens in Australia at present. If I achieve a bilateral emmetropic end point in patient A and the same emmetropic end point in patient B, then Patient A may not require glasses for any activities, whereas Patient B might require +1.50 readers for near tasks.

Exactly the same refractive end point with the same lenses and some people get better unaided near and intermediate vision than others. Why is that? It can be frustrating. Dr Chris Hodge and I have studied my patients and have looked at all the variables via a multiple regression analysis, and have come up with an initial finding that pupil size is a significant indicator; that is, the smaller the natural pupil the better the unaided near vision will be, other things being equal. A cornea which has more spherical aberration likewise has a trend to better unaided near vision in this post-op circumstance.

There will be other factors and perhaps combinations of factors, but over the next year we will be able to better predict patient function if we achieve a targeted end point. The same will almost certainly be true for regular aspheric monofocal lenses, and it will help us to use these better in the context of mini monovision.

use monofocal lenses, then they will keep being offered monofocal lenses. If they widen their suite of lenses to what is actually available for patients, then almost certainly they will be recommended lenses they do not normally use. It will force ophthalmologists to consider a wider range of lenses and I think will be quite confronting. If in the end you as a surgeon are rejecting the lens chosen by ZEISS Veracity in favour of a more “conservative” lens, then you, the ophthalmologist, may be the problem (or barrier) to patients getting the lens best suited to their personality and lifestyle, rather than the problem being the artificial intelligence program. Something to consider.

I also talked about attempts to use large data sets and artificial intelligence to help with IOL selection. I used, as an example, the ZEISS Veracity surgical planner, which is not available in Australia yet, but is widely used in the US. It takes pre-operative information from the patient, both in terms of their lifestyle and expectations from surgery, combines this with the regular diagnostics and imaging of the eye, and in the mix are the lenses; the specific IOLs that a particular surgeon likes to use. The system is close to coming up with a recommended lens for a particular patient based on their lifestyle and their ocular anatomy. I posed the conflict that will occur if surgeons have a very limited range of lenses. For example, if they never use a trifocal or an EDOF but only

Given that I started with suggesting the future is already here, bilateral same day cataract surgery is a good example, commonly performed in the Nordic countries and by enthusiast surgeons in different parts of the world, but rarely in Australia at present.

Finally I talked about immediate sequential bilateral cataract surgery (ISBCS); that is, doing both eyes on the same day under set protocols.

There is really no clinical reason not to adopt this for the majority of patients. There are plenty of reasons to adopt it: efficiency, less waste of resources, cost, less disruption to relatives and carers, even less traffic on the roads. The barriers are financial and cultural, and ophthalmology in Australia will be forced to consider this with more seriousness in the near future.

The near future is ours to grasp, and it looks challenging and promising.

Name: A/Prof Michael Lawless Qualifications: MB,BS. FRACS. FRANZCO Affiliations: Clinical Associate Professor, University of Sydney. Ophthalmologist, Vision Eye Institute Location: Sydney Years in industry: 40

BILATERAL SAME DAY CATARACT SURGERY IS A GOOD EXAMPLE, COMMONLY PERFORMED IN THE NORDIC COUNTRIES AND

BY ENTHUSIAST SURGEONS IN DIFFERENT PARTS OF THE WORLD, BUT RARELY IN AUSTRALIA.

2023/24 CALENDAR DECEMBER 2023 ASIA PACIFIC TELEOPHTHALMOLOGY SOCIETY CONGRESS

Pattaya, Thailand 2 – 3 December 2023.asiateleophth.org

THE 16TH CONGRESS OF THE ASIA-PACIFIC VITREO-RETINA SOCIETY (APVRS) 2023 Hong Kong 8 – 10 December 2023.apvrs.org

JANUARY 2024 OPTI2024

Munich, Germany 12 – 14 January opti.de/en

SKI CONFERENCES FOR EYECARE PRACTITIONERS

San Vigilio, Italy 13 – 20 January skiconf.com

SINGAPOREMALAYSIA JOINT MEETING IN OPHTHALMOLOGY

Singapore 19 – 21 January sophth-sinmal2024.com

100% OPTICAL

Singapore 24 – 26 April silmosingapore.com/

MARCH 2024

MAY 2024

MIDO EYEWEAR SHOW

Milan, Italy 3 – 5 February mido.com

ANZGS CONGRESS 23

Hobart, Australia 16 – 19 February anzgsconference.com

Furano, Japan 3 – 10 March skiconf.com

Potential to Earn in Excess of 220k - Designate Partnership in Wagga Wagga, NSW! Specsavers Wagga Wagga have an exciting opportunity for an experienced Optometrist looking to take the next step in their career. No upfront cost and opportunity to try partnership before committing long term.

Specsavers Wagga Wagga

Optometrist opportunity – Specsavers Dunedin, NZ Seeking a talented optometrist to join our extraordinary team at Specsavers Dunedin. They are our NZ Specsavers’s store of the year! They offer cuttingedge technology, a friendly environment, and a commitment to professional growth. Embrace the relaxed pace of life and enjoy a perfect work-life balance.

Explore stunning coastal views and enjoy a fantastic outdoor lifestyle. Don’t miss this incredible opportunity to be part of Specsavers Dunedin.

Graduate Opportunities The Specsavers Graduate Recruitment Team have a number of exciting graduate

OSHOW24

Sydney, Australia 17 – 18 May o-show.com.au

APRIL 2024

Sydney, Australia 19 May (immediately after OSHOW24) vision@oaansw.com.au

Fremantle, Australia 16 – 17 March admin@optometrywa.org.au

SUPER SUNDAY 2024

ASIA-PACIFIC ACADEMY OF OPHTHALMOLOGY (APAO) CONGRESS

has 4 Optical test rooms and 1 dedicated Audiology room with a varied patient demographic and a welcoming and supportive team. You will be partnered with an experienced Specsavers Retail Partner and have access to our Pathway and Partnership development program for duration of time in role.

Interested in partnership? Why not try before you buy!

ARVO 2024

Washington, US 5 – 9 May arvo.org

WAVE 2024

AUSTRALIAN VISION CONVENTION (AVC)

Gold Coast, Australia 6 – 7 April optometryqldnt.org.au

All Specsavers stores now with OCT Optometrist opportunity – Specsavers Townsville, QLD Specsavers Townsville Castletown are seeking a full time Optometrist to join their supportive and experienced team. We’ll support your ongoing career development, and offer you a great work life balance, with regular RDO’s and 5 weeks annual leave! Castletown is a 4 test room store, equipped with market leading technology, including OCT – which is free for every patient. Located in a tropical paradise located in far north QLD, Townsville has all amenities you could need, in addition to a local airport with regular flights to Brisbane.

We’re offering a very generous $180,000 package for this role, plus relocation costs covered!

SILMO SINGAPORE

London, UK 24 – 26 February 100percentoptical.com

SKI CONFERENCES FOR EYECARE PRACTITIONERS

FEBRUARY 2024

Bali, Indonesia.

22 – 25 February 2024.apaophth.org

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

opportunities available across Australia & New Zealand. 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.

Locum Opportunity - Townsville Specsavers Townsville Castletown has block locum work available starting mid December 2023 ongoing throughout 2024. Townsville are offering unbeatable rates and we will book and cover the cost of all your travel including car hire for the duration of your booking.

This is a great opportunity to visit FNQ and explore the Great Barrier Reef and surrounding islands on your days off.

Bookings are available from 2+ weeks (min) to as many months as you would like with flexible rosters available.

Specsavers YOUR CAREER, NO LIMITS

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 opportunities enquiries: Kimberley Forbes on +61 (0) 429 566 846 or E kimberley.forbes@specsavers.com Australia Optometrist employment enquiries: Marie Stewart – Recruitment Consultant marie.stewart@specsavers.com or 0408 084 134 Locum employment enquiries: Matthew Cooney matthew.cooney@specsavers.com or 0447 276 483 New Zealand employment enquiries: Chris Rickard – Recruitment Consultant chris.rickard@specsavers.com or 0275 795 499 Graduate employment enquiries: apac.graduateteam@specsavers.com

Visit spectrum-anz.com

CAREER

People ON THE MOVE

Insight's monthly bulletin to keep the Australian ophthalmic sector updated on new appointments and personnel changes, nationally and globally.

OPTOMETRIST WAREHOUSE APPOINTS HEAD OF STORE OPERATIONS

SAFILO GROWS MARKETING TEAM IN AUSTRALIA

OPTHEA REVEALS LEADERSHIP RESHUFFLE; APPOINTS NEW CEO

Rhys Nunn has recently joined Optometrist Warehouse as the Head of Store Operations. A former Specsavers store partner, he sold up in 2022 and is now in his current role where he has broad responsibility overseeing day-to-day operations that impact the customer experience. This includes recruitment of clinical and retail teams, negotiating with wholesalers, and building relationships with the pharmacists and their teams to refine the processes around the network’s new offering.

Safilo Australia has expanded its marketing department with the appointment of Sara Al-Alami to the newly created position of Marketing Co-ordinator. With two years' marketing experience, she is also currently completing the last semester of her Bachelor of Business degree with a major in marketing.

Australian biopharmaceutical company Opthea has announced a change in its leadership structure as the company begins formulating its commercial blueprint. On 27 October, it was confirmed former CEO Dr Megan Baldwin would transition to founder and chief innovation officer. The appointments of US-based executives, Dr Frederic Guerard as CEO and Mr Peter Lang as CFO, were also announced as part of the reshuffle. The company said this is reflective of a strategy to advance its US and global presence and commercialisation strategy for lead product candidate, sozinibercept (OPT-302), for macular disease.

EXPERIENCED NURSE JOINS ZEISS OPHTHALMOLOGY TEAM

SPECSAVERS ANZ COMBINES OPTOMETRY AND DISPENSING FUNCTIONS

SPECSAVERS CREATES NEW HEAD OF DISPENSING ADVANCEMENT ROLE

ZEISS ANZ has appointed Ms Charis McKerrell as the Product Specialist for Surgical Ophthalmology in Queensland. She brings established background in nursing – including scrub nurse and Acting Director of Nursing positions – which has enabled her to develop an understanding of optimising patient care and the vital role medical devices play in achieving successful outcomes. McKerrell will have primary responsibilities for developing education and sales of the ZEISS intraocular lens, viscoelastic and phacoemulsification portfolios in the Brisbane South to Lismore territory.

In an Australian and New Zealand industry first, Specsavers has combined its optometry and dispensing functions to create a ‘Clinical Services’ team. Headed by a newly titled Clinical Services Director ANZ, Dr Ben Ashby, the internal move is being rolled out at Specsavers globally and will see more collaboration.

“The internal move is a testament to the value and importance of dispensing professionals and their optometry peers working together to provide great patient care. Combining the strengths and successes of both Specsavers professional teams will improve the sight and lives of people across Australia and Aotearoa,” said Ashby.

As part of the new ‘Clinical Services’ structure at Specsavers, Ms Amy Kenefeck will be taking on the newly created role of Head of Dispensing Advancement for ANZ. In her new role, she will be leading Specsavers’ dispensing strategy, driving continuous improvement to customer experience through to enhancing the quality and consistency of dispensing capabilities within the store network. “Specsavers has led the charge and brought about so many transformations to the industry that have changed lives through better sight. Now that dispensing and optometry are united, I’m ready to elevate our professions even further," Kenefeck said.

DO YOU HAVE CAREER NEWS TO SHARE? EMAIL EDITOR MYLES HUME AT MYLES.HUME@PRIMECREATIVE.COM.AU TO BE FEATURED. 58

INSIGHT December 2023

VISION IMPAIRMENT FROM GEOGRAPHIC ATROPHY (GA) LEADS TO REDUCED INDEPENDENCE AND QOL1-3 2 out of 3 patients with GA lost the ability to drive in <2 years4* *A retrospective cohort analysis of a multicentre electronic medical record (EMR) database of patients who were aged ≥ 50 years (N=1901) with bilateral GA and no history of choroidal neovascularization (CNV).4

Visit geographicatrophy.com.au to discover more about GA or scan the QR code QoL: quality of life.

References: 1. Singh RP, et al. Am J Ophthalmic Clin Trials 2019;(1):1-6. 2. Sivaprasad S, et al. Ophthalmol Ther 2019;8(1):115-24. 3. Patel PJ, et al. Clin Ophthalmol 2020;14:15-28. 4. Chakravarthy U, et al. Ophthalmology 2018;125:842-849. ©2023 Apellis Australia Pty Ltd. Level 1, 718 High Street, Kew East, Victoria, 3102.

ABN 87 600 316 612. October 2023. AU-GA-2300050. APEL0061.

APEL0061F_GA_Insight_FPA_235x297mm_R2_FA.indd 1

31/10/2023 9:33 am

At OPSM we offer complete professional autonomy, the latest technology in equipment and eyewear so you can deliver the highest clinical care. To find out how you can further advance your career - contact us now! .

DECEMBER 2023

OPPORTUNITIES FOR PROFESSIONAL CAREER PROGRESSION

Accelerate your career aspirations with OPSM. Visit opsm.com.au/careers today.

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