8 months ago

April 2018

for optometrists and eye

for optometrists and eye care professionals with Professors Charles McGhee & Dipika Patel Series Editors Should glaucoma patients avoid caffeine? BY DR JINNY YOON AND PROFESSOR HELEN DANESH-MEYER* Caffeine is a popular psychostimulant that acts as an adenosine receptor antagonist at physiological concentrations. It is the most widely used drug in history, consumed daily by more than 70% of New Zealanders in the form of coffee, tea, chocolate and caffeinated soft drinks. It has been estimated that adults aged between 20 and 64 years are exposed to an average of 3.5mg of caffeine/kg body weight/day 1 . Historical studies suggest some ophthalmologists have long expressed concerns about the effect of caffeine on intraocular pressure (IOP) in glaucoma patients 2,3 . To date, IOP remains the only treatable risk factor in primary open angle glaucoma (POAG), the most common type of glaucoma. Thus, establishing the link between caffeine and IOP is of great importance for improving the management of POAG. Effect of caffeine on IOP A number of clinical trials have investigated the immediate effect of caffeine on IOP. The effect of caffeine has been regarded as controversial due to inconsistencies amongst study findings. These inconsistencies can be attributed to variable study protocols, such as sources and doses of caffeine, methods of tonometry and time points of IOP measurement. Additionally, participant characteristics and severity of glaucoma were often not clearly documented in some studies. Nonetheless, a careful review of the literature reveals a common trend. In young and healthy volunteers without history of ocular diseases, no significant changes in IOP were detected up to four hours following ingestion of caffeine capsules 4,5 . One study, however, demonstrated a post-caffeine increase in IOP of 2-3 mmHg in healthy volunteers aged between 20 and 29 and this increase was maintained for three hours 6 . However, the volunteers drank a litre of coffee in this study and the authors did not delineate the effects of volume overload and high dose caffeine. Several randomised controlled trials and subsequent meta-analysis of those studies reported IOP changes in patients with POAG or ocular hypertension following caffeine ingestion. There was a statistically significant increase in IOP when the patients were exposed to 180mg of caffeine in coffee, equivalent to approximately one double-shot espresso 7,9 (see Table 1). The metaanalysis showed the weighted mean IOP differences before and after coffee consumption in patients with glaucoma or ocular hypertension: 0.347 at 30 minutes, 2.395 at 60 minutes and 1.998 at 90 minutes (95% confidence interval 0.078-0.616, 1.741-3.049, 1.522-2.474, respectively) 7 . A major shortcoming of this meta-analysis is the lack of age-matched controls, leaving the effect of aging unknown. The healthy controls were mostly in their 20s. The age range of glaucoma patients were not stated in the papers but were expected to be in a much older age group. Furthermore, the authors did not differentiate high tension POAG from ocular hypertension, or normo-tension POAG, when they could represent distinct disease entities. Despite these weaknesses, the consensus is that caffeine, at least transiently, induces a small increase in IOP in glaucomatous eyes, but not in young healthy eyes. What is the pathophysiological significance of the IOP change? Two large-scale epidemiologic studies addressed the question whether caffeine consumption is associated with the development or progression 22 NEW ZEALAND OPTICS April 2018 of glaucoma. The Blue Mountains Eye Study, a cross-sectional study conducted in Australia, investigated correlation between IOP and regular daily caffeine intake in POAG patients 10 . The participants completed questionnaires on their pattern of coffee consumption and underwent comprehensive glaucoma assessment. The study demonstrated a positive association between daily coffee drinking and high IOP, only in people with POAG. POAG patients who drank coffee daily had higher mean IOP (19.6mmHg) than those who did not (16.8mmHg). This result reached statistical significance after adjusting for age, sex, systolic blood pressure, myopia, current smoking and diabetes. A large-scale prospective study of health professionals in the USA showed an association between coffee consumption and development of POAG in people with a family history of glaucoma¹¹. A large number of health professionals over 40 years of age and without a history of POAG were followed up for 18 years in this study. Daily caffeine intake of up to 600mg per day (approximately four doubleshot espresso coffees or five cups of brewed coffee) was not associated with increased risk of developing POAG as shown by relative risks of around 1. With over 600mg of daily caffeine intake, the relative risk increased slightly to 1.61. Notably, in people with a family history of glaucoma, high caffeine intake of more than 600mg per day increased the relative risk from 0.94 to 2.01. In other words, people with a family history were twice as likely to develop POAG as those without, if they were heavy coffee drinkers (>600mg per day). Taken together, there is still insufficient evidence to support caffeine as an independent risk factor for the development of POAG, but people with POAG or with a family history of glaucoma (ie. genetic susceptibility) may be more vulnerable to the effects of caffeine. Mechanism of caffeine-induced IOP elevation The main mechanism of caffeine’s effect is via adenosine receptor antagonism and subsequent increase in sympathetic tone and a slight elevation of blood pressure¹². In young and healthy volunteers, 200mg of oral caffeine led to significant retinal vasoconstriction one hour post-ingestion 4 . This was negatively correlated with mean arterial pressure, suggesting an auto-regulatory response to increased blood pressure. Another study demonstrated that ingestion of 300mg of caffeine caused an increase in the resistive index of retrobulbar arteries in young and healthy volunteers¹³. Hypothetically, the increase in systemic blood pressure will increase pressure within the ciliary arteries, which in turn will increase ultrafiltration and aqueous production, thereby elevating IOP. Increased arterial pressure can also increase venous pressure and reduce aqueous clearance, thereby contributing to elevated IOP. Caffeineinduced vasoconstriction was however not associated with high IOP in the young and healthy, suggesting the presence of an unknown homeostatic mechanism to maintain the IOP. Table 1. Average IOP before and after caffeine ingestion in patients with normo-tension glaucoma and ocular hypertension 9 Coffee and glaucoma? Consequently, more questions arise as to why caffeine elevates IOP in only glaucoma patients. Several researchers postulate there may be an inherent susceptibility to the effect of caffeine in glaucomatous eyes. There is mounting evidence that vascular and autonomic dysfunction is a key pathologic process in glaucoma (for a comprehensive review, see reference 14). Doppler ultrasound imaging studies demonstrated that POAG patients failed to auto-regulate central retinal artery blood flow during postural change. Gene expression studies identified impairment of nitric oxidemediated smooth muscle cell relaxation and excessive plasma levels of endothelin, a potent vasoconstrictor, in response to physiological perturbations in POAG patients. Polymorphisms of nitric oxide synthase and caveolin, which lead to impaired vasodilation, have been associated with POAG. Genetic dysautonomic conditions such as familial dysautonomia and nail-patella syndrome are associated with subtypes of POAG. Moreover, examination of the nail bed capillary network revealed abnormal peripheral microvascular circulation in glaucoma patients. It is possible that caffeine produces a pathologic haemodynamic response and consequent IOP change in glaucoma patients with structurally and functionally impaired microvasculature. The debate continues… Based on the evidence accumulated to date, glaucoma patients may be advised to avoid caffeine intake for 90 minutes before IOP measurement, in order to obtain a more accurate IOP reading. However, there is no known clinical benefit of avoiding caffeine in the long-term management of POAG and without clear evidence we are more likely to cause unnecessary anxiety associated with caffeine consumption. A few crucial questions remain to be answered before clinicians can make evidence-based recommendations on caffeine consumption. l If caffeine transiently elevates IOP, does frequent coffee drinking lead to sustained elevation in IOP? What is the effect of repetitive caffeine intake? l Vasoconstriction was observed in healthy eyes following caffeine administration, but the haemodynamic response to caffeine is yet to be explored in glaucoma patients. l The link between chronic caffeine exposure and the severity of glaucoma has not been established. Is chronic caffeine exposure associated with more advanced POAG? Does withholding caffeine provide any long-term benefit in terms of POAG progression? These questions need to be addressed in future studies to establish evidence-based recommendations. In the meantime, it would be reasonable to advise patients to avoid excessive caffeine intake if IOP control is critical since even a small reduction in IOP has been shown to reduce the risk of glaucoma progression 15 . ▀ References 1. Ministry for Primary Industries. Caffeine. New Zealand: 2012 November. 2. Leydhecker W. Influence of coffee upon ocular tension in normal and in glaucomatous eyes. Am J Ophthalmol. 1955 May;39(5):700-5. 3. Davis RH. Does caffeine ingestion affect intraocular pressure?. Ophthalmology. 1989 Nov;96(11):1680-1. 4. Terai N, Spoerl E, Pillunat LE, Stodtmeister R. The effect of caffeine on retinal vessel diameter in young healthy subjects. Acta Ophthalmol (Oxf). 2012 Nov;90(7):524. 5. Adams BA, Brubaker RF. Caffeine has no clinically significant effect on aqueous humor flow in the normal human eye. Ophthalmology. 1990 Aug;97(8):1030-1. 6. Okimi PH, Sportsman S, Pickard MR, Fritsche MB. Effects of caffeinated coffee on intraocular pressure. Appl Nurs Res. 1991 May;4(2):72-6. 7. Li M, Wang M, Guo W, Wang J, Sun X. The effect of caffeine on intraocular pressure: a systematic review and meta-analysis. Graefes Arch Clin Exp Ophthalmol. 2011 Mar;249(3):435-42. 8. Higginbotham EJ, Kilimanjaro HA, Wilensky JT, Batenhorst RL, Hermann D. The effect of caffeine on intraocular pressure in glaucoma patients. Ophthalmology. 1989 May;96(5):624-6. 9. Avisar R, Avisar E, Weinberger D. Effect of coffee consumption on intraocular pressure. Ann Pharmacother. 2002 Jun;36(6):992-5. 10. Chandrasekaran S, Rochtchina E, Mitchell P. Effects of caffeine on intraocular pressure: the Blue Mountains Eye Study. J Glaucoma. 2005 Dec;14(6):504-7. 11. Kang JH, Willett WC, Rosner BA, Hankinson SE, Pasquale LR. Caffeine consumption and the risk of primary open-angle glaucoma: a prospective cohort study. Invest Ophthalmol Vis Sci. 2008 May;49(5):1924-31. 12. James JE. Critical review of dietary caffeine and blood pressure: a relationship that should be taken more seriously. Psychosom Med. 2004;66(1):63-71. 13. Ozkan B, Yuksel N, Anik Y, Altintas O, Demirci A, Caglar Y. The effect of caffeine on retrobulbar hemodynamics. Curr Eye Res. 2008 Sep;33(9):804-9. 14. Pasquale LR. Vascular and autonomic dysregulation in primary open-angle glaucoma. Curr Opin Ophthalmol. 2016 Mar;27(2):94-101. 15. Leske MC, Heijl A, Hussein M, Bengtsson B, Hyman L, Komaroff E, et al. Factors for glaucoma progression and the effect of treatment: the early manifest glaucoma trial. Arch Ophthalmol. 2003 Jan;121(1):48-56. Dr Jinni Yoon Prof Helen Danesh-Meyer About the authors *Dr Jinny Yoon is a neuroophthalmology research fellow. She studied neuroscience at the University of Auckland and graduated with a PhD. After completing basic medical training in Auckland, she followed her passion for eye health and joined the Department of Ophthalmology. Professor Helen Danesh-Meyer is an international authority on glaucoma and neuroophthalmology and chair of Glaucoma NZ. She is a sought after international speaker, has published more than 150 articles and is a respected international journal editor.

MyHealth1st now in NZ BY LESLEY SPRINGALL Klaus Bartosch knows more than most the importance of being able to act on a whim and book a health appointment quickly and easily, out of hours. The co-founder of patient booking and engagement software MyHealth1st, and managing director of the platform’s parent company 1stGroup, had just finalised plans for his Vision Crusaders cycling team to complete the Australian Ride to Conquer Cancer fundraising races when his family urged him to get the swelling of his right knee looked at. Bartosch thought it was just a symptom of his recently diagnosed arthritis, but given his family’s concerns he somewhat begrudgingly went online, using his own platform, at 9pm to book an appointment the next day with a local doctor. He had no white blood cells left in his body. The doctor packed him off to a specialist pronto and he was diagnosed with advanced-stage leukaemia and committed to hospital for emergency treatment. If he’d gone cycling; if it had not been so simple to book the appointment, he could easily have died, he says. The memory is a powerful one, and few at the Auckland launch of MyHealth1st didn’t tear up when Bartosch went on to share how his daughter took his place in the endurance race, raising the promised funds for much-needed cancer research. That was 2013 and neatly illustrates why Bartosch, together with an experienced team of online and health practice veterans, had joined forces to shake up the age-old way of booking healthcare appointments and engaging with patients. Background Since launching in Australia in 2012, first in dentistry before moving into other health areas, MyHealth1st has netted more than 6,000 customers and booked more than 6.5 million online appointments. It began selling the platform to Australian optometry practices just over a year ago and today books online appointments for more than 1,200 Australian practice owners; over 60% of the country’s independent optometry market. Of the optometry bookings made online in Australia today, 43% are new customers and 57% are existing. But perhaps the most interesting statistic of all, says Bartosch, is that 70% of all online bookings are made during business hours, demonstrating that the vast majority of patients, if given the choice, would rather book online than have to call a practice. A Kiwi case study Sharing the Auckland launch platform in March for MyHealth1st in New Zealand, was Whangarei-based practice Visualeyez director Craig Robertson. Frustrated by his own business’ inability to allow new and existing customers to book online, last year Robertson asked his practice management software provider, Optomate, for help and was referred to 1stGroup. After just two months of using the MyHealth1st booking system, Robertson was hooked. It helped drive bookings to his practice, was simple to use and integrated seamlessly with Optomate, his website and his Facebook page, he says. He also can’t wait to add 1stGroup’s patient recall service, EasyRecall, to his online marketing toolbox, despite the extra cost, he says, as soon as it becomes available in New Zealand. “As a consumer I want to be part of the digital revolution. I want to contact people with emails and book online and I found it very frustrating that I couldn’t do that with my own practice, so that’s why I tried it. It’s a cost effective, very simple platform. It’s easy,” Robertson told the Auckland launch audience. More compelling numbers Of the 30-plus practice owners and managers at the Auckland launch, all the ones NZ Optics’ spoke too were having the same frustrations and were keen to provide an easy and effective online booking service to their current practice management systems. Many Klaus Bartosch presenting at the Auckland launch Klaus Bartosch, MD of MyHealth1st platform, and Visualeyez director Craig Robertson at the Auckland launch signed up on the night. Bartosch, quoting from an international survey, says these frustrations are common among consumers, with 90% saying they wanted to use digital channels to manage their healthcare, 88% preferring digital reminders and a worrying 37% who switched providers to ones who offered online appointments. Using an online booking and engagement platform like MyHealth1st allows you to convert your website and social media traffic into booked appointments, 24/7, says Bartosch. To date, the average return on investment for practices which have joined MyHealth1st’s booking and patient recall service is A$5,000 to A$20,000 a month per practice, with an average 41% of bookings being new patients, according to the ASX-listed company’s own data. Other services As well as its patient online booking and EasyRecall services, 1stGroup will also be rolling out its EasyFeedback service, allowing patients to engage more easily with the practice and let it know how it’s performed and what it can do better. The company also runs a free, optional contact lens service, designed to encourage more patients to consider contact lenses as an option. On average, those practices which have opted in to the contact lens addon are having 20% more discussions about contact lenses, says Bartosch, 62% of which are converted into contact lens sales. As in Australia, 1stGroup also intends to launch a MyHealth1st portal in New Zealand in June or July, which acts as an independent online directory to drive consumers to your practice, says Bartosch. Once a consumer selects and books with a practice, however, those consumers won’t see any competitor practices when they decide to sort out their next booking, just the first practice they booked with, and complimentary local healthcare service providers, such as dentists or GPs, until they’ve built up a group of their preferred suppliers and can then use the portal to book all their health requirements online, whatever the time of day or night, he explains. The pitch Given the way the internet is changing the way we do business, you can’t just sit idly by, Bartosch tells his audience. “Here we are, in the age of the internet and yet nearly all of us still require patients to pick up a telephone in business hours to do something as simple as book an appointment… Can you imagine booking hotels like we used to… looking for a job, browsing for a home? “The way we do business is changing, whether we like it or not. We can’t stop it. The question is how are you going to engage with it, leverage it, get ahead of the curve and do it, before others do!” ▀ Focus on Business sponsored by Independent spirit, collective strength FOCUS Too small ON BUSINESS for How independent to become advice? a better BY DAVID PEARSON* independent the optical sector assume that Many small business owners in company boards are for the big boys, yet the BY benefits JANE SMITH* of independent directors or advisors apply to all businesses, Accabo. Et hil expella boresequi berum nos irrespective of size or structure. intio esenecus diam et lant am nienemp Owner-run businesses can be averse to oremquos corenistio magnaturero volora dolorum appointing lamus outside et, velibusam directors voluptatur? or advisors, El evenes driven dis by a entemporem mix of ‘she’ll qui be ute right’ sum mentality, cullandiscid a desire to ma keep dolorepratur everything solupta in ‘the si family’ omnit volorae or simply pudam, putting con re, change tem digendiati in the ‘too que hard’ quae cus basket, aut aperuptati which can verorem stall business porrunt otasperibus and growth debitate potential. et dolorit officimenem invelibust esciis This modis mindset et voluptatem is likely to aborem be holding fugia back perrore mpostium sae vidiore rnatia voluptatur many owner-run businesses. Looking at sitet veliberit am ipsum et ute suntiscias sim family businesses run in New Zealand, eturia pa consed ut modi ius, od ut doluptatur most do not have a functioning board of sumquam, sintum nullend anihite volupta directors. Many only have a single director, ant, occae. Ut rempore, sequosam, essi cora quodit, or one quaepersperi or two directors cus sequi who iumendi only meet simin num formally re labore to cullenectum sign the annual qui te report. doluptatium If you’re dit a volorist, business nihicium owner, assitis have a aut look voluptae at your sunt board aut minutes. que pa volupta When con did your eum quis board rerrovid last meet to que plan nonectur, strategically? consequ idebis aut parchictia volorisserae Even where dusdae an owner-operator inciisc illiquam que believes laborio beri they doluptatio. have the Facilla skills verio. required Et poresed to implement igent. Sub these heading strategies, an external, non-family and non-executive director or advisor will Fuga. Nam hiciliquas dissint unte cum fuga. provide access to a broader base of skills Itaqui que verchilis evellan duntiistrum re, custi and experience, as well as becoming an nem quid qui sitibus cillandit, officit exerro ambassador for the business across new minient hicipiet asperch illiquate cus, quos networks of influence. doluptas pa eiumquost, con pre dolut ut es re derovit There iundipsunt is concern mi, that occaera major corrum structural quatur autemol weaknesses endenie relating nestiis modionsequis to the governance sam qui blaut of private es es rerspit and family-owned ut volupta tiuntotas businesses natem in pratur? exists in Cus New eossit, Zealand. siti alitatque Daily operations maionsequi cum tend volest, to take ex eum over facerum at the expense eos sum of cum harum ea important dolut enienis strategic ellignis decisions magnime that niam set qui ut et quas the sa course quas sa for doluptat the business’ quas dolupta future turio. and Qui re nosae none provit fugia sandes exerspicidis protect the margins under which most nihiciis inctia ne apitatem accab inus eiciis est industries operate. Business owners are ab iusam eiur, officaeratus peruntium et eates commonly guilty of working too hard ‘in cumenem olesenis aciam nis quiat exceari the business’ instead of working ‘on the taquatest volupti sit, ne la quosam soluptate doluptur? business’. Tatia This conem constant faceatis juggling as iur as act is a millaborum day-to-day quas occurrence volore autatur with a assequae multitude repro of il et warring endem priorities iur? Os reste that eos keep et aut you por from molore these vel important iliquatur accus tasks. voluptati quo toratque odi que But officab an essential il explandae responsibility ma sequate of any Idiciet director adio. is Ebit to aceati ensure remperferum the sustainable as future invenimet of the business ratqui volores enterprise. equuntibus It is not sim feasible accusam for the vendant directors faceaquia of a family voluptur business sent. to do that without taking time out to consider Sub heading the big picture: the economic environment, Quis the similluptas competition, acero the comnihilit threats and audi the dusaerum eationem. opportunities Ehendit, that illuptae are unique porehendit, to their nihitat esequatur business. seque An external sequo optaspelit advisor can venimus often quistiis provide eost the eiciantio prompt modit needed as si to autem ensure etur you molorem allocate ex the est necessary audae quist time quam to focus quidebitis on the ero volorumque oditatius el ea con plis eum aut ‘big picture’ aspects of your business. dolutem aut landa vendessi res expellupide nus, cusandenihil A good external earum director estiiss untionsecus or advisor will nus ad es ex start et haruntias thinking dolupta and planning tiante pla in qui a multitude consediti dolest of areas accatur, you suntem had not qui previously culparumqui considered. officaturit Because aut they eiciates are external accus. to the daily Me operations del erunto of etur? the Sum business, aciet etur, they inulpa will be deles doluptas particularly volo blabore useful optam, in the identification sundit optaers of peritati risks commoloribea to your business volorenis and then debistia in assisting cum, que to si devise cor rehenih appropriate illam, tem strategies harcimagnis to deal erum labor with sitinct those otatesciet risks. maximos voluptium faccus assumquas et offic torporempost repera dolorporem The risks que of being eium a fugiam, director coressimus may be high arias aut due dolupta to potential tianim ut personal inctemo liability. im numqui Where aut etur resti quam inctur sequi ut laborem porat. THE INDEPENDENT OPTOMETRY GROUP, PROVIDING parum THE re id ADVICE quidi dist AND SERVICE INDEPENDENTS NEED TO THRIVE. Apitiis es experferem raturio corepero temporum quo doles aut quias as eati simus aut il ipsandi THE INDEPENDENT OPTOMETRY GROUP, PROVIDING THE ADVICE The To find AND Independent out SERVICE more contact Optometry INDEPENDENTS Neil Group, Human NEED providing on 0210 TO THRIVE. 292 the 8683 advice and service or independents need to thrive To find out more contact Neil Human On 0210 292 8683 To find out more contact Neil or Human on 0210 292 8683 or April 2018 NEW ZEALAND OPTICS 14 NEW ZEALAND OPTICS April 2018 that is the case, it is still worthwhile having an external advisor. That person will be an advisor to the board and still participate in discussions, but will not be a formal director, and they can carefully define the offici omnis sequae mo est faccatur re numque boundary over which they will not cross so porrovit aut ipsam, am, quiam, nate voluptiandi that they do not become deemed a director. beatum dolor re comniasseque vitiatatet ut que con External pa voluptatur? advisors provide Moditatis support niasi consequam, and ipsumquo guidance to quiatibusam business owners laudita and turiam even re ati acium valuable facitae mentoring sequas to explabo possible rrovidu successors. citaquibus, corpore The objectivity nullaccabo. and Eveleni professionalism ssimus, esenis ea corum they bring que excea can also quam enhance faccatiam family eumquo or que shareholder asitium experfero harmony. ma adias magnam non nimus voluptatiam que volor accum, ex et il ides eatem Most optical fuga. Repudan business damente owners recte have omnimai oreped technical mo skills quisit and ad qualifications molestem quam in volorro their errum particular nobit area, hicipiendis but often ut quatus lack formal vero ommodio dolenda training mentius. or strong skills in all aspects of managing and growing their business. Sub Sometimes heading the missing skill sets are Molupta covered by tuscimus employees, eic to but dolumenihit at a governance quas moluptam level, the right quod person evendipidi will que bring iuntiatin a further rem cus, range nemporessum of skills and fugitas experience seditis which sim labo. may Nam niscia not currently sinctib uscienis exist in esequat your business. eos re nobitium nis alic tora volupici quis et as audaept atint. In the current competitive environment, Fugit optatur asperupient volorum fugit fuga. businesses need to take extra steps to gain Cus. Fugit optatur asperupient volorum fugit market share or improved margin. A person fuga. Cus.tatur asperupient volorum fugit fuga. Cus. from Fugit a different optatur background asperupient will volorum bring fugit. a fresh perspective as well as objectively Natquos siminverovit es as vellecto blate con challenge the status quo. plit abo. Pa natur, nempos nobis sum volupitia earum How do id you quatiore find the nos right re voles person perum to rere serve dus si on inum your dolorpo board of rrovidit directors? dolorisci The derest local et pratioratur? Institute of Directors can assist. Look for Us someone inis aut whose quam autatio personality, et a consecabora values and nest, imus culture dolorem you respect facepta and sincid believe quodi will temquunte be a nobis good fit modi with omnis you milla and your plit re business. laborum Speak quidendistem to your business ut quianduntem advisers – accountants quunt. and Cumquia lawyers – quod they quaeri are likely ommoles to have tinctio people nsequae in volupta their network nia assequi who atecatin might be consed a good quatquatiis fit for eicipsum, your business. volupta tiissunt estrum dunt voluptatur? Once you have found the appropriate Sub person, heading they need to be properly briefed and given sufficient material to properly Optae essedita dit ipsam enihiciet ab in pernatq understand your business, your part of uistemquia dolo dentecta voluptas ilit, suntiis the industry and the market environment. mossust eicia ipitate consectur sam ut hilit fuga. They need to know what the problems and Adit imint, te doluptiur? Iciunt am eum nonsecus autem challenges in remposam, are so that omnis these qui matters solorempero can be et, iditi addressed ulluptio rather earum than ut ulpa ignored nis dolore and allowed nobita sum to fester liquam, further. ommoluptatur audam fuga. Os ant liquo A good magnim person earchil will add lupitatur? structure Qui and nonsed rigor ex et volore to directors’ nones meetings de sus volorecab and will ipsum challenge ea voloren imillores you. This porum is likely ne to nullestis be a significant volorro qui dolupit, con pos repudanda dus sunti quis archillenti change from the way you have previously tem eni aditior mod magnatis as assinctenest operated and should result in a significant quat fugiae cuptas restibuscit, utaturit accum improvement to the way the business hilignisquam fugitae nihilitatam aritatq operates and its performance as a whole. uatquae. Ipsum necum aceperr uptaspietus vent. Um About facimusam the author la doluptatum quae. Erspe sandae *David Pearson ex estiores is managing pa dollitiuste partner of pro chartered quaturiat ellaut accountants alit et and dolore business ni doluptatiur? advisors BDO Central Osamus and arciant. has a speciality Um facimusam interest in advisory la doluptatum services to quae. the Erspe sandae ex estiores pa dollitiuste optometry pro sector. quaturiat ellaut alit et dolore He ni doluptatiur? has extensive experience Osamus arciant.earit volecus. assisting both small and medium About sized the entities Author Ga. Ad with es dolo a wide corem ea dolo etur range re omnihilique of advisory pa voloreptat. services. Caes For que se nihiliquodi more information bea sequatur? Atio. Lorrovidia contact David peliquamus at utenderat david.pearson@ enimpore exerorepuda parum or visit re id quidi distr? Atio. Lorrovidia peliquamus utenderat enimpore exerorepuda 23