Feb 2016

Innovating against preventable blindness
Ophthalmologists have helped to address
the main cause of avoidable blindness in
developing countries through a variety of
innovative programmes making cataract surgery
affordable and accessible, said Dr Neil Murray,
who gave the annual Fred Hollows Lecture at
the 2015 RANZCO Scientific Congress, but the
next leading cause of preventable blindness—
diabetes—will require more innovative thinking
to combat.
“Change is required to bring about a solution to
this massive problem of avoidable blindness and
that change needs to be transformative,” Murray
said during his presentation Progress through
innovation: The Fred Hollows effect.
He divided “transformative change” into two
broad camps.
“There is innovation that occurs within a known
paradigm, or value added innovation, and then
there’s innovation that is totally disruptive.”
As of 2010, there were 32.5 million blind people
in the world, 80% of which was avoidable.
The vast majority of those with preventable
blindness live in the developing world and while
efforts like Vision 2020—launched in 1997—
presented a “disruptive innovation” to combat
preventable blindness, similar efforts will be
necessary as diabetic retinopathy increases.
“(Vision 2020) represented a unique
collaboration of public, private and not-forprofit
organisations seeking to develop enduring
solutions to eliminating avoidable blindness by
2020.
“It emphasised there were three key areas to
those enduring blindness solutions,” Murray said.
This included cataract surgery, which has been
proven to be one of the most cost-effective
surgical interventions available; infrastructure
and technology development; and human
resource development.
Murray said Vision 2020 went further by calling
for solutions that integrated with existing health
systems, were sustainable within those systems,
were equitably accessible and provided excellent
of care.
Transformative change at work
Murray noted that extracapsular cataract surgery
with posterior chamber IOLs was a “value-added”
innovation that enabled developing world
surgeons “to aspire to achieve 6/18 or better
vision for their cataract patients.”
Affordability prevented the developing world
from using this “value-added” innovation until
Fred Hollows instituted high-quality, low cost IOL
production facilities in developing nations, which
“disrupted the paradigm.”
Another value-added innovation has been the
visiting team, the “fly-in/fly-out service provision
model to an area that has little or no health
resource to deal with their own eye care needs.”
“This can and has been a successful model and
will remain a part of the fight against avoidable
blindness, but there are some issues with this,
relating primarily to the quality of outcomes that
the visiting teams achieve,” Murray said.
Developing a local resource, along the lines of
Vision 2020’s concept of integrated, sustainable,
equitable and excellent (shortened to ISEE)
solutions, that are fit for purpose and fit for the
future, would be an enduring transformation.
“Nepal is a fantastic example of how an
enduring solution can make a difference,” Murray
said.
Following a rapid assessment of avoidable
blindness in 1981, eye care groups banded
together to combat the problem and 30 years
later have cut the prevalence of blindness in Nepal
by half, while increasing the number of training
programmes within the country from zero to six,
so that today, Nepal is a net exporter of trained
ophthalmologists.
The next problem
Diabetes has exploded in recent history, but
nowhere as much as in the Pacific, which Murray
described as a “vast blue continent with little
pockets of humanity, isolated”.
“Nine of the top-ten countries in the world for
prevalence of diabetes are in the Pacific…at our
back door,” Murray said.
Murray discussed the case of Fiji, one of
those top ten nations, to illustrate how quickly
diabetes has exploded. In 1985 the prevalence of
diabetes was 4%, in 2010 it had shot up to just
under 30% of the entire population. Meanwhile,
the prevalence of diabetic retinopathy among
diabetics in Fiji is around 50%, totalling 80,000
diabetics with retinopathy as of 2012.
“This is all too common a presentation,” Murray
said.
He also noted an anecdotal cultural shift in
which, at one time, if you asked for a sweet drink
in Fiji, you would have been offered coconut milk.
Today, that may be true for more remote locations,
but in the main, Murray said, you will be offered
a “heavily sugared, carbonated fizzy drink that is
black or orange or raspberry.”
“That whole cultural norm needs to change in
our ‘whole of society’ response,” he said.
Cultural shifts take decades and in the meantime,
“what will happen to the people who have diabetes
in a low-resource environment: how can we stop
them from becoming blind?” said Murray.
“Innovation again is required and that
innovation may very well be value-added, as
with micro-pulse lasers and smarter treatment
protocols. We can certainly do with affordable,
accessible anti-VEGFs that are actually not a
part of the current treatment paradigm in the
developing world.
“The innovation will almost certainly not need
to be disruptive,” he added.
The good news, perhaps, is that ophthalmic
resources have been coming together throughout
the Pacific, with two training programmes
established in Fiji in 2007, bringing the total
throughout the Pacific to 11 and an anticipated 20
programmes by the beginning of the next decade.
“I want to embed the disruptive, innovative
spirit Fred Hollows had and re-present it to you
as a challenge.” In conclusion, Murray posed a
question: “How are we going to, in a low-resource
context, prevent avoidable blindness until
societies get the diabetes epidemic under control
and what are you going to do about it?” ▀
Eye Doctors’
Shuan Dai
applauded
Eye Doctors’ Dr Shuan Dai (second from
right) was recognised for services to the
Asian community at the end of last year
and presented with an award for excellence in
service for the Health of the Asian Community
by the New Zealand Health Foundation for
Asian and Ethnic Communities.
The award was presented by (from left to right)
Peter Goodfellow, NZ National Party president
and Dr Jian Yang, Parliament Health Committee
vice-chair, in the presence of Chen Mao Song, the
Vice Consul-General of the Chinese Embassy in
Auckland, at Auckland’s Metropolitan Museum. ▀
Turning back the clock
A patient’s perspective by Australian artist John Lovett on his experience with LISA tri IOL.
John Lovett having his eyes measured
This may seem an unusual thing to discuss,
but far more important than brands of colour,
types of paper or any painting technique, the
ability to see clearly has a huge impact on what we
create.
One thing that has crept up on me over the years
is a gradual loss of close vision. Glasses didn’t really
solve the problem— they would focus on the area
right in front of me, but the far end of a large sheet
of paper would require craning over to bring it back
into focus. I tried multifocal lenses but they felt like
looking through distorted glass.
Mono-vision contact lenses, where one eye
wears a close up lens and the other a distance lens,
worked well for a number of years, but the twice
daily chore of removing and inserting contact
lenses and the problems associated with outback
dust and smoke, plus the AUD$1200 a year cost
finally pushed me to inquire about laser surgery.
The specialist I spoke to said because of my
age (61) and there was the first sign of cataracts
present, cataract surgery would be my best option.
Cataract surgery requires removing the natural
lens and replacing it with a small precision acrylic
lens. The newest lenses made by Carl Zeiss are a
trifocal lens employing a series of tiny concentric
rings giving clear close up, middle and distant
vision. My eye surgeon recommended these
lenses based on the results he had had since their
introduction.
Tests were done, forms filled out and a surgery
date arranged.
The surgery was quick and painless. I was
rendered semi-conscious as soon as I entered the
theatre and the next thing I remember was sitting
in a recovery room with a cup of tea and a number
of other patients decorated with similar eye
patches to mine. A nurse explained what I should
and should not do for the next month while the
eye heals and settles.
Next morning I woke up, removed the eye patch
and immediately could read close up and clearly
focus on distant objects without glasses or contact
lenses, and this was with just one eye done. A
follow up appointment that morning confirmed
my new eye was working perfectly.
I asked the surgeon about the colour shift I
noticed between the eye with the new lens and
the other eye. Once cataracts begin, he explained,
colour saturation and contrast diminish and the
eye takes on a yellow cast. So what I was seeing
through the new eye was how things should
appear. The slight magenta tint will disappear over
the next few days.
A slight colour shift was noticeable between the natural
deteriorated eye (left) and the new lens (right)
A couple of weeks passed and I had the second
eye done with similar results.
Since the day after my first eye was operated on
I have not worn glasses or contacts and my vision
now is better than I can ever remember it being.
The only noticeable downside to the new lenses
is a slight halo around strong light sources at night.
The eye surgeon said this will diminish as I become
more used to the lenses.
So, for me it’s no more lost glasses, no more
fiddling around with contact lenses and clear,
sharp vision for the rest of my life - these lenses
don’t deteriorate like a natural lens. As far as
painting is concerned, the best sable brush is only
as good as the eyes of the person holding it, so I’m
very happy - all my brushes work better now!
Case study from John Lovett supplied by Zeiss. ▀
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Feb 2016
NEW ZEALAND OPTICS
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