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2 NEW ZEALAND OPTICS <strong>Oct</strong>ober <strong>2016</strong>


Lensworx in liquidation<br />

Auckland-based optical lens manufacturing<br />

laboratory Lensworx was placed into<br />

liquidation on 23 August.<br />

Managing director Albie Hanson emailed creditors<br />

and customers on 26 August explaining the company<br />

had been dealing with shareholder issues for the<br />

past two years, which had affected the company’s<br />

ability to operate. “It was restricting our ability to<br />

gain appropriate financial and banking services as<br />

would be expected for operating a company of our<br />

size on a daily basis. The frustration this has been<br />

causing has made it extremely difficult to expand<br />

the business and its NZ Kodak Lens and Safety<br />

eyewear lines. As this problem has been ongoing<br />

without satisfactory resolution today it was decided<br />

to voluntary liquidate Lensworx as it is becoming<br />

too difficult and personally very costly to manage<br />

the company properly.”<br />

According to Companies Office records’ the<br />

current shareholders of Lensworx are Hanson, with<br />

a fifth share, stock breeder and feed supplier Karyn<br />

Maddren, also with a fifth, and Crystal Sand Limited,<br />

owned by Christopher James Taylor of Kohimarama,<br />

who owns three fifths of the company.<br />

The news came as a surprise given that Lensworx<br />

had begun the rollout of its long-anticipated Kodak<br />

Lens Vision Centres (KLVCs) retail programme for<br />

independent optometrists earlier this year.<br />

First mooted in February 2015, the programme<br />

offered independent optometrists the opportunity<br />

to partner with Kodak and use the brand, which<br />

is owned under license by Californian company<br />

Signet Armorlite. Under the programme,<br />

independent optometrists can choose to<br />

incorporate the Kodak brand into their practices<br />

as a concession, or whole-of-premises branding,<br />

(effectively a franchise), without the associated<br />

fees. Practices commit to a level of Kodak lens<br />

sales in return for marketing and branding support<br />

and use of the Kodak name. In May, four practices<br />

had agreed to join the programme, with six more<br />

expected to sign up by the end of June.<br />

Talking to NZ Optics after announcing the<br />

liquidation, Hanson remained committed to the<br />

Kodak programme. “Even though Lensworx has<br />

chosen to liquidate, we feel the outcome will<br />

be better for Signet Armorlite and the Kodak<br />

branding for independent optometrists. Lensworx<br />

management still feels this is the best model<br />

internationally for supporting independent practices<br />

with the world leading Kodak brand and will do all it<br />

can to see this continues to be available to the New<br />

Metabolites and AMD?<br />

New findings suggest that oxidative stress stemming from a<br />

growing accumulation of visual cycle adducts may play an<br />

important role in the pathogenesis of AMD, said Dr Janet<br />

Sparrow, Anthony Donn professor of ophthalmic science at Columbia<br />

University, New York. “There are a number of genes that have<br />

been implicated in AMD and there are likely multiple modifiable<br />

environmental factors at work,” she continued in an article in<br />

Ophthalmology Times. Non-genetic risk factors include smoking,<br />

diet and exposure to sunlight. The protective effects of smoking<br />

cessation, increased intake of antioxidants, and sunglasses all play<br />

roles in reducing oxidative stress in the visual system, particularly in<br />

RPEs. All cells are subject to oxidative stress, she said, but the visual<br />

system appears to be particularly vulnerable. ▀<br />

Jeremy Ang and Chien Chiang from Signet Armorlite flank Albie Hanson<br />

from Lensworx in happier times earlier this year<br />

Zealand independent practitioner.”<br />

However, given no buyer stepped forward in the<br />

limited time allotted by the liquidators Meltzer<br />

Mason, Signet Armorlite has closed its account<br />

with Lensworx and transferred all existing and<br />

ongoing Kodak work and commitments to<br />

Independent Lens Specialists (ILS) in Christchurch.<br />

The move was a “natural fit”, said Chien Chiang,<br />

managing director of Signet Armorlite AMERA,<br />

based in Singapore, as ILS distributed Kodak lenses<br />

in the South Island and the two organisations<br />

have had a long-standing relationship. “We do not<br />

wish for Kodak Lens customers to be left in limbo.<br />

Therefore, for the time being, all of the customers<br />

and jobs, which were going to Lensworx are being<br />

routed through ILS in Christchurch.”<br />

Chiang also reiterated his company’s<br />

commitment to rolling out the Kodak brand and<br />

supporting independent optometrists in New<br />

Zealand. “We would also like to communicate<br />

to the optical trade that we are committed to<br />

promoting and supporting the brand in the region.<br />

The demise of Lensworx was not due to the lack of<br />

support for Kodak Lens from the trade/consumer<br />

nor due to a lack of support from Signet’s side. As<br />

our retail program was off to a promising start, our<br />

ambition will continue as planned.”<br />

Glenn Bolton, ILS director, said both he and<br />

business partner John Clemence were very<br />

surprised and saddened by the news, especially<br />

for Lensworx’s loyal staff. “We have obviously<br />

worked closely over the years with the Kodak<br />

Lens brand and have continued this supply to<br />

Lensworx’s customers.”<br />

Lensworx was formed in<br />

2005 as a full wholesaler and<br />

specialist prescription optical lens<br />

manufacturing laboratory. It gained<br />

the Kodak Lens agency in 2007<br />

and was certified for processing<br />

prescription safety eyewear.<br />

According to the liquidators’<br />

report, at the time of liquidation<br />

the company owed $33,541 to<br />

secured creditors, $496,000 to<br />

unsecured trade creditors and<br />

$718,293 to an unsecured “related<br />

party”. With no buyer on the<br />

horizon, the remaining assets of<br />

the company are expected to be<br />

sold by public auction in <strong>Oct</strong>ober.<br />

Disclosure: NZ Optics is a<br />

creditor of Lensworx ▀<br />

Earthquake shakes East Coast<br />

On 2 September at 4.37am, a magnitude<br />

7.1 earthquake struck off the coast of<br />

the eastern cape of the North Island.<br />

Optometrist Steve Stenersen in Gisborne said he<br />

felt they were lucky this time.<br />

“Although the earthquake was quite large and<br />

sent us all out of bed diving to the floor, it was not<br />

too bad here. It was more rolling, although still<br />

violent, as opposed to the sudden jolts which cause<br />

more damage. We only had the odd thing fall over,<br />

no breakages.”<br />

Other locals also described it as a strong, rolling<br />

quake. It was located 130km north-east of Te<br />

Araroa, was 55kms deep and lasted for around<br />

30 seconds. Locals reported some minor damage<br />

including toppling chimney’s, artwork falling<br />

from walls and products dislodged from shelves<br />

in local businesses. A Tsunami alert was issued<br />

afterwards, and with many local schools and<br />

businesses closed, residents of coastal towns<br />

such as East Cape, Hicks Bay and Tologa Bay<br />

headed for higher ground.<br />

Stenersen said he was thankful the effects<br />

weren’t worse as the magnitude 6.7 Gisborne<br />

earthquake of 2007 caused major disruption<br />

and cost him around $150,000 in repair bills.<br />

“We’ve learned a lot about insurance since<br />

then,” he said.<br />

Aftershocks have continued in the cape area,<br />

with Geonet predicting they could last for up to<br />

two years. With the earthquake having changed<br />

the stresses in the Hikurangi Subduction Zone,<br />

Geonet experts said there is a small chance of a<br />

very major event occurring, similar to the Tohoku<br />

earthqauke in Japan in 2011, however, they added<br />

this is very unlikely. ▀<br />

Highs, lows and dry eye<br />

This month has been a<br />

roller coaster of highs and<br />

lows. The biggest high<br />

was completing our second,<br />

even better, Dry Eye Special<br />

Feature (see pages 9-19). The<br />

wonderful A/Prof Jennifer<br />

Craig, NZ’s international dry eye<br />

superstar, helped us to decide,<br />

curate and review the material<br />

for this feature which, I’m sure<br />

you will agree, covers a wealth<br />

of information on dry eye from<br />

the latest research here and<br />

across the ditch to views on the<br />

latest technology and thinking<br />

in areas as diverse as hormones<br />

and bacteria to contact lenses<br />

and triage. There’s even a<br />

little tip for making your own<br />

tearscope with a ping pong ball! We can’t thank<br />

all the DryEye contributors enough, both for the<br />

time they’ve taken to put their articles together,<br />

and for their enthusiasm when asked to share<br />

their knowledge and experiences with the wider<br />

industry.<br />

Lows include the sad news about the passing<br />

of Emeritus Professor Leon Frank Garner and<br />

Precision Contact Lens founder Johan Steeman,<br />

each ably remembered by those who knew<br />

them well, A/Prof Rob Jacobs (p4) and Johan’s<br />

daughter Kathryn (p25) respectively. Then there<br />

was the earthquake in Gisborne – glad to hear<br />

it was just the crockery that got hurt! And the<br />

liquidation of Lensworx, whose creditor list<br />

sadly reads like a who’s who of the company<br />

side of the industry (see news story, this page).<br />

In another sort of passing, we say goodbye to<br />

columnist Alan Saks who has decided to focus<br />

on other projects. We wish him well, and are in<br />

the process of introducing a new column that<br />

will most definitely get you talking!<br />

Other highs include the Eye Institute’s<br />

entertaining and educating evening (check out<br />

the smiling faces on p23) and Specsavers annual<br />

EDITORIAL<br />

clinical conference (SSC5), which was supported<br />

by a number of New Zealanders, including many<br />

who now live in Australia but were delighted to<br />

shout about their Kiwiness for NZ Optics while<br />

we were in Brisbane. SSC5 was also packed<br />

full of useful and practical information, the<br />

highlights of which we’ve distilled for you on<br />

p20-21.<br />

And finally, by the time you read this, I’ll be in<br />

Paris for my first Silmo fair! Yes, it is fair to say<br />

I am a tad excited! Silmo will be covered in our<br />

November issue, along with our Summer and<br />

Sun special, and an ever so amusing take on<br />

the bad side of homemade scleral lenses by our<br />

wonderful speciality CL columnist Alex Petty. So<br />

don’t miss it; it’s going to be another bumper<br />

issue!<br />

Au revoir<br />

Lesley Springall, publisher, NZ Optics<br />

Charity Fundraiser A day at the Ellerslie Races<br />

Saturday 18 th February 2017<br />

Did you know that 1 in 7 people over 50 will get Macular Degeneration? For thousands there<br />

is a treatment that can stop its progression. MDNZ is committed to slowing this epidemic.<br />

Please support this fundraising event and help us save the sight of thousands of New<br />

Zealanders. Funds raised will support awareness campaigns, education, information and<br />

support for those with Macular Degeneration, their families and carers.<br />

Donate an<br />

auction item<br />

We welcome any<br />

item for the live or<br />

silent auction.<br />

Philip Walsh, Damien Koppens and our own Jai Breitnauer at SCC5 in Brisbane<br />

How you can help:<br />

Purchase<br />

a table<br />

Invite 10 guests to be at<br />

your personal table for<br />

a fabulous day including<br />

a gourmet buffet lunch,<br />

celebrity guests, auctions,<br />

raffles, horse racing at its<br />

best and more!<br />

Sponsor<br />

a race<br />

Naming rights to a race<br />

on the day comes with<br />

wide brand exposure<br />

and VIP opportunities.<br />

For more information please contact: Alice McKinley on events@mdnz.org.nz or phone 027 634 0495<br />

<strong>Oct</strong>ober <strong>2016</strong><br />

NEW ZEALAND OPTICS<br />

3


News<br />

in brief<br />

DRUG DISPENSING CONTACT LENSES<br />

Researchers at Harvard Medical School are developing drugdispensing<br />

contact lenses that could offer new hope to glaucoma<br />

patients at risk of going blind. The lenses, which are designed to<br />

deliver medication gradually, may improve the treatment of patients<br />

who struggle with eye drops, which can be imprecise and difficult<br />

to self-administer, said Dr Joseph Ciolino, an ophthalmologist at<br />

Harvard Medical School. “Based on our preliminary data, the lenses<br />

have not only the potential to improve compliance for patients, but<br />

also the potential of providing better pressure reduction than the<br />

drops.”<br />

OCULAR SURFACE EVALUATION IN GLAUCOMA<br />

In a study, published in Optometry and Vision Science, patients with<br />

ocular surface disease (OSD) and open-angle glaucoma (OAG) taking<br />

anti-glaucoma medication showed greater reductions in tear lipid<br />

layer thickness than those without OAG; plus the total duration of<br />

anti-glaucoma medication use significantly correlated with tear lipid<br />

layer thickness. A total of 85 eyes in 85 patients were included, with<br />

34 in the control group (OSD without OAG). “Results suggest that<br />

greater tear lipid layer damage, represented as a thinning of lipid<br />

layer thickness, can be characteristic of OSD associated with topical<br />

anti-glaucoma medication use,” researchers concluded.<br />

RETINAL CHANGES MAY SIGNAL PARKINSON’S<br />

Retinal changes may serve as a marker for Parkinson’s disease, a new<br />

study in mice suggests. “We show that rosiglitazone can efficiently<br />

protect retinal neurons from the rotenone insult, and that systemic<br />

administration of liposome-encapsulated rosiglitazone has an<br />

enhanced neuroprotective effect on the retina and central nervous<br />

system,” wrote Eduardo Maria Normando of Imperial College London,<br />

UK, and colleagues in Acta Neuropathologica Communications.<br />

Previously researchers observed that intracytoplasmic inclusions<br />

called Lewy bodies, characteristic of Parkinson’s, appear not just in<br />

the brain, where they damage cells that produce dopamine, but<br />

throughout the central nervous system, including the retina, which<br />

led to the mouse study. Animal trials, administering rosiglitazone,<br />

also showed promise in protecting against the effects of rotenone as<br />

it appears to promote an anti-inflammatory response and to reverse<br />

inhibition of monoamine oxidase, a crucial enzyme for dopamine<br />

metabolism, said researchers.<br />

COOPERVISION HONOURED<br />

CooperVision has been honoured by the Puerto Rico Manufacturers<br />

Association (PRMA) with a series of prestigious environmental,<br />

health and safety awards, which recognise advancements in its<br />

Puerto Rico high volume production facility, culminating with<br />

PRMA’s Environmental Innovation Project of the Year award. The<br />

company reported a reduction of 12.4% in its use of alcohol, a 55%<br />

decrease in water and significantly reduced landfill disposal at its<br />

Puerto Rico facility. The reductions are expected to result in cost<br />

savings of more than US$8.5 million by the end of 2017.<br />

PIG-VISION<br />

Scientists in China are developing transplant alternatives for those<br />

suffering from cornea damage. Long waiting lists and the halting<br />

of a controversial programme that allowed organ transplants from<br />

executed prisoners, has led to government support for alternative<br />

donors – pigs. More than five million people in China are estimated<br />

to need a cornea transplant, so researchers from China Regenerative<br />

Medicine International (CRMI) are trialling the use of pig corneas<br />

– a bi-product of the meat industry that is readily available and<br />

cost effective. Several<br />

transplants have<br />

already taken place at<br />

Zhongshan University,<br />

in the southern city of<br />

Guangzhou. CRMI has<br />

also been producing<br />

bio-engineered pig<br />

corneas for human<br />

use since approval was<br />

given in April 2015.<br />

DIY MEDICINE RESEARCH ON THE RISE<br />

Almost four out of five Australians (78%) report looking for<br />

information about medicines on the internet, while 58%, and<br />

79% of 18-34 year olds, admitted looking up information about<br />

health conditions on the internet to avoid going to see a health<br />

professional, according to a survey released during Australia’s Be<br />

Medicinewise Week from 22-28 August. This compares to just one<br />

in three people who said they were likely to search the internet for<br />

information about their symptoms before they visited their doctor<br />

in a 2012 survey by NPS MedicineWise.<br />

ESSILOR INNOVATION<br />

Essilor has again been named one of the world’s “Most Innovative<br />

Companies” by Forbes in its prestigious, annual 100 Most Innovative<br />

Companies list. This is the sixth year in a row Essilor has earned a<br />

spot on the list, which recognises publicly traded companies that<br />

have been identified by investors as being innovative now and<br />

in the future. “Innovation has always been a cornerstone of our<br />

strategy. We have one goal: to push back the frontiers of poor vision<br />

worldwide,” said Jean Carrier, chief operating officer for Essilor<br />

International. ▀<br />

Obituary: Emeritus Professor<br />

Leon Frank Garner<br />

BY A/P ROB JACOBS, SCHOOL OF OPTOMETRY AND VISION SCIENCE<br />

Originally from Melbourne, Professor<br />

Leon Garner held positions in<br />

Canada and Malaysia before<br />

moving to New Zealand with wife, Rosie.<br />

They arrived in Auckland in 1978 and in<br />

his 25 years with the University, Leon’s<br />

achievements were remarkable.<br />

His drive led the development of the<br />

discipline of optometry from its early roots<br />

in 1965 as a section hosted within the<br />

Department of Psychology. Leon added vision<br />

science content to the Diploma of Optometry<br />

enabling the formation of the four-year<br />

Bachelor of Optometry degree in 1982. By<br />

1987 Leon had developed resources, research,<br />

staffing and activities to the point that the<br />

establishment of a separate Department of<br />

Optometry and Vision Science was agreed.<br />

During this period Leon was the quiet<br />

driving force behind the creation of the<br />

New Zealand Optometric Vision Research<br />

Foundation which, with generous and<br />

ongoing donations from industry and the<br />

New glaucoma<br />

test<br />

Researchers from the University of New South Wales<br />

(UNSW) have developed a new test that could<br />

detect glaucoma four years earlier than current<br />

available techniques.<br />

The new diagnostic test asks patients to look at small<br />

dots of light of specially chosen size and light intensity. An<br />

inability to see them indicates blind spots in the eye and<br />

early loss of peripheral vision – a precursor to glaucoma.<br />

A study assessing the new technique on 13 patients<br />

was recently published in the journal Ophthalmic and<br />

Physiological Optics, and further trials are ongoing.<br />

“The researchers have presented results using a new<br />

paradigm for visual field testing using the Humphrey<br />

visual field analyser,” explained glaucoma specialist, Dr<br />

Hussain Patel from Eye Surgery Associates in Auckland.<br />

“Instead of a single target size to test sensitivity at each<br />

point, multiple targets of varying size are used.”<br />

Glaucoma is one of the leading causes of irreversible<br />

blindness in the world and in the early stages patients<br />

usually have no symptoms and are not aware they are<br />

developing permanent vision loss, said Professor Michael<br />

Kalloniatis, director of the UNSW Centre for Eye Health.<br />

“The cause of the disease is unknown and there is no<br />

cure, but its progression can be slowed with eye drops or<br />

surgery to lower pressure in the eye. So, early detection<br />

and early treatment is vital for prolonging sight.”<br />

The UNSW diagnostic test has been patented in the<br />

US and EU, with the inventors named as Professor<br />

Kalloniatis, Dr Sieu Khuu of the UNSW School of<br />

Optometry and Vision Science and Dr Noha Alsaleem, a<br />

former Masters student at UNSW.<br />

Ray-Ban honoured<br />

Luxottica brand, Ray-Ban, distributed through Luxottica<br />

companies’ OPSM and Sunglasses Hut, has been named<br />

Brand of the Year by the US Accessories Council, a not-for<br />

profit organisation that includes the world’s leading brand names,<br />

designers, publications, retailers and associated providers for the<br />

accessories, eyewear and footwear industries. Each year, the Council<br />

pays homage to those brands, designers and businesses that have<br />

had a big impact on the accessories industry by assigning the<br />

Accessories Council Excellence Awards. Over the past 12 months,<br />

Ray-Ban announced the fusion of its Round and Clubmaster styles<br />

that led to Clubround, and the new campaign #ittakescourage that<br />

focuses on Ray-Ban’s theme: the courage to be yourself.<br />

profession, still supports NZ research in<br />

optometry and vision science today. Leon<br />

was appointed the Foundation Professor of<br />

Optometry in 1989.<br />

His research focus was optics including<br />

the development of refractive error. Specific<br />

populations within New Zealand, its Pacific<br />

neighbours and also in Nepal where myopia<br />

was uncommon, provided ideal groups<br />

for study. Comparison of the dimensions<br />

of components of eyes from these groups<br />

with measurements from cultures where<br />

myopia was a growing problem provided<br />

publications which are the foundation of<br />

today’s research into causes of myopia.<br />

Leon had a principle that guided his<br />

decisions and work at Auckland throughout<br />

his 25 years and this principle was that the<br />

good of optometry and the Department was<br />

foremost. He was an incisive thinker and a<br />

greatly respected academic.<br />

Leon was appointed Emeritus Professor<br />

of the University of Auckland in recognition<br />

Professor Leon Garner<br />

of his achievements on his retirement in<br />

2003. Following his retirement, Leon and his<br />

wife Rosie moved to Australia to be closer<br />

to their children and families. They had<br />

originally planned to settle in Queensland<br />

but one fateful day in 2004 they drove<br />

past a granite house on a stud estate,<br />

called Roseleigh, in Victoria, and Rosie<br />

immediately fell in love with the property.<br />

Together they established Garners Heritage<br />

Wines on the property and produced many<br />

award winning wines.<br />

Leon Frank Garner died on 31 August after<br />

battling cancer, aged 75.<br />

Leon, his family and his achievements<br />

will be remembered warmheartedly by the<br />

University, the profession and the many<br />

individuals on whose careers and lives he<br />

was an important influence. ▀<br />

Pharmac reviews anti-<br />

VEGFs<br />

There has been a lot of debate<br />

about the three most widelyused<br />

injectable anti-vascular<br />

endothelial growth factor (anti-VEGF)<br />

drugs to treat wet age-related macular<br />

degeneration (AMD) – ranibizumab<br />

(brand name Lucentis), aflibercept<br />

(Eylea) and bevacizumab (Avastin)<br />

– with anecdotal feedback in New<br />

Zealand suggesting that, given the costs and effectiveness, Avastin is the<br />

preference, though Eylea would be if it was funded. NZ Optics spoke to Sarah<br />

Fitt, director of operations at Pharmac, about the current funding situation.<br />

“These are medicines primarily given in a hospital setting. Pharmac didn’t<br />

manage the list of hospital medicines until July 2013,” said Fitt. “Medicines<br />

already in use by DHB’s, such as Lucentis and Avastin, were carried over on to<br />

the Hospitals Medicines List (HML).”<br />

Ranibizumab is a second line medication after Avastin, she said, adding<br />

that Pharmac has not received any negative feedback regarding Lucentis.<br />

“Patients on a second line medication are perhaps less likely to be responsive,<br />

so perhaps that could be the issue.”<br />

That said, however, Pharmac is currently considering its anti-VEGF<br />

treatments for wet AMD.<br />

“We’ve had an application from a supplier for Eylea and it was referred<br />

to PTAC (Pharmacology and Therapeutics Advisory Committee) and<br />

the ophthalmology subcommittee for review and PTAC gave us the<br />

recommendation to run a competitive process” said Fitt.<br />

The request for proposals (RFP) process closed about a month ago with<br />

responses from a number of suppliers, she said. “We now have to look at all<br />

the information and decide on if and which treatments we can fund. We are<br />

assessing all factors at the moment.”<br />

Fitt was keen to stress the process takes time, but Pharmac is hoping to be<br />

able to offer some news around anti-VEGF funding soon. ▀<br />

Ray Ban Clubround campaign<br />

www.nzoptics.co.nz | PO Box 106954, Auckland 1143 | New Zealand<br />

For general enquiries, please email info@nzoptics.co.nz<br />

For editorial and classifieds, please contact Jai Breitnauer, editor, on 022 424 9322 or editor@nzoptics.co.nz.<br />

For advertising, marketing, the OIG and everything else, please contact Lesley Springall, publisher, on 027 445 3543 or lesley@nzoptics.co.nz.<br />

To submit artwork, or to query a graphic, please email lesley@nzoptics.co.nz.<br />

NZ Optics magazine is the industry publication for New Zealand’s ophthalmic community. It is published monthly, 11 times a year, by New Zealand Optics 2015 Ltd. Copyright is held by<br />

NZ Optics 2015 Ltd. As well as the magazine and the website, NZ Optics publishes the annual New Zealand Optical Information Guide (OIG), a comprehensive listing guide that profiles the<br />

products and services of the industry. NZ Optics is an independent publication and has no affiliation with any organisations. The views expressed in this publication are not necessarily<br />

those of NZ Optics (2015) Ltd.<br />

4 NEW ZEALAND OPTICS <strong>Oct</strong>ober <strong>2016</strong>


NZ<br />

0800 447 272<br />

EYESRIGHT.CO.NZ<br />

<strong>Oct</strong>ober <strong>2016</strong><br />

NEW ZEALAND OPTICS<br />

5


Specsavers rolls out “value” lens<br />

Johnson & Johnson (J&J) has teamed up with<br />

Specsavers in Australia and New Zealand to<br />

roll out its new “value-conscious” monthly<br />

contact lens, Acuvue Vita this year.<br />

“It’s for the value-conscious patient, so it fits<br />

Specsavers’ business model well and it allows<br />

us to help optometrists add Acuvue to their<br />

portfolio,” says Dr Emma Gillies, professional<br />

affairs manager at J&J Vision Care ANZ.<br />

In recent surveys of monthly contact lens<br />

(CL) wearers, J&J found more than two-thirds<br />

of respondents experienced comfort-related<br />

issues with their lenses at some time during the<br />

month; 84% of these patients used compensating<br />

behaviours such as re-wetting drops or taking<br />

breaks from wearing their CLs; and 73% said they<br />

did not plan to tell their optometrist about their<br />

lens wearing experience because most considered<br />

their comfort issues “normal”, with some raising<br />

concerns they were worried they would be taken<br />

out of CLs if they mentioned it.<br />

Though J&J maintains a shorter-wearing<br />

cycle is better for contact lenses, the studies<br />

demonstrated an unmet need in the monthly<br />

category, says Dr Gillies.<br />

J&J’s Dr Emma Gillies, Sarah Rivers and new senior brand manager ANZ, David Neary at SCC5<br />

J&J claims to have solved many of the monthly<br />

comfort-related issues with Acuvue Vita’s<br />

HydraMax technology, which employs a noncoated<br />

silicon hydrogel formulation to maintain<br />

hydration over the month. Dr Gillies says this is<br />

different to J&J’s HydraLuxe technology used<br />

in the manufacture of its Acuvue Oasys 1-Day<br />

lenses, though both focus on maintaining and<br />

working with the natural tear film. According<br />

to the marketing material, the HydraMax<br />

technology in Acuvue Vita helps maximise lens<br />

hydration by integrating the maximum amount<br />

of hydrating agent, polyvinylpyrrolidone (PVP), in<br />

the lens and then maintaining hydration through<br />

optimal density and distribution of beneficial<br />

lipids throughout the lens. Costs are kept down<br />

through changes to the manufacturing process,<br />

says Dr Gillies.<br />

The lens was launched to the Australasian<br />

market at the Specsavers Clinical Conference<br />

(SCC5) in Brisbane in September and will be<br />

available for sale through Specsavers’ stores from<br />

November. It will be rolled out to the rest of the<br />

eye care market from early 2017. ▀<br />

For more about SCC5 go to p20.<br />

EVF heads south<br />

The Essilor Vision<br />

Foundation (EVF) has<br />

conducted its first school<br />

screening in the South Island at<br />

New River Primary School. The<br />

decile one, Southland school<br />

is the first of many taking part<br />

in the screening programme,<br />

thanks to the involvement of<br />

Ria Bond, the New Zealand First<br />

List MP based in Invercargill.<br />

“I’m pleased that the<br />

children in our community<br />

will be screened as part of<br />

this programme and have the<br />

opportunity to address any<br />

potential issues with their<br />

sight,” said Bond in a statement.<br />

“There is a clear link between<br />

eye issues and academic achievement, so to be<br />

able to rectify any problems at this stage will help<br />

even the playing field for these children.”<br />

Claire Martin, from Martin and Lobb Eyecare in<br />

Invercargill, volunteered her time to help with the<br />

screening on 18 August. “Although most children<br />

have a basic eyesight test when they start school,<br />

their eyes don’t mature until around the age of<br />

nine. At that stage our equipment can identify<br />

previously undiagnosed vision conditions.<br />

New River Primary principal Elaine McCambridge<br />

said she was delighted the school had been asked<br />

to take part. “Ensuring our students can make<br />

progress and achieve to the best of their ability<br />

is always our priority. We are constantly looking<br />

for barriers to learning. As a group of educational<br />

professionals, we may have suspicions that a<br />

child’s vision is problematic to their learning,<br />

but we have to rely on parents taking action or<br />

following up, and this doesn’t always happen.<br />

“The Essilor Vision Foundation have provided<br />

an amazing opportunity for us to have our year<br />

three to year six students checked. An important<br />

aspect of this process is that we will have some<br />

control over the follow-up testing and will ensure<br />

it happens for each child that has been identified.<br />

Such a practical and effective programme, provided<br />

by a very dedicated group of community-minded<br />

people, could change the course of a child’s life.”<br />

The EVF was officially launched in January this<br />

Marnie Lankow from Martin and Lobb Optometrists at New River Primary School, Invercargill<br />

year after a pilot programme in Hawke’s Bay. It<br />

provides eye tests and follow-up care for children<br />

in decile 1 and 2 schools. Essilor’s platinum partner<br />

optometrists volunteer to help run the screening<br />

programmes, while the school’s commit to taking<br />

any referred children to follow up appointments<br />

and glasses fitting. Glasses not covered by a<br />

community services card are paid for by the<br />

Foundation and all students are “awarded” their<br />

glasses in a graduation ceremony so it’s seen as<br />

an exciting privilege. The first EVF graduation was<br />

held at South Auckland’s Rowandale school in July<br />

and attracted significant general media coverage.<br />

“Let’s face it, sometimes kids can be teased for<br />

wearing glasses, but I liken it to the fact these<br />

children aren’t just wearing glasses, they’re<br />

superheroes!” said Rowandale’s deputy principle<br />

Lois Hawley-Simmons, adding the graduation<br />

ceremony helps remove any stigma around<br />

wearing spectacles.<br />

So far EVF has facilitated screenings in 10<br />

schools, testing around 200 children at each<br />

school. Kumuda Setty, Essilor NZ’s marketing<br />

manager and EVF coordinator, said the aim is to<br />

have screened more than 3,000 children by the<br />

end of this year. Data collected from screenings<br />

and follow ups is being used by Massey University<br />

to compile accurate figures around eye problems<br />

and its impact on Kiwi children’s educational<br />

achievement. ▀<br />

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NZOptics_halfpage_FREESENSITY_18x28cm_OCT16.indd 1<br />

6 NEW ZEALAND OPTICS <strong>Oct</strong>ober <strong>2016</strong><br />

8/09/<strong>2016</strong> 2:23:45 PM


NZ Optics.half page ad<strong>2016</strong>v1.indd 1<br />

2/09/16 11:32 AM<br />

TPA optometrists to<br />

issue Standing Orders<br />

TPA optometrists are now authorised to<br />

issue Standing Orders, written instructions<br />

that allow timely access to medicines in<br />

situations where an authorised prescriber is not<br />

available.<br />

In <strong>Oct</strong>ober 2015, the Ministry of Health<br />

consulted on a proposed amendment to the<br />

Medicines (Standing Order) Regulations 2002 to<br />

authorise nurse practitioners to issue standing<br />

orders. The NZ Association of Optometrists<br />

(NZAO), supported by the Optometrist and<br />

Dispensing Opticians Board (ODOB), then<br />

put a case to the Ministry for an amendment<br />

to authorise both nurse practitioners and<br />

optometrists (with therapeutic endorsement) to issue standing orders,<br />

which was accepted.<br />

The new regulations, the Medicines (Standing Order) Amendment<br />

Regulations <strong>2016</strong>, allowing TPA optometrists and nurse practitioners to<br />

issue standing orders under the same conditions that apply to medical<br />

practitioners and dentists, came into effect on 17 August <strong>2016</strong>,<br />

Dr Lesley Frederikson, NZAO national director, says this new<br />

amendment rectifies an anomaly brought about by the previous wording.<br />

“The previous exclusion of nurse practitioners and optometrists from<br />

being able to issue standing orders is a legal anomaly arising after the<br />

2013 amendment of the Medicines Act 1981 which was not intentional.<br />

“Post-amendment, the Medicines Act already defined a Standing<br />

Order as a written instruction issued by a practitioner, registered<br />

midwife, nurse practitioner or optometrist in accordance with any<br />

applicable regulations. However, the Medicines (Standing Order)<br />

Regulations 2002, definition of practitioner included only dentists and<br />

medical practitioners thus defeating the intent of the primary Act.<br />

“All parties recognise that healthcare demand is increasing and costs<br />

are rising so it makes sense to enable these two groups of authorised<br />

prescribers (TPA optometrists and nurse practitioners) to work to their full<br />

scope of practice. Authority to issue a Standing Order permits therapeuticsendorsed<br />

optometrists to provide more efficient and safe care by enabling<br />

other non-prescribing practitioners in the primary healthcare team to<br />

supply and/or administer specified medicines to a specified class of persons<br />

in specified circumstances without a prescription.”<br />

Dr Frederickson says issues of safety are covered in the Ministry of<br />

Health guidelines for Standing Orders and they are quite specific and<br />

very comprehensive. “Enabling TPA optometrists to issue Standing<br />

Orders will improve teamwork and efficiency between therapeuticsendorsed<br />

optometrists, doctors, non-prescribing optometrists and<br />

registered nurses in a variety of community settings.”<br />

RANZCO’s new digital museum<br />

As an industry, ophthalmology<br />

is often very focussed on<br />

the future – what is new?<br />

Cutting edge? Smart? How can we<br />

evolve and do things better? But<br />

Confucius said, “Study the past<br />

if you would define your future,”<br />

and to that end, RANZCO has been<br />

collecting and cataloguing artefacts<br />

and memories since the 1950s.<br />

“It began as a small collection<br />

of discarded instruments by<br />

Dr Geoffery Serpell,” says Dr<br />

David Kaufman, a full-time<br />

ophthalmologist and volunteer<br />

curator of the museum. “It<br />

began to grow with private<br />

collections being donated and<br />

artefacts passed on from trade. A<br />

large collection was donated by<br />

(Melbourne ophthalmologist and<br />

former RANZCO president) Dr Ken<br />

Howsam, and it was all stored at<br />

the Royal Victorian Eye and Ear<br />

Hospital in Sydney.”<br />

The previous curator, Dr Jim<br />

Martin, spent 12-years painstakingly<br />

cataloguing the collection, but it wasn’t<br />

very accessible.<br />

“We have two small rooms at the<br />

RANZCO offices in Sydney,” explains Dr<br />

Kaufman. “And we put on an exhibition<br />

at the RANZCO Congress each year.<br />

Otherwise, it’s all in storage. When I took<br />

over in 2012, I decided I wanted to make it<br />

more accessible to ophthalmologists and<br />

the public; more useful.”<br />

Dr Kaufman realised that with<br />

the profession spread across a wide<br />

geographical area, the best way to display<br />

the collection was digitally.<br />

“I moved the collection to a storage<br />

facility near me in Melbourne. It’s bigger<br />

and easier to move around in. Then I<br />

invested in electronic museum software,<br />

the type that is used by many major<br />

institutions to catalogue collections.”<br />

With the help of an assistant, Dr<br />

Kaufman has spent a day each week for<br />

the last few years photographing artefacts<br />

and writing their entry to be displayed<br />

online. He has come across many<br />

interesting and amazing items.<br />

“There are lots of curious instruments,<br />

things that ophthalmologists had<br />

made off the back of some crazy idea.<br />

You wouldn’t find them in any modern<br />

catalogue! One of the most unusual items<br />

we have is a cute little pocket dispensary.<br />

They were popular in the 1920s. We have<br />

about six and one is particularly beautiful<br />

with a snake skin cover. They’re about half<br />

the size of a matchbox with room inside<br />

for a small tube of pellets that could be<br />

dissolved and made into eye drops.”<br />

One of the museum’s biggest selling<br />

points are the digital memories.<br />

“We’ve got oral archives recorded<br />

between 1990 and 2000, memories from<br />

eminent ophthalmologists. We’ve also got<br />

some video, including Barbara McKay’s<br />

account of being an ophthalmic nurse in<br />

the 1950s.”<br />

The museum also offers a list of notable<br />

people, catalogues of diagnostic tools and<br />

journals, and welcomes the opportunity<br />

to share private collections through<br />

this platform. Much of the work on the<br />

museum, and the development of the<br />

website, has been made possible by a<br />

large donation from Dr (Charles) Neville<br />

Banks, who passed in 2010.<br />

“We’ve been well supported by senior<br />

colleagues, and also younger volunteers,”<br />

says Dr Kaufman. “Not a week goes by<br />

without a new donation. I just want to<br />

try and inform people. I want people to<br />

be able to use it as a resource and also to<br />

link with other websites. Our collection is<br />

expanding and evolving constantly.”<br />

You can now visit the new RANZCO digital<br />

museum at www.ranzco.edu/museum ▀<br />

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<strong>Oct</strong>ober <strong>2016</strong><br />

NEW ZEALAND OPTICS<br />

7


Saving Sight celebrates 50 years<br />

From left; Joanne Pearson, Ingrid Sole, Sally Read, Jude Lipanovic, Sue Handley, Cheryl Rice and Jill Gimblett<br />

Hannah Kersten and Dr Aaron Wong<br />

DFV’s Ralph Thompson demonstrates the IC100 Tonometer on Alex Petty<br />

BY DR AARON WONG*<br />

Celebrating 50 years since its foundation,<br />

the Save Sight Society hosted its annual<br />

conference on 26 August. For me, this<br />

meeting is all about great local speakers, a variety<br />

of clincally relevant topics and a good catch-up<br />

with colleagues. The fact this years meeting was<br />

set on the shores of Tauranga harbour made it all<br />

the more enticing. Dr Sam Kain co-ordinated an<br />

engaging programme that reflected the everyday<br />

clinic dilemmas of a general ophthalmologist or<br />

optometrist.<br />

Associate Professor Dipika Patel kicked off the<br />

day with an update on the research that the Save<br />

Sight Society has funded over the last year. It was<br />

particularly encouraging to see that donations<br />

and money raised from conferences like this one<br />

allows New Zealand researchers to perform cutting<br />

edge clinical and lab-based eye research. Some of<br />

the projects suported by the Save Sight Society<br />

have even gone on to garner further funding from<br />

overseas. The Save Sight Society has an important<br />

role to provide a launchpad for our researchers in<br />

rapidly advancing areas such as ocular genetics.<br />

Since less than 10% of applications for funding<br />

came from outside of Auckland this year, A/Prof<br />

Patel also took the opportunity to encourage<br />

researchers from all regions of New Zealand to<br />

apply.<br />

Everyone was intrigued to hear Dr Neil Murray<br />

explain why SIC (small incision cataract) surgery<br />

could be more aptly named ‘SLICK’ surgery. This<br />

phaco-less version of cataract surgery is more<br />

commonly performed in the developing world for<br />

cost reasons. Dr Murray presented his experience<br />

with SIC surgery in Rotorua. His audit found that in<br />

the right hands, SIC surgery has similar outcomes<br />

to phacoemulsification – with the exception of<br />

slightly more surgically-induced astigmatism in SIC<br />

surgery patients. He advocated for the use of SIC<br />

surgery in more challenging cases such as those<br />

with dense cataracts.<br />

In contrast to Dr Murray’s talk about less<br />

technology in cataract surgery, Professor Charles<br />

McGhee spoke about a shift towards more<br />

technology in cataract surgery. More specifically,<br />

the role of femtosecond laser-assisted cataract<br />

surgery in New Zealand. Although the initial<br />

excitement around femtosecond laser-assisted<br />

cataract surgery has subsided, there is no doubt<br />

the technology can offer better capsulorhexis<br />

centration, less phaco time and less endothelial<br />

cell damage during cataract surgery.<br />

Hans Vellara an optometrist and PhD candidate<br />

at the University of Auckland talked about an<br />

innovative technique to measure orbital compliance<br />

in thyroid eye disease. Using the Corvis ST noncontact<br />

Scheimpflug tonometer they were able to<br />

diagnose thyroid eye disease with a 92% sensitivity<br />

and 84% specificity in a group of 20 patients.<br />

After lunch, and a break to take in the<br />

Tauranga sea breeze, Dr Jo Sims gave a talk<br />

about sympathetic ophthalmia. This potentially<br />

blinding form of uveitis can attack a patient’s<br />

good eye weeks to years after an eye injury or even<br />

significant eye surgery. Fortunately a majority of<br />

the patients in her series of 12, maintained good<br />

visual acuity, largely due to prompt recognition<br />

of the condition and aggressive treatment with<br />

immune modulating medication.<br />

Dr Shenton Chew, a glaucoma specialist from<br />

Auckland gave an update on the current protocols<br />

for peripheral iridotomy for angle closure. He<br />

mentioned that these protocols are in for an<br />

update as soon-to-be-published trials such as ZAP<br />

and EAGLE seem to indicate a greater role for lens<br />

extraction in the management of angle closure.<br />

There is hope yet for sufferers of macular atrophy<br />

as Dr Mike O’Rourke explained. The CentraSight<br />

magnifier lens implant is a 4.4mm telescope<br />

that can be implanted instead of an intraocular<br />

Angela James, Margaret Riordan and Ruth Mangnall<br />

lens during cataract surgery or even replace an<br />

existing intraocular lens during lens exchange<br />

surgery. A magnified image means that the<br />

patients central scotoma takes up less area in<br />

objects around fixation. The CentraSight however<br />

requires very careful patient selection: those<br />

with bilateral central vision loss, healthy corneal<br />

endothelium and who respond well to a simulation<br />

magnification device.<br />

The <strong>2016</strong> Save Sight Society meeting delivered<br />

on all my expectations and more. In fact, it was<br />

so good even NBA star Steven Adams decided to<br />

make a fleeting appearance. Although he may<br />

have been lost looking for the bathroom whilst<br />

at the venues hotel. Or maybe he heard there<br />

was free food? At any rate, the Save Sight Society<br />

and all the sponsors should be congratulated for<br />

hosting another fantastic meeting. ▀<br />

* Dr Aaron Wong is an ophthalmology trainee at the University of<br />

Auckland and father to eight-week-old baby Dylan (aka the cute<br />

baby who made brief appearance at lunch time).<br />

Dr Sarah Welch and John Kelsey<br />

Dr Stephen Guest and Dr James McKelvie<br />

Hans Vellara, A/Prof Dipika Patel and Akilesh Gokul<br />

Chantal O’Rouke, Dr Mike O’Rouke and Kay Evans<br />

Convenor Dr Sam Kain<br />

Jagrut Lallu and Graeme Nicholls Ellen Wong, Drs Bia Kim, Yi Wei Goh, Ammar Bin Sadiq and Dr Aaron Wong and Zak Prime Eastside! Joanna Bell, Mary-Ann Considine and Dr David Pendergast<br />

8 NEW ZEALAND OPTICS <strong>Oct</strong>ober <strong>2016</strong>


SPECIAL FEATURE: DRY EYE<br />

Dry eye: a hot topic<br />

A<br />

week doesn’t go by without someone<br />

issuing a press release or circulating a paper<br />

where dry eye diagnosis or treatment is the<br />

topic. More and more companies are developing<br />

new technologies or introducing software<br />

upgrades to tackle the thorny issue of dry eye.<br />

There’s still much debate, however, about what<br />

works and what doesn’t as will become evident in<br />

the following articles in this special feature.<br />

But knowledge about dry eye has grown<br />

exponentially over the past decade, fuelled by<br />

research following the internationally-renowned<br />

Tear Film & Ocular Society’s Dry Eye Workshop<br />

(DEWS), which was instrumental in bringing the<br />

problem to the fore by developing a common<br />

starting platform from which organisations<br />

could develop products and researchers could<br />

undertake new research. Out went the old<br />

definitions, deemed inadequate, and in came a<br />

new consensus definition:<br />

Dry eye is a multifactorial disease of the tears<br />

and ocular surface that results in symptoms<br />

of discomfort, visual<br />

disturbance and tear film<br />

instability with potential<br />

damage to the ocular<br />

surface. It is accompanied by<br />

increased osmolarity of the<br />

tear film and inflammation of<br />

the ocular surface.<br />

It’s pleasing to note how<br />

New Zealand, together with<br />

our trans-Tasman neighbour,<br />

is leading a lot of the research<br />

out there and there’s more<br />

to come with the results<br />

of DEWS II, the second Dry<br />

Eye Workshop, expected<br />

in the next few years, with<br />

preliminary results being<br />

discussed at the TFOS meeting<br />

in Montpellier in France,<br />

ongoing at the time of this<br />

feature’s publication.<br />

EDITORIAL BY LESLEY SPRINGALL<br />

Acknowledgements<br />

With that in mind, NZ Optics would like to thank<br />

the authors of all the contributed articles in this<br />

feature for updating us about their research,<br />

their progress and their interesting and personal<br />

take on the treatments and diagnosis of dry eye<br />

and the tools available (as well as some of their<br />

own invention – see Greg Nel’s article about his<br />

ping pong ball tearscope on p14). Their stories<br />

provide a breadth of understanding about where<br />

we’re at with dry eye and where we’re going and<br />

it’s a privilege to be able to curate and present<br />

these articles here.<br />

Special thanks must also go to New Zealand’s<br />

own dry eye expert, Associate Professor Jennifer<br />

Craig, vice-chair of DEWS II and passionate<br />

researcher into all things dry eye, who was<br />

instrumental in helping to curate and review the<br />

following articles, which we both hope will serve<br />

to enlighten and inform current thinking on the<br />

increasingly hot topic of dry eye.<br />

TFOS imagery used to launch the now highly anticipated DEWS II<br />

TFOS, OSL and where we are<br />

with dry eye<br />

BY ASSOCIATE PROFESSOR JENNIFER CRAIG*<br />

The Tear Film and Ocular Surface Society<br />

(TFOS) is a non-profit society created in<br />

2000 with a network that extends to more<br />

than 85 countries. As such, it represents a global<br />

community whose mission is to advance the<br />

research, literacy and educational aspects of the<br />

scientific field of the tear film and ocular surface.<br />

Since the initial International Conferences on the<br />

Lacrimal Gland, Tear Film and Dry Eye Syndromes<br />

in 1992 and 1996 in Bermuda, the incorporated<br />

TFOS Society has continued to organise meetings,<br />

initially every four years and now every three, with<br />

the latest meeting held as this article goes to press<br />

in Montpellier, France. These vibrant meetings<br />

provide a forum for critically appraising current<br />

knowledge and the latest research on the ocular<br />

surface, and promoting international exchange<br />

of information and ideas between scientists,<br />

academic clinicians and industry representatives<br />

dedicated to understanding the field and<br />

ultimately to improving patient care.<br />

At the time of writing, the current meeting is<br />

shaping up to be the best yet, with an impressive<br />

line-up of presenters promising to provide insight<br />

into the unique challenges and unmet needs for<br />

the treatment of ocular surface disease across the<br />

different regions of the globe; and many topical<br />

matters such as sex-differences in dry eye and the<br />

role of neuropathic pain in the disease. Debates<br />

provide insight into topical concepts and around<br />

250 posters will be presented across the three full<br />

days of the meeting.<br />

Beyond the conferences, TFOS is undoubtedly<br />

best known for the International Workshops it has<br />

sponsored; the Dry Eye Workshop (DEWS, 2007), the<br />

Meibomian Gland Dysfunction Workshop (MGDW,<br />

2011) and the Contact Lens Discomfort Workshop<br />

(CLDW, 2013). Critical to these workshops has been<br />

an evidence-based approach to achieving global<br />

consensus, with open communication, dialogue<br />

and transparency. It is with this charge, that 150<br />

clinical and scientific experts have come together,<br />

under the organisation of Associate Professor<br />

David Sullivan, TFOS founder and Harvard senior<br />

scientist, and the<br />

leadership of Dr<br />

Dan Nelson, chair of<br />

the Workshop, and<br />

myself, as vice-chair,<br />

to compile DEWS<br />

II, an update on dry<br />

eye from the 10<br />

years of research<br />

published since the<br />

original DEWS.<br />

The conference in<br />

Montpellier is the<br />

first opportunity to<br />

hear some of the<br />

DEWS II findings<br />

presented in an<br />

Associate Professor Jennifer Craig<br />

vice-chair of DEWS II<br />

open forum. So it’s pleasing to see that there will<br />

be a sizeable Australasian contingent attending,<br />

reflecting the volume and quality of research being<br />

conducted in dry eye within Australia and New<br />

Zealand. In particular, there will be representation<br />

from the University of New South Wales (UNSW)<br />

research group, which includes Dr Maria Markoulli<br />

and Dr Laura Downie’s laboratory in Melbourne<br />

(see stories later in this feature), as well as<br />

from the Ocular Surface Laboratory within the<br />

Department of Ophthalmology at the University of<br />

Auckland in New Zealand.<br />

Ocular Surface Laboratory (OSL) update<br />

The last year or so has seen significant expansion<br />

in the size of the OSL team, which now comprises<br />

12 full-time and part-time individuals that include<br />

registered PhD students, MSc students and Honours<br />

students (in medicine, optometry and physics),<br />

as well as postgraduate optometrists (including<br />

Grant Watters – see story p14) and undergraduate<br />

medical students who undertake collaborative<br />

research projects in their spare time, under the<br />

guidance and leadership of post-doctoral researcher<br />

Dr Isabella Cheung and myself. Cheung brings a<br />

wealth of laboratory research skills to the team, to<br />

complement the clinical research expertise.<br />

CONTINUED ON PAGE 10<br />

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8/04/16 5:22 PM<br />

9


SPECIAL FEATURE: DRY EYE<br />

CONTINUED FROM PAGE 9<br />

For the first time this year, clinical exposure, that can contribute<br />

to the requirements for a Clinical MSc, has been offered through<br />

the Laboratory, in collaboration with the University’s School of<br />

Optometry and Vision Science (SOVS). The Clinical MSc programme,<br />

coordinated by senior lecturer, Dr Nicola Anstice, provides<br />

postgraduate optometrists with an opportunity to expand their<br />

knowledge and clinical skills in an area of interest. Sang Hoo Lee is<br />

the inaugural Clinical MSc student in the OSL, where he has been<br />

focussing on advanced dry eye diagnosis and management.<br />

Researching dry eye in New Zealand…<br />

In addition to the blepharitis and Demodex projects described by<br />

the individual team members in the following article, the Ocular<br />

Surface group has an interest in better understanding dry eye<br />

development and its risk factors. Published in The Ocular Surface<br />

journal this year, the group, including medical student, Michael<br />

Wang who has co-authored a number of papers with the team,<br />

described novel findings that highlighted differences in the<br />

morphology of the meibomian glands between the Asian eye and<br />

the Caucasian eye in a cohort of University students. Over the next<br />

year, the group, with the help of medical student Ji Soo Kim and<br />

optometry student Alicia Han, will be continuing to investigate<br />

this apparent ethnic predisposition to dry eye in other age groups,<br />

with particular interest in the possible link identified between<br />

incomplete blinking and meibomian gland morphology.<br />

…and overseas as part of a global study<br />

To address limitations posed by the lack of normative data on<br />

meibomian gland morphology across different age groups and<br />

ethnicities, the OSL in Auckland is collaborating with researchers in<br />

the UK and around the world, in a global epidemiology study. Leslie<br />

Tien, a Part V BOptom student, has been contributing to this, while<br />

evaluating age effects on the tear film and ocular surface in a local<br />

cohort, for her Honours project this year. Medical student Joevy<br />

Lim, like Ji Soo, plans to take a year away from her medical studies<br />

to undertake a BMedSci Honours project, during which she too will<br />

be developing and expanding this work next year.<br />

Dissemination<br />

Dissemination of research findings is critical so researchers at<br />

the Laboratory are encouraged to write up their research findings<br />

whenever possible and to present findings at national and<br />

international conferences. PhD students Sanjay and Ally have<br />

already travelled to meetings in Barcelona, Spain and Beijing,<br />

China, respectively within the last year to present their work and<br />

will be heading to Montpellier with me. Both also have aspects of<br />

their research in review or published already.<br />

I am also planning to travel to Anaheim, California later in<br />

the year for the American Academy of Optometry meeting, to<br />

present the results of an international multicentre clinical trial<br />

involving the Ocular Surface Laboratory and New Zealand-based<br />

ophthalmology practices, Eye Institute and Auckland Eye. Targeting<br />

patients with aqueous deficiency, the Oculeve device uses<br />

intranasal neurostimulation to encourage tear production from the<br />

lacrimal gland. Positive preliminary results have led to Allergan,<br />

which acquired the Oculeve company in July 2015, currently<br />

seeking FDA approval for the device (see p16).<br />

* Associate Professor Jennifer Craig is head of the Ocular Surface Laboratory at the<br />

University of Auckland. She chaired the TFOS Workshop Subcommittee on “Contact Lens<br />

Interactions with the Tear Film” and, in 2015, was appointed vice-chair of the global<br />

initiative DEWS II (Dry Eye Workshop II), which will update the original DEWS report<br />

of 2007.<br />

Dry Eye & Allergy<br />

Centre of Excellence<br />

123 Remuera Rd, Remuera<br />

0800 393 527<br />

info@eyeinstitute.co.nz<br />

DED research update<br />

from the University<br />

of Auckland<br />

The following is a summary of just some of the research<br />

into dry eye disease (DED) currently being undertaken by<br />

researchers from the Ocular Surface Laboratory (OSL) and<br />

other departments at the University of Auckland.<br />

Blepharitis and Demodex studies<br />

Justin Sung, Varny Ganesalingam, Dr Isabella Cheung and Andy Kim<br />

Blepharitis is one of the most commonly observed ophthalmic<br />

conditions, with an impact on quality of life that is both<br />

significant and life-long, requiring patients to commit to ongoing<br />

management. Performed regularly, eyelid hygiene is an effective<br />

first-line management option for anterior blepharitis, helping to<br />

rid the lashes of crusting and reducing the bacterial load around<br />

the lid margins. As such, it is well established as a clinical mainstay.<br />

Controversy exists, however, between recommendations for use<br />

of diluted baby shampoo as a cost-effective remedy versus more<br />

expensive, custom-designed, commercial lid cleansers. Anecdotal<br />

reports have suggested a tendency for baby shampoo, as a nonophthalmic<br />

product, to induce ocular surface inflammation in<br />

some patients, by stripping the ocular surface of essential tear film<br />

lipids, as well as the troublesome lash crusts and debris. Evidence<br />

in the literature, however, is inconclusive.<br />

Medical student Justin Sung, who is presently undertaking<br />

a BMedSci Honours programme in the OSL between the fifth<br />

and sixth years of his medical degree, has been addressing<br />

this conundrum by performing a paired-eye, double-masked,<br />

randomised controlled trial to directly compare diluted baby<br />

shampoo against a leading commercial lid cleanser in terms of<br />

ocular surface inflammation levels pre and post-treatment. It’s<br />

hoped the results will help to guide clinicians in providing sound,<br />

evidence-based recommendations for patients affected by this<br />

highly prevalent condition.<br />

Blepharitis and Manuka honey<br />

While the pathophysiology of blepharitis is complex and its<br />

etiology uncertain, current research continues to find bacteria and<br />

inflammation as key contributing features. Because of this link, a<br />

topically-applied lid treatment embracing the unique antibacterial<br />

and anti-inflammatory properties of New Zealand Manuka Honey<br />

has been under development by collaborating researchers within<br />

the Department of Ophthalmology and Department of Molecular<br />

Medicine and Pathology. The resulting formulation – Manuka<br />

Honey with CycloPower microemulsion (MHCPME) – contains<br />

Manuka Health New Zealand’s proprietary combination of Manuka<br />

honey with cyclodextrin, a naturally occurring type of sugar, to<br />

increase its efficacy.<br />

Optometrist Varny Ganesalingam has been conducting laboratorybased<br />

research, as a part-time MSc student within the OSL, under<br />

the supervision of Associate Professors Jennifer Craig and Trevor<br />

Sherwin. Her study forms part of a larger investigation objectively<br />

assessing the tolerance of the human eye to the novel MHCPME<br />

product. Ganesalingam was responsible for evaluating RNA<br />

expression of three biomarkers of inflammation; MMP-9, IL-6<br />

and MUC5AC, from ocular surface tissue samples collected by<br />

impression cytology before and after a two-week treatment period<br />

on 23 healthy participants. After conducting preliminary studies<br />

to develop and refine the methodology, she subjected the samples<br />

to gene quantification analysis using real-time qPCR. The levels<br />

of all three genes of interest were found not to alter significantly<br />

following eyelid treatment with the Manuka honey-based emulsion.<br />

The results of her investigations, together with similarly favourable<br />

outcomes from the clinical component of the safety and tolerability<br />

trial, indicate that the treatment is suitable to progress towards the<br />

next and current phase, in which efficacy in patients with signs of<br />

chronic blepharitis is being tested.<br />

In addition, post-doctoral researcher Dr Isabella Cheung is<br />

evaluating the effectiveness of three months’ nightly use of this<br />

cyclodextrin-complexed Manuka honey formulation on the eyelids,<br />

as well as on the tear film and ocular surface, of individuals affected<br />

by blepharitis in an investigator-masked trial. The paired eye<br />

evaluation will be supported by clinical testing and with sensitive,<br />

laboratory-based quantification of the levels of inflammation.<br />

With scientific evidence demonstrating its effectiveness in treating<br />

blepharitis, this cyclodextrin-complexed Manuka honey preparation<br />

could become commercially available. This study is currently at the<br />

recruitment stage, so practitioners are encouraged to refer patients<br />

with blepharitis who might be interested in participating to the OSL<br />

for further information and to have their eligibility to participate<br />

confirmed.<br />

Blepharitis and Demodex<br />

Cheung is also supervising a<br />

novel study being undertaken<br />

by BMedSci Honours student,<br />

Andy Kim, who is between the<br />

third and fourth years of his<br />

medical degree, and who is<br />

also under the joint supervision<br />

of A/Profs Craig and Sherwin.<br />

Kim’s project concerns<br />

Demodex mites (see Fig 1.)<br />

which have been shown to be a<br />

significant contributing factor<br />

Fig 1. Demodex folliculorum can cause<br />

anterior blepharitis<br />

CONTINUED ON PAGE 12<br />

10 NEW ZEALAND OPTICS <strong>Oct</strong>ober <strong>2016</strong>


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References: 1. Christensen M, Blackie CA, Korb DR, et al. An evaluation of the performance of a novel lubricant eye drop. Poster D692 presented at: The Association for Research<br />

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Lubricant Eye Gel. Presented at American Academy of Optometry 2011, Boston, MA. 3. Davitt WF, Bloomenstein M, Christensen M, et al. Efficacy in patients with dry eye after treatment<br />

with a new lubricant eye drop formulation. J Ocul Pharmacol Ther. 2010;26(4):347-353. 4. Aguilar A. Efficacy of a Novel Lubricant Eye Drops in Reducing Squamous Metaplasia in Dry Eye<br />

Subjects. Presented at the 29th Pan-American Congress of Ophthalmology in Buenos Aires, Argentina, July 7-9, 2011. 5. Geerling G, et al. The International Workshop on Meibomian<br />

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<strong>Oct</strong>ober <strong>2016</strong> NEW ZEALAND OPTICS<br />

11


SPECIAL FEATURE: DRY EYE<br />

CONTINUED FROM PAGE 10<br />

Fig 2. Cylindrical collarettes are suggestive of Demodex<br />

infestation<br />

in blepharitis. Unfortunately, there are<br />

major deficits in our ability to diagnose<br />

ocular demodicosis in the clinical<br />

setting, which impacts upon the timely<br />

instigation of appropriate treatment.<br />

Currently clinicians rely on high<br />

magnification microscopic examination<br />

of epilated lashes to confirm Demodex<br />

presence (see Fig 2.), but inaccuracies<br />

in this technique, that complicate<br />

diagnosis, are recognised to exist due to<br />

variations in mite numbers between an<br />

individual’s lashes, and the potential for<br />

obscuration of mites by crusts around<br />

the lash base. In order to overcome these<br />

difficulties, Kim has helped develop a<br />

polymerase chain reaction (PCR)-based<br />

assay that detects and amplifies a<br />

Demodex-specific sequence from the<br />

16s ribosomal RNA gene; the presence<br />

and quantity of which can be visualized<br />

using gel electrophoresis. He is also<br />

working with the team to develop a latex<br />

agglutination assay using chitinase and<br />

wheat germ agglutinin which binds to<br />

chitin, the main constituent of Demodex.<br />

This in-clinic diagnostic test will enable<br />

practitioners to determine whether the<br />

patient has Demodex infestation at a<br />

clinically significant level to indicate need<br />

for treatment and may have benefits in<br />

future epidemiological studies.<br />

Microbial keratitis studies<br />

Sanjay Marasini<br />

Microbial keratitis (MK) describes a<br />

potentially devastating acute corneal<br />

infection that can be caused by a variety<br />

of pathogens including bacteria, virus,<br />

fungi and protozoans, with dry eye<br />

disease being a common predisposing<br />

factor. Despite improving diagnostic<br />

approaches and management options,<br />

however, MK remains a difficult disease<br />

to treat, and disease incidence has been<br />

rising steadily. Sanjay Marasini, a PhD<br />

student within the OSL, has recently<br />

completed a retrospective review of<br />

hospitalized cases of MK (2013-2014)<br />

at Greenlane Clinical Centre (GCC),<br />

Auckland. In his review, he identified<br />

increasing disease due to more virulent<br />

bacterial species, such as Pseudomonas<br />

aeruginosa. Contact lens use was the<br />

most common risk factor leading to MK in<br />

Auckland followed by pre-existing ocular<br />

surface disease of varying aetiology.<br />

Consistent with previous literature,<br />

gram-negative bacteria, most frequently<br />

Pseudomonas aeruginosa, were more<br />

common among contact lens wearers.<br />

Increasingly, inefficacy of commonly used<br />

antibiotics, against such virulent bacteria,<br />

has been predicted as a major threat. In<br />

Maransini’s recently published paper on<br />

this Auckland-based retrospective review,<br />

he noted that, in laboratory testing 67%<br />

of gram-negative bacteria exhibited<br />

resistance to cefuroxime, one of the<br />

most frequently prescribed antibiotics for<br />

bacterial keratitis during the 2013 to 2014<br />

period. (For more on how bacteria affects<br />

dry eye see p14).<br />

Tackling antibiotic resistance<br />

Concerning antibiotic resistance<br />

statistics, such as these, provide<br />

impetus for the pharmaceutical industry<br />

to develop the next generation of<br />

antibiotics, but they also make the quest<br />

for alternative bactericidal therapies<br />

increasingly attractive. In this context,<br />

the OSL – in collaboration with patentholder,<br />

ophthalmologist Dr Simon Dean<br />

– is continuing to explore the potential<br />

of ultraviolet C (UVC) radiation to treat<br />

corneal infection. Marasini’s pre-clinical<br />

research, investigating the minimum<br />

safe dose of UVC that is effective in<br />

halting bacterial growth, has shown<br />

interesting preliminary results. These<br />

are being translated to the next phase<br />

of his study, which will be completed<br />

over the next year and will involve the<br />

use of bioluminescent bacteria. With<br />

the prevalence of visual impairment<br />

secondary to infectious keratitis on<br />

the rise globally, the potential for UVC<br />

to contribute to the safe and effective<br />

management of corneal disease, either<br />

alone or as an adjunct therapy, is an<br />

exciting prospect which, if successful,<br />

could be extended to other branches of<br />

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algorithms using online infrastructure for practitioners.<br />

Currently, the process for effective patient care employs<br />

a series of questionnaires, as no one questionnaire fulfills<br />

all needs. Examples include: OSDI, McMonnies and SPEED.<br />

Ours includes a patient/practitioner portal and treatment<br />

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two being repeated prior to each follow-up/review.<br />

A brief summary of the diagnostic tests (not all) that<br />

our tool will include are:<br />

• Phenol red thread test – if less than 10mm dry eye<br />

indicated<br />

• Tear Lab – measures tear film osmolarity. In general,<br />

an increase in osmolarity is a marker for increased<br />

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NEW ZEALAND OPTICS<br />

13


SPECIAL FEATURE: DRY EYE<br />

Characterisation of the ocular surface microbiome<br />

BY GRANT WATTERS*<br />

Understanding and managing ocular surface<br />

disorders such as anterior blepharitis,<br />

meibomian gland dysfunction and<br />

dry eye disease remains challenging. Many of<br />

these conditions, being chronic, recurrent and<br />

debilitating, frustrate patients and clinicians alike<br />

with a plethora of treatments that are, at best,<br />

usually only partially effective¹.<br />

As in the intestine, there is a growing belief that<br />

dysregulation of the normal ocular commensal<br />

microbiota population may contribute to many of<br />

these conditions, so understanding the resident<br />

ocular surface microbiome in normal and diseased<br />

states may give us some clues as to whether we<br />

could more accurately regulate these microbe<br />

populations as a therapeutic strategy².<br />

Extensive research into the role that bacteria<br />

have in eyelid disease began with Thygeson’s work<br />

in the early half of the 20th century. He identified<br />

gram-positive (gm+) Staphylococcus aureus (S.<br />

aureus) as the organism most frequently isolated<br />

from the lid margins of blepharitis sufferers.<br />

Author(s);<br />

(year published)<br />

Albietz & Lenton<br />

(2006)<br />

Graham et al<br />

(2007)<br />

Bowman et al<br />

(1987)<br />

Dougherty &<br />

McCulley (1984)<br />

Groden et al<br />

(1991)<br />

Watters et al<br />

(<strong>2016</strong>)<br />

Country N C-N S<br />

(%)<br />

S.Aureus<br />

(%)<br />

P.acnes<br />

(%)<br />

Corynebact.<br />

sp.(%)<br />

Subsequent studies showed that while S. aureus<br />

was more common in blepharitis, coagulasenegative<br />

Staphylococcus (C-NS) was the most<br />

prevalent organism. Anaerobic gram-positive<br />

Proprionibacterium acnes (P. acnes) was also found<br />

to be more prevalent in eyes with lid disease 3,4 .<br />

We* have recently completed a study across<br />

three departments here at Auckland University<br />

to characterise the ocular surface microbiome<br />

present in New Zealanders with and without<br />

eyelid disease. Inferior lid margin swabs were<br />

collected from 157 randomly selected subjects<br />

subdivided into three categories: no lid disease<br />

(normal: n= 66); mild-to moderate lid disease (n=<br />

41), and moderate-to severe lid disese (n= 50).<br />

We also compared contact lens (CL) wearers and<br />

non-CL wearers. All subjects were analysed for<br />

aerobic isolates and 87 subjects were additionally<br />

investigated for anaerobic bacteria (P. acnes) 5 .<br />

Table 1. summarises our results in New Zealand<br />

normal eyes compared to relevant overseas<br />

studies. Of note is our sample exhibited a relatively<br />

higher percentage of individuals with S. aureus, a<br />

slightly lower incidence of C-NS, and an absence<br />

of Corynebacterium<br />

Streptococcus<br />

sp.(%)<br />

Australia* 18 84.0 6.0 22.0 6.0 0 6.0<br />

Ireland* 12 81.0 0 19.0 19.0 6.0 6.0<br />

Texas USA* 21 100.0 13.0 31.0 69.0 6.0 9.0<br />

Texas USA* 47 95.7 8.5 87.2 63.8 - -<br />

Florida USA* 160 87.5 15.6 73.7 45.0 - 4.3<br />

New<br />

Zealand*<br />

39 64.1 48.7 25.6 0 0 5.1<br />

Rubio (2004) Spain # 4366 56.8 6.4 - 30.2 7.5 6.2<br />

Hsu et al (2013)<br />

de Kaspar et al<br />

(2005)<br />

Capriotti et al<br />

(2009)<br />

Karthika et al<br />

(2014)<br />

Missouri<br />

USA #<br />

California<br />

USA #<br />

Sierra Leone<br />

(Rural) #<br />

India<br />

(Rural) #<br />

183 74.8 4.9 - 7.6 0.9 9.4<br />

162 76.0 11.7 - - 4.9 6.8<br />

276 28.6 19.9 - - - 16.0<br />

100 32.0 10.0 - 11.0 2.0 -<br />

Gm neg. rods inc.<br />

Pseudomonas (%)<br />

Table 1. Comparison of the ocular microbiome in different countries.<br />

(-) denotes not measured; (*) denotes normal subjects in studies comparing normal and dry eye subjects;<br />

(#) denotes consecutive and randomised “healthy” subject selection from the general population<br />

spp. This could be due<br />

to unique climatic<br />

and environmental<br />

conditions in New<br />

Zealand affecting the<br />

relationships between<br />

these different<br />

species. For example, a<br />

Queensland, Australia<br />

study showed higher<br />

C-NS and lower<br />

S. aureus counts<br />

than New Zealand,<br />

presumably due to<br />

the warmer and more<br />

humid climate 6 .<br />

Anaerobic P. acnes has<br />

previously been linked<br />

with blepharitis and,<br />

in our study, was the<br />

second most prevalent<br />

microorganism<br />

isolated in subjects<br />

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Staphylococcus aureus is the most frequently isolated bacteria from the<br />

lid margins of blepharitis sufferers<br />

with blepharitis after C-NS. This suggests that the<br />

synergistic relationship between S. aureus, C-NS<br />

and P. acnes changes between normal and diseased<br />

states. We also found this was the case with CL<br />

wearers, and other studies have found similar results<br />

(7,8)<br />

. Again our New Zealand cohort exhibited a<br />

notable absence of Corynebacterium spp.<br />

Further work is now being undertaken by<br />

our group to target therapeutic treatments to<br />

re-regulate the ocular surface microbiome for<br />

the management of blepharitis, including the<br />

development of a novel medical Manuka honeybased<br />

extract acting as an antimicrobial and a mild<br />

anti-inflammatory agent, (see P10).<br />

BY GREG NEL*<br />

Dysfunctional tear films have always<br />

tormented me. The clinical signs of dry eye<br />

disease (DED) and patient symptoms don’t<br />

always seem to fit very well in my chair. Patients<br />

who stain with lissamine and fluorescein aren’t<br />

always the unhappy ones and vice versa. Even<br />

more curious, contact lenses-associated dry eye<br />

symptoms have some patients preferring to wear<br />

the most illogical choices of lenses on occasion.<br />

The worst part of everything is that, as<br />

optometrists, we are supposed to be the ones<br />

that know what is going on. I didn’t feel up to the<br />

job and in the mid-noughties I declared war on<br />

dry eye and made it a pet project.<br />

The 2007 DEWS report (www.tearfilm.org/<br />

dewsreport/pdfs/TOS-0502-DEWS-noAds.<br />

pdf) helped identify a couple of key factors,<br />

evaporation and osmotic change in particular,<br />

but I needed to look at more than staining to<br />

evaluate what was happening on the eye.<br />

Critical signs included tear film meniscus<br />

height, meibomian function and the meibomian<br />

glands themselves. The lipid film thickness and<br />

properties are also excellent predictors and<br />

generally agree with the tear film surface quality<br />

assessment (TFSQ) module on the Medmont<br />

topographer. I had read papers on evaluating<br />

the lipid film and that interference fringes could<br />

be used to evaluate its thickness and character,<br />

but hadn’t thought of this as clinically useful<br />

To create your ping pong ball tearscope, cut the ball so that one<br />

slit allows it to sit over the diffuser lens in front of the mirror<br />

and another slit so that the widest beam illuminates the mirror<br />

(brightest light)<br />

References<br />

1. Nelson JD, Shimazaki JM, Benetez-del-Castillo JM, Craig JP,<br />

McCulley JP, Den S, Foulks GN. The International Workshop<br />

on Meibomian Gland Dysfunction: Report of the Definition<br />

and Classification Subcommittee. IOVS 2011; 52: 1930-37<br />

2. Zegans ME, Van Gelder RN. Consideratons in<br />

understanding the ocular surface microbiome. Am J<br />

Ophthalmol 2014; 158: 420-422<br />

3. Lee SH, Oh DH, Jung JY, Kim JC, Jeon CO. Comparative<br />

ocular microbial communities in humans with and<br />

without blepharitis. IOVS 2012; 53: 5585-93<br />

4. Miller D, Iovieno A. The role of microbial flora on the<br />

ocular surface. Curr Opin Allergy Clin Immunol 2009; 9:<br />

466-70<br />

5. Watters G, Craig JP, Swift S, Petty A, Turnbull P.<br />

Characterisation of the ocular surface microbiome present<br />

in New Zealanders with and without eyelid disease. Brit. J<br />

Ophthalmol (in press)<br />

6. Albietz JM, Lenton LM. Effect of antibacterial honey on<br />

the ocular flora in tear deficiency and meibomian gland<br />

disease. Cornea 2006; 25: 1012-19<br />

7. Dougherty JM, McCulley JP. Comparitive bacteriology of<br />

chronic blepharitis. Brit. J Ophthalmol 1984; 68: 524-28<br />

8. Graham JE, Moore JE, Jiru X, Moore JE, Goodall EA, Dooley<br />

JSG, Hayes VEA, Dartt DA, Downes CS, Moore TCB. Ocular<br />

pathogen or commensal: a PCR-based study of surface<br />

bacterial flora in normal and dry eyes. Invest.Ophthalmol.<br />

Vis.Sci 2007; 48: 5616-23<br />

* Grant Watters, MScOptom, a practicing Auckland optometrist<br />

and a lecturer and researcher with the University of Auckland,<br />

worked with Simon Swift PhD, Alex Petty BOptom, Philip<br />

Turnbull PhD, BOptom and Associate Professor Jennifer<br />

Craig PhD, MCOptom on the study. The researchers spanned<br />

three departments: the Department of Ophthalmology, the<br />

Department of Molecular Medicine and Pathology and the<br />

Department of Optometry and Vision Science at the University<br />

of Auckland, New Zealand.<br />

Evaluating, treating DED and ping pong balls!<br />

because tearscopes weren’t common outside the<br />

research arena until a mis-focussed image of the<br />

corneal endothelium yielded a spectacular image<br />

of the tear film lipid layer. Experimentation and<br />

improved cellphone cameras make this simple<br />

to record on a regular basis. You get a great view<br />

of the tear lipids by also using a ping-pong ball!<br />

Incidentally, the modern ping pong ball is larger<br />

than it used to be in an attempt to slow the game<br />

down – even better for us! So, for just 75 cents at<br />

your local sports shop (or mine anyway), you can<br />

make your own tearscope. Just mount your ping<br />

pong ball on your slit lamp’s diffuser after cutting<br />

a couple of perpendicular slots in it with a Dremel<br />

Tool or hacksaw blade – one to fit the diffuser and<br />

one to get the slit beam to the diffuser.<br />

Retroilluminating the lid with a transilluminator<br />

and playing with the colour sliders in the slit lamp<br />

camera software also gives great views of the<br />

meibomian glands, superior to some of the infrared<br />

systems I’ve tried. Encysted glands and gland<br />

dropout and atrophy are far more common than I<br />

had presumed. Imaging this is an excellent way of<br />

convincing people of the need to actively manage<br />

their lids on a day-to-day basis!<br />

Another useful assessment is the use of<br />

questionnaires; they are more sensitive as regards<br />

symptoms in my opinion – we use the SPEED<br />

(Standardised Patient Evaluation of Eye Dryness)<br />

questionnaire, especially as your slit lamp diagnosis<br />

is very situational, an “at-the-moment” snapshot.<br />

IPL treatment has been a game changer for<br />

many patients, both for dry eye symptoms and<br />

contact lens intolerance. My criticism of this<br />

quite futuristic intervention, however, is twofold.<br />

Firstly, we still have to try it and see. As a<br />

single intervention its success rate is impressive<br />

and doesn’t hinge on patient diligence, but<br />

exactly who benefits most remains as fractal as<br />

dry eye disease itself. Patients with neuropathic<br />

dry eye (mostly post-LASIK) and significant<br />

meibomian gland dropout seem to have the<br />

CONTINUED ON P15<br />

a<br />

b<br />

Transilluminator meiboscopy<br />

For further information call 0800 954 536 or email whitney@corneal-lens.co.nz<br />

c<br />

Examples of interference fringes: (a) thick, (b) disorganised and<br />

unstable, (c) not too bad – some debris, (d) thin – notice vertical bands<br />

d<br />

Pre and post-IPL TFSQ over a MyDay contact lens in a symptomatic<br />

patient, with improvement shown by the shallower gradient<br />

indicating less rapid destabilisation<br />

14 NEW ZEALAND OPTICS <strong>Oct</strong>ober <strong>2016</strong>


To IPL or not?<br />

BY ALLY XUE*<br />

The current mainstay therapies for<br />

meibomian gland dysfunction (MGD) are<br />

either palliative, providing only transient<br />

relief from dry eye symptoms, or they are<br />

unsuitable for long-term use in chronic cases.<br />

One novel treatment to emerge in recent years,<br />

however, is intense pulsed light (IPL), which was<br />

discovered, serendipitously, to provide relief<br />

from symptomatic MGD, around a decade ago.<br />

Despite the dearth of scientific evidence<br />

supporting its anecdotal positive ocular effects,<br />

IPL therapy is now being offered in more than<br />

100 practices across Australasia. The rising<br />

popularity of IPL as a treatment for evaporative<br />

dry eye prompted the Ocular Surface Laboratory<br />

(OSL) at The University of Auckland to conduct<br />

the first randomised, double-masked, placebocontrolled<br />

pilot study (published in IOVS last<br />

year). The research team, led by Associate<br />

Professor Jennifer Craig, demonstrated<br />

significant and cumulative improvements<br />

to the lipid quality and stability of the tear<br />

film, as well as reduced symptoms following<br />

IPL application. However, it was deemed that<br />

further study was necessary to establish the<br />

underlying mechanism(s) and determine<br />

applicability in different patient sub-groups to<br />

improve prognostic value and enable further<br />

therapeutic refinements.<br />

CONTINUED FROM P14<br />

poorest prospects in my opinion. My other<br />

criticism is that it is actually expensive for<br />

patients in an unsubsidised environment. I<br />

had visions of using it more often, and I find it<br />

frustrating that I don’t use it more frequently.<br />

I probably need sales training!<br />

References<br />

Differentiation of Lipid Tear Deficiency Dry Eye by<br />

Kinetic Analysis of Tear Interference Images; Eiki Goto,<br />

MD; Scheffer C. G. Tseng, MD, PhD; Arch Ophthalmol.<br />

2003;121:173-180<br />

Assessment of the Tear Film; Jane Veys MSc MCOptom<br />

FBCLA FAAO, Education Director, Vision Care Institute<br />

Classic meibomian gland dysfunction<br />

In a few weeks’ time, under the supervision of<br />

A/Prof Craig, I will begin conducting a second<br />

IPL study to validate the promising results<br />

demonstrated by the prospective pilot trial.<br />

The aim is to refine and expand upon the pilot<br />

research methodology by tracking its efficacy<br />

over a longer time period and collect data<br />

to help investigate the potential underlying<br />

mechanisms. Specifically, myself and the other<br />

researchers will be evaluating the effects of IPL<br />

therapy on neurobiological and inflammatory<br />

pathways, eyelid microflora and the tear film<br />

lipidome. The OSL is currently recruiting eligible<br />

dry eye patients with symptomatic MGD<br />

from Auckland optometric clinics, and it is<br />

expected that recruitment will be ongoing until<br />

December <strong>2016</strong>. In exchange for a few hours<br />

of their time, participants are offered free IPL<br />

treatments and a contribution towards travel<br />

costs. Therefore, if you believe your patient may<br />

be a suitable candidate for this study, please<br />

send referrals to me at a.xue@auckland.ac.nz<br />

or email me for further information.<br />

*Ally Xue is a PhD student with OSL.<br />

Johnson & Johnson Vision Care: www.jnjvisioncare.<br />

co.uk/sites/default/files/public/uk/tvci/eclp_<br />

chapter_4.pdf<br />

Computer-Synthesis of an Interference Color Chart of<br />

Human Tear Lipid Layer, by a Colorimetric Approach;<br />

Eiki Goto, Murat Dogru, Takashi Kojima and Kazuo<br />

Tsubota; IVOS. Nov 2003: 44:11<br />

Tear film dynamics and lipid layer characteristics—<br />

Effect of age and gender; Cécile Maïssa, Michel<br />

Guillon, Contact Lens and Anterior Eye; August 2010,<br />

Volume 33, Issue 4, Pages 176–182.<br />

* Greg Nel has practiced optometry in both South Africa<br />

and New Zealand and is a partner with Total Eyecare.<br />

He is passionate about specialised contact lens fitting,<br />

corneal refractive therapy (CRT) and paediatric/<br />

development optometry, plus he’s a keen photographer,<br />

surfer and home-brewer.<br />

Dry eye in NZ<br />

With our aging population, the<br />

current state of dry eye disease<br />

(DED) diagnosis and management in New<br />

Zealand needs to be examined. Recently,<br />

an anonymous, web-based questionnaire<br />

was distributed to New Zealand eye<br />

care clinicians (optometrists n=614,<br />

ophthalmologists n=113). The questionnaire<br />

sought information about practitioners’<br />

interest in DED, their practice experience,<br />

practice modality, preferred diagnostic and<br />

management strategies and the evidencebase<br />

they use to guide patient care.<br />

The survey revealed both professions<br />

(optometrist response rates: 26%,<br />

and ophthalmologist: 26%) possess<br />

similarly strong knowledge of tear film<br />

assessment. Consistent with evidencebased<br />

guidelines, New Zealand eye care<br />

professionals use subjective and objective<br />

techniques to diagnose DED. Almost all<br />

respondents considered patient symptoms<br />

and meibomian gland evaluation as the<br />

most valuable and commonly performed<br />

diagnostic techniques. However,<br />

standardised grading scales and validated<br />

dry eye questionnaires were infrequently<br />

adopted.<br />

Most respondents indicated eyelid<br />

hygiene and non-preserved lubricants<br />

as the mainstay therapies, nevertheless<br />

DED management was tailored to disease<br />

severity. There’s increased recommendation<br />

for omega-3 fatty acids intake (see p18),<br />

topical corticosteroids and systemic<br />

tetracyclines in moderate to severe DED<br />

relative to mild disease, highlighting<br />

recognition of inflammation as a feature<br />

associated with dry eye, particularly in more<br />

advanced cases.<br />

Lastly, it was concluded that dissemination<br />

of research evidence relating to clinical bestpractice<br />

for DED could be further improved,<br />

potentially through mechanisms focussed<br />

upon continuing education conferences, as<br />

this was the preferred method to inform their<br />

management approach, clinicians report.<br />

* Submitted by the OSC<br />

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NEW ZEALAND OPTICS<br />

15


SPECIAL FEATURE: DRY EYE<br />

Contact lenses and dry eye<br />

Dry eye is one of the most common<br />

conditions seen by eye care practitioners<br />

around the world. It is estimated that<br />

25% of patients will report symptoms of dry<br />

eye¹. For our contact lens (CL) patients this<br />

frequency is likely higher due to the effects that<br />

an in situ contact lens can have on the tear film<br />

and ocular tissue. Reported rates of contact lens<br />

discontinuation internationally vary from 15%<br />

to 31%². Consistently, discomfort and dryness<br />

are rated as the top reasons for this dropout 3 4 5,6 .<br />

However, certain types of contact lenses can also<br />

be an important management option for patients<br />

with mild to severe dry eye. This article will briefly<br />

explore why contact lenses cause dry eye, explain<br />

what can be done to reduce the incidence of dry<br />

eye symptoms in contact lens wearers and describe<br />

some of the contact lens options available to<br />

patients with existing dry eye disease.<br />

Why do CLs cause dryness?<br />

In 2013 the Tear Film and Ocular Surface Society<br />

(TFOS) international workshop on contact lens<br />

discomfort carried out a robust investigation into<br />

this question. Helmed by our very own Associate<br />

Professor Jennifer Craig, the TFOS report on tear<br />

film stability in contact lens wearers suggested<br />

that contact lens induced dryness stems from the<br />

alteration of the tear film into pre- and post-lens<br />

layers (Fig 1.) 7 . The resulting pre-lens tear film has<br />

reduced lipid layer thickness, reduced tear volume<br />

and an increased evaporation rate compared<br />

to the normal tear film 8 . As a result of this<br />

compromised tear film, previously asymptomatic<br />

patients may begin to experience discomfort and<br />

dry eye symptoms 9 . Another school of thought<br />

suggests decreased corneal sensation from contact<br />

lens wear leads to a ‘neurotrophic state’, which<br />

promotes inflammation and compromises the<br />

signal for tear production 10 .<br />

Lid wiper epitheliopathy (LWE) is a clinical sign that<br />

is gaining in popularity amongst practitioners when<br />

describing dry eye. LWE refers to disruption of the lid<br />

margin that ‘wipes’ across the anterior eye surface or<br />

contact lens during blinking (Fig 2.). Studies suggest<br />

BY ALEX PETTY*<br />

Get to the main<br />

cause of dry,<br />

irritated eyes*<br />

that the presence of LWE is highly associated with<br />

discomfort in contact lens wearers, occurring in<br />

80% of symptomatic contact lens patients versus<br />

13% for asymptomatic wearers 11 . LWE is a sign of<br />

increased friction with each blink; expected in a<br />

dry eye or with the use of a poorly wetting contact<br />

lens. Efron et al.’s recent comprehensive review<br />

of LWE states there is consistent evidence of a<br />

relation between contact lens surface friction and<br />

wearing comfort 12 .<br />

Improving dry eye symptoms in CL<br />

patients?<br />

The presence of LWE in CL patients has<br />

highlighted the importance of having a slippery<br />

lens surface to decrease friction and discomfort.<br />

Coles and Brenan showed that contact lenses<br />

with a higher lubricity tend to be more<br />

comfortable 13 . CL companies have been quick to<br />

release a number of excellent products that serve<br />

to increase the lubricity of patient’s lenses. These<br />

include Alcon’s Dailies Total1 water gradient<br />

lens and Bausch and Lomb’s “MoistureSeal”<br />

technology, incorporated in their Ultra range<br />

of lenses. We should not forget, however, that<br />

silicone hydrogels are naturally more hydrophobic<br />

than hydrogels due to their siloxane components,<br />

and may lead to decreased wettability, and<br />

therefore lubricity in certain wearers 14 . In<br />

these instances, hydrogel materials such as<br />

B+L’s Biotrue ONEday daily and Coopervision’s<br />

Proclear family (incorporating zwitterionic PC<br />

technology; still the only FDA material approved<br />

for patients that experience dryness with contact<br />

lens wear) may be useful. Alcon have also recently<br />

incorporated ‘Hydraglyde moisture matrix’,<br />

a hydrophilic compound that embeds onto a<br />

lens and decreases friction, into their hydrogen<br />

peroxide cleaning solution, AOSept, as well as their<br />

PureMoist multi-purpose disinfecting solution.<br />

Rigid lenses too can benefit from technologies<br />

to improve wettability. This includes the use of<br />

materials such as Optimum Extra with its very<br />

low wetting angles, and plasma-treatment of<br />

rigid lenses to decrease the hydrophobicity of<br />

4UP TO<br />

HOURS<br />

RELIEF 2<br />

CLINICALLY PROVEN<br />

the surface 15 . We should<br />

not forget to encourage all<br />

CL patients to use artificial<br />

tear drops as needed for an<br />

immediate improvement<br />

in lens lubricity, especially<br />

after longer-wear time.<br />

To avoid exacerbating any<br />

inflammatory aspects of<br />

dry eye, non-preserved<br />

formulations should be<br />

recommended.<br />

Options if the patient<br />

still cannot wear CLs<br />

comfortably?<br />

Despite advances in<br />

technology some patients,<br />

especially as they age and<br />

their tear volume naturally<br />

decreases, will continue<br />

to experience discomfort<br />

with soft contact lens wear.<br />

In this case sometimes no<br />

lens is better than any lens.<br />

Orthokeratology can be an<br />

excellent modality for patients<br />

who experience regular<br />

contact lens discomfort<br />

but otherwise only show<br />

mild signs of dry eye. One<br />

study showed that patients<br />

refitted from SiHy lenses<br />

into orthokeratology wear<br />

had a statistically significant<br />

increase in goblet cell density<br />

and improvement in dry eye<br />

symptoms after one month 16 .<br />

Anecdotally I have looked after<br />

a number of very satisfied<br />

orthokeratology patients that<br />

were previously unhappy with<br />

their SCL comfort.<br />

Scleral CLs<br />

A report on dry eye and<br />

contact lenses would not be<br />

complete without discussing<br />

scleral contact lenses. Sclerals<br />

are mainly reserved for<br />

patients with severe dry eye,<br />

such as Sjogren’s syndrome<br />

and graft-vs-host disease<br />

(GvHD), that do not find<br />

relief with other treatments.<br />

They are effective as the lens<br />

shields the eye and allows<br />

the post-lens fluid reservoir<br />

to bathe the compromised<br />

ocular surface during wear. Scleral lenses,<br />

including the PROSE lens (Prosthetic Replacement<br />

of the Ocular Surface Ecosystem; an impressive<br />

sounding scleral lens treatment that really just<br />

refers to onsite custom fitting at the B+L contact<br />

lens laboratory), have been shown to improve the<br />

visual function in patients with ocular surface<br />

disease over a five-year period 17 .<br />

A colleague of mine from the States, Dr<br />

Nate Schramm, a scleral lens expert from Fort<br />

Lauderdale, shared this relevant case with me<br />

recently: a 21-year-old man presented to his<br />

practice with severe dry eye symptoms. He has<br />

psoriasis and low testosterone and due to his<br />

programming occupation spent 75% of his day in<br />

front of a computer screen. He had been treated<br />

with meibomian gland probing and punctal<br />

cautery three months before and given a course<br />

of topical cyclosporin, however his symptoms did<br />

not improve. Examination showed instantaneous<br />

tear breakup, stagnant meibomian glands and<br />

Fig 1. Tear film structure with a soft contact lens<br />

Fig 2. Moderate lid-wiper epitheliopathy present on an everted upper lid margin, stained with<br />

lissamine green. Courtesy of OSL<br />

Fig 3. Central corneal OCT scan of the scleral lens fit for the dry eye patient case described<br />

Another SCL patient of mine with punctate epitheliopathy due to mild dry eye. I refitted her into<br />

hyperopic orthokeratology lenses and after a month her epitheliopathy had resolved and daytime<br />

comfort was much improved. Note the lack of corneal staining<br />

scattered corneal epitheliopathy. MGD treatments<br />

were initiated, including Lipiflow, and a scleral lens<br />

was fitted in conjunction with autologous-serum<br />

drops in the lens bowl during insertion (Fig 3).<br />

Despite initial difficulties with handling, this<br />

patient noticed immediate improvement in<br />

comfort when wearing his sclerals. After a year’s<br />

treatment the patient commented the only<br />

treatment that decidedly helped his dry eye were<br />

his scleral lenses.<br />

In summary, technologies for managing dry<br />

eye are improving each year, with contact lens<br />

advancements helping our patients achieve<br />

freedom from spectacle wear in an increasingly<br />

comfortable and safe manner. It should not be<br />

forgotten that certain contact lens modalities<br />

provide important dry eye therapies and should be<br />

considered in recalcitrant cases.<br />

CONTINUED ON P17<br />

Optrex ActiMist – clinically proven to work<br />

How does Optrex ActiMist work?<br />

Optrex ActiMist contains<br />

liposomes (tiny bubbles fi lled with<br />

moisture) that migrate across the<br />

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These liposomes mix with natural<br />

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Always read the label. Use only as directed. If symptoms persist, see your healthcare professional. †When wearing make-up, it is recommended to apply from 20cm. *Due to disturbed lipid layer of the tear fi lm. References:<br />

1. Lee S et al. Klin Monatsbl Augenheilkd 2004; 221:1–12. 2. Khaireddin R, Schmidt KG. Klin Monatsbl Augenheilkd. 2010; 227: 128-134. 3. Pult H et al. Contact Lens Anterior Eye 2012, 35:203-207. Reckitt Benckiser, Auckland. TAPS DA1541<br />

FDA and Oculeve<br />

Allergan has filed a de novo application with the US Food and Drug Administration (FDA) for its<br />

Oculeve Intranasal Tear Neurostimulator Device. The de novo classification process is a rapid<br />

regulatory pathway for novel, low- to-moderate-risk medical devices that are deemed to be<br />

first-of-a-kind.<br />

The neurostimulator was acquired by Allergan last year, when it bought Oculeve for US$125<br />

million cash. Allergan has openly stated that dry eye is a priority area. “The Oculeve Intranasal Tear<br />

Neurostimulator is an exciting potential option for patients suffering from dry eye disease, and we<br />

are pleased to have filed the de novo application with FDA that will allow patients to gain access to<br />

this novel medical device,” said David Nicholson, Allergon’s chief R&D officer in a statement.<br />

The device is a non-invasive nasal neurostimulation that stimulates tear production. An element<br />

is inserted into the mucous membrane of the nasal cavity and another under the skin below the<br />

eyebrow, allowing the patient to manually adjust the rate of tear delivery using a wireless controller.<br />

Just prior to filing the application, Allergan announced two pivotal trials (one of which involved the<br />

University of Auckland’s OSL team) of the neurostimulator each met their effectiveness endpoints.<br />

16 NEW ZEALAND OPTICS <strong>Oct</strong>ober <strong>2016</strong>


CONTINUED FROM P16<br />

References<br />

1. O’Brien, P, and Louis, C. “Dry eye: diagnosis and current<br />

treatment strateg ies.” C urrent allergy and asthma<br />

reports 4.4 (2004):314319.<br />

2. “New Data on Contact Lens Dropouts: An International<br />

Perspective.” Rumpakis, J. <strong>2016</strong>. < https://www.<br />

reviewofoptometry.com/article/newdataoncontactlensdrop<br />

outsaninternationalperspective<br />

3. Research in dry eye: report of the Research Subcommittee<br />

of the International Dry Eye WorkShop (2007). Ocul Surf.<br />

2007Apr;5(2):17993.<br />

4. Pritchard N, Fonn D, Brazeau D. Discontinuation of<br />

contact lens wear: a survey. Int Contact Lens Clin. 1999<br />

Nov;26(6):15762.<br />

5. Weed K, Fonn D, Potvin R. Discontinuation of contact lens<br />

wear. Optom Vis Sci. 1993;70(12, suppl.):140.<br />

6. Richdale K, Sinnott LT, Skadahl E, Nichols JJ. Frequency of<br />

and factors associated with contact lens dissatisfaction<br />

and discontinuation. Cornea. 2007;26(2):16874.<br />

7. Craig, JP et al. “The TFOS International Workshop on<br />

Contact Lens Discomfort: Report of the Contact Lens<br />

Interactions With the Tear Film Subcommittee Report on<br />

Interactions With Tear Film.” Investigative ophthalmology<br />

& visual science 54.11 (2013): TFOS123TFOS156.<br />

8. Nichols, JJ et al. “The TFOS International Workshop on<br />

Contact Lens Discomfort: Executive SummaryExecutive<br />

Summary.” Investigative ophthalmology & visual science<br />

54.11 (2013): TFOS7TFOS13.<br />

9. Nichols, JJ, and Sinnott, L. “Tear film, contact lens, and<br />

patient related factors associated with contact lens–<br />

related dry eye.”Investigative ophthalmology & visual<br />

science 47.4 (2006): 13191328.<br />

10. Cox, S and Nichols J. Contact Lens Dry Eye: Neurotrophic<br />

Disease or MGD? Contact Lens Spectrum, Volume: 31 ,<br />

Issue: July <strong>2016</strong>, page(s): 3235<br />

11. Korb, D.R., Greiner, J.V., Herman, J.P., Hebert, E.,<br />

Finnemore, V.M., Exford, J.M., Glonek, T., Olson, M.C., 2002.<br />

Lidwiper epitheliopathy and dryeye symptoms in contact<br />

lens wearers. CLAO J. 28, 211216.<br />

12. Efron N , Brennan NA , Morgan PB , Wilson T Lid wiper<br />

epitheliopathy. Prog Retin Eye Res. <strong>2016</strong> Jul;53:14074.<br />

doi:10.1016/j.preteyeres.<strong>2016</strong>.04.004. Epub <strong>2016</strong> Apr 14.<br />

13. Coles, C.M.L., Brennan, N.A., 2012. Coefficient of friction<br />

and soft contact lens comfort. Optom. Vis. Sci. 88.<br />

Eabstract 125603.<br />

14. Jones, L. Editorial: Hydrogel contact lens materials: Dead<br />

and buried or about to rise again? Contact Lens Update.<br />

<strong>Oct</strong>ober 7 2013. http://www.contactlensupdate.com/<br />

15. http://www.gpli.info/labconsultantmaterialstreatments/<br />

16. Carracedo, Gonzalo et al. Effect of overnight<br />

orthokeratology on conjunctival goblet cells. Contact Lens<br />

and Anterior Eye,Volume 39 , Issue 4 , 266 269<br />

17. Agranat JS, Kitos NR, Jacobs DS. “Prosthetic replacement<br />

of the ocular surface ecosystem: impact at 5 years.” Br J<br />

Ophthalmol <strong>2016</strong>; 100 :11711175<br />

*Alex Petty is a New Zealand optometrist based in Tauranga with<br />

a particular interest and knowledge in speciality contact lenses,<br />

ortho-k and myopia control.<br />

Dry eyes and allergy: a common association?<br />

BY DR ADAM WATSON*<br />

Dry eye and allergy problems are usually<br />

considered as separate entities and, if<br />

there is consideration given to both, it<br />

is usually in terms of differential diagnosis: “is<br />

this a dry eye or an allergy problem causing the<br />

patient’s symptoms?”<br />

But the two may co-exist and there may be a<br />

causative relationship between the two in many<br />

cases.<br />

Dry eye problems are common, affecting up to<br />

15% of people over 50 with a greater proportion<br />

of women affected. Ocular surface allergy is<br />

also common with around 20% of people having<br />

some degree of seasonal or perennial allergic<br />

conjunctivitis. When both are present, a tailored<br />

management strategy that takes both into<br />

account is desirable.<br />

Symptom overlap<br />

The symptoms of dry eye include burning,<br />

stinging, tired eyes and grittiness sensation.<br />

Vision may be variably affected by ocular surface<br />

disturbance and poor tear film quality. Allergy also<br />

frequently causes burning, stinging and irritated<br />

sensations, while vision may be variably affected<br />

by mucus production and tear film abnormalities.<br />

A cardinal symptom of allergy, however, is<br />

itching of the eyes due to histamine release<br />

– itching is very suggestive of an allergic<br />

component to the ocular surface disease.<br />

Dry eye and allergy association – evidence<br />

Inflammation has been recognised as a key<br />

component of dry eye disease. More than likely<br />

this has multifactorial causation including<br />

tear film instability, hyperosmolarity of the<br />

tear film and meibomian gland related factors.<br />

Inflammation is also the underlying cause of<br />

ocular surface allergy symptoms and signs –<br />

type I hypersensitivity, in the case of seasonal or<br />

perennial allergic conjunctivitis; type IV cellmediated<br />

response in vernal and atopic disease.<br />

Studies in children with both type I and<br />

type IV (vernal) allergic disease have shown a<br />

significantly decreased tear breakup time leading<br />

to variable dry eye symptoms.<br />

In atopic keratoconjunctivitis, the earlier age<br />

of onset is associated with poorer Schirmer and<br />

Rose Bengal scores, presumably as a result of the<br />

more prolonged inflammation worsening ocular<br />

surface damage and inducing dryness.<br />

Among other risk factors including age,<br />

rheumatoid arthritis and depression, the<br />

presence of any allergy, asthma and eczema<br />

(atopy) were significantly associated with dry eye<br />

disease in a large study of female twins in the<br />

UK. Additionally, in a study of 689 adults using<br />

a validated questionnaire, most patients with<br />

symptoms consistent with allergic conjunctivitis<br />

(57%) also had dry eyes.<br />

Management suggestions<br />

When combined allergy and dry eye disease is<br />

suspected, treatment should ideally address<br />

both conditions. However, there is probably<br />

room to rationalise the approach to simplify<br />

what otherwise can be a veritable onslaught of<br />

intervention.<br />

Since both conditions involve inflammation<br />

of the ocular surface, rational therapy includes<br />

treatment or prevention of inflammation as<br />

part of the approach. This may be helpful in<br />

stabilising the tear film, thereby assisting in the<br />

management of dry eye. Therefore, an initial<br />

strategy may be the use of olopatadine (Patanol)<br />

eye drops twice daily for their mast cell stabilising<br />

and anti-histamine effect; and the addition<br />

of a (preservative-free) lubricant drop to help<br />

augment the tear film and to flush away ocular<br />

surface allergens<br />

Reviewing this after a couple of weeks will tell<br />

you whether you’re on the right track. If the itching<br />

and inflammation have improved, but dry eye<br />

symptoms are still a feature, incorporating more<br />

frequent preservative-free lubrication, eyelid<br />

therapy including heat treatment, doxycycline<br />

or azithromycin, and possibly punctal plug<br />

placement may be appropriate.<br />

If inflammation is a more prominent feature,<br />

then a tapering course of a topical steroid<br />

(fluorometholone or non-preserved prednisolone<br />

or methylprednisolone) while continuing<br />

olopatadine may be a useful strategy to optimise<br />

the ocular surface. Again, attention to meibomian<br />

gland dysfunction (MGD) may be an important<br />

component of treatment.<br />

Other modalities such as intense pulsed<br />

light (IPL) therapy may play a part. More<br />

severe allergic inflammation (vernal or atopic<br />

keratoconjunctivitis) can be effectively treated<br />

with topical cyclosporine or tacrolimus that often<br />

help the dry eye problems as well.<br />

In summary, dry eye and allergic eye conditions<br />

are likely often present in combination, with<br />

the link between them being ocular surface<br />

inflammation. Control of the inflammation is an<br />

important first step in managing both.<br />

References:<br />

DEWS Report. Ocular Surface. 2007;5:65-204<br />

Chen et al. High incidence of dry eye…Acta<br />

Ophthalmologica. May <strong>2016</strong> (epub)<br />

Villani et al. Dry eye in vernal keratoconjunctivitis.<br />

Medicine(Baltimore). 2015;94:e1648<br />

Hon et al. Allergic conjunctivitis and dry eye syndrome. Ann<br />

Allergy Asthma Immunol. 2012;108:163-6<br />

Vehof et al. Prevalence and risk factors of dry eye disease…<br />

Br J Ophthalmol. 2014;98:1712-7<br />

Onguchi et al. The impact of the onset time of AKC on the<br />

tear function… Am J Ophthalmol. 2006;141:569-71<br />

* Dr Adam Watson works at Eye Institute in Auckland. He has<br />

subspecialist interests in ocular surface disease, cataract,<br />

corneal and refractive surgery and oculoplastic surgery.<br />

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NEW ZEALAND OPTICS<br />

17


SPECIAL FEATURE: DRY EYE<br />

New dry eye drug<br />

launched<br />

Shire’s dry eye drug Xiidra (lifitegrast ophthalmic solution) went<br />

on sale in the US market at the end of August, just weeks after<br />

its approval by the US Food and Drug Administration (FDA)<br />

for the treatment of signs and symptoms of dry eye disease. Xiidra<br />

is the first medication in a new class of drugs, called lymphocyte<br />

function-associated antigen 1 (LFA-1) antagonist approved by the<br />

FDA for dry eye disease.<br />

“Normal tear production is needed for clear vision and eye health.<br />

This approval will provide a new treatment option for patients<br />

with dry eye disease,” said Dr Edward Cox, director of the Office of<br />

Antimicrobial Products at the FDA’s Centre for Drug Evaluation and<br />

Research, in a statement.<br />

The safety and efficacy of Xiidra was assessed in more than a<br />

thousand patients, aged 19 to 97, with 76% being women, in four<br />

separate, randomised, controlled studies. Patients were randomised<br />

equally to receive either Xiidra eyedrops or placebo eyedrops, which<br />

were used twice a day for twelve weeks. The studies found groups<br />

treated with Xiidra demonstrated more improvement in both the<br />

signs and the symptoms of eye dryness than the groups treated<br />

with placebo. The most common side effects of Xiidra include<br />

eye irritation, discomfort or blurred vision and an unusual taste<br />

sensation (dysgeusia).<br />

Xiidra is Shire’s first FDA-approved medicine in ophthalmics and<br />

the first significant new drug to enter the dry eye market in more<br />

than a decade. It is expected to severely effect sales of Allergan’s<br />

Restasis (cyclosporine ophthalmic emulsion 0.05%), which was<br />

approved in 2003.<br />

Omega-3 for<br />

treating DED<br />

BY DR LAURA DOWNIE*<br />

Dry eye disease (DED) is a highly<br />

prevalent condition that has a<br />

significant, negative impact upon<br />

quality of life. Although the pathogenesis<br />

of DED is not fully understood, the<br />

condition involves an immune-based<br />

inflammation of the anterior eye 1 . DED is<br />

characterised by an abnormal elevation of<br />

tear film tonicity, known as a state of tear<br />

hyperosmolarity 2 , which promotes ocular<br />

surface inflammation 3 . Tear hyperosmolarity<br />

leads to corneal and conjunctival epithelial<br />

cell apoptosis and inflammatory events that<br />

culminate in the loss of mucin-secreting<br />

goblet cells 4 . Together, these changes are<br />

recognised to promote tear film instability<br />

and perpetuate a chronic, pro-inflammatory<br />

cycle.<br />

Given the prominent role of inflammation<br />

in the pathogenesis of DED, antiinflammatory<br />

agents are often prescribed<br />

to reduce the signs and symptoms of the<br />

condition. As an alternative to traditional<br />

anti-inflammatory therapeutics, such as<br />

corticosteroids, oral omega-3 (Ω-3) essential<br />

fatty acid (EFA) supplements can be used<br />

to modulate ocular inflammation. EFAs are<br />

termed ‘essential’ as they are required for<br />

optimal general health 5 . As EFAs are unable<br />

to be synthesised directly within the body,<br />

they must be derived from dietary sources.<br />

The two main types of EFAs are the omega-3<br />

(Ω-3) and omega-6 (Ω-6) fatty acids, which<br />

are found in different food sources. Omega-3<br />

EFAs occur in relatively high concentrations<br />

in oily fish (eg. tuna, salmon, sardines) and<br />

some plant-based foods (eg. chia seeds,<br />

walnuts). Foods rich in Ω-6 EFAs include<br />

meat, poultry and eggs.<br />

The ratio of consumed Ω-3 to Ω-6 EFAs<br />

has a direct effect on the inflammatory<br />

status of the body 6 . In contemporary<br />

Western diets,<br />

the ratio of<br />

Ω-6:Ω-3 intake<br />

is often as high<br />

as 15:1, whereas<br />

an ideal ratio is<br />

considered 4:1 or<br />

less 7 . Omega-3<br />

EFAs bias systemic Dr Laura Downie<br />

prostaglandin<br />

metabolism towards the production of<br />

anti-inflammatory eicosanoids, which limit<br />

and resolve inflammation 7 . In contrast,<br />

the Ω-6 fatty acid metabolic pathway<br />

primarily promotes the production of proinflammatory<br />

mediators.<br />

As summarised in a recent systematic<br />

review and meta-analysis 8 , several small<br />

clinical trials have investigated the use<br />

of oral Ω-3 EFA supplements for treating<br />

DED. Together, these investigations report<br />

promising findings in terms of reducing dry<br />

eye symptoms and improving tear stability,<br />

however the mechanism(s) underlying<br />

the potential clinical benefits are not well<br />

understood. Furthermore, there is a need<br />

for improved scientific understanding into<br />

the optimal dosage, duration of treatment<br />

and form of Ω-3 EFA supplements for<br />

treating DED.<br />

The Downie ‘Anterior Eye, Clinical Trials<br />

and Research Translation Unit’, based in<br />

the Department of Optometry and Vision<br />

Sciences at the University of Melbourne,<br />

has recently completed a double-masked,<br />

randomised, placebo-controlled clinical trial<br />

investigating the safety and efficacy of two<br />

different forms of Ω-3 EFA supplements<br />

for treating mild-to-moderate DED.<br />

Findings from this study will be available<br />

over the coming months and will provide<br />

novel clinical insights into how Ω-3 EFA<br />

supplementation modulates the clinical<br />

expression of DED.<br />

References<br />

1. Calonge M, Enrique-de-Salamanca A, Diebold<br />

Y, et al. Dry Eye Disease as an Inflammatory<br />

Disorder. Ocul Immunol Inflamm. 2010;18:244-<br />

253.<br />

2. The definition and classification of dry<br />

eye disease: report of the Definition<br />

and Classification Subcommittee of the<br />

International Dry Eye WorkShop (2007). Ocul<br />

Surf. 2007;5(2):75-92.<br />

3. Jackson D, Zeng W, Wong C et al, Downie<br />

LE. Tear interferon-gamma as a biomarker<br />

for evaporative dry eye disease. Invest<br />

Ophthalmol Vis Sci. <strong>2016</strong>; In press, July <strong>2016</strong>.<br />

4. Baudouin C, Aragona P, Messmer EM, et al.<br />

Role of hyperosmolarity in the pathogenesis<br />

and management of dry eye disease:<br />

proceedings of the OCEAN group meeting.<br />

Ocul Surf. 2013;11(4):246-258.<br />

5. Simopoulos AP. Omega-6/omega-3 essential<br />

fatty acids: biological effects. World Rev Nutr<br />

Diet. 2009;99:1-16.<br />

6. Calder PC. N-3 polyunsaturated fatty acids<br />

and inflammation: from molecular biology to<br />

the clinic. Lipids. Apr 2003;38(4):343-352.<br />

7. Simopoulos AP. The importance of the ratio of<br />

omega-6/omega-3 essential fatty acids. Biomed<br />

and Pharmacother. 2002;56(8):365-379.<br />

8. Zhu W, Wu Y, Li G, Wang J, Li X. Efficacy<br />

of polyunsaturated fatty acids for<br />

dry eye syndrome: a meta-analysis of<br />

randomized controlled trials. Nutrition Rev.<br />

2014;72(10):662-671.<br />

* Dr Laura Downie is a senior lecturer and<br />

National Health and Medical Research Council<br />

Translating Research Into Practice (TRIP) fellow<br />

at the Department of Optometry and Vision<br />

Sciences at the University of Melbourne. She leads<br />

the specialty Cornea Clinic and heads her own<br />

research laboratory, the ‘Downie Anterior Eye,<br />

Clinical Trials and Research Translation Unit’.<br />

18 NEW ZEALAND OPTICS <strong>Oct</strong>ober <strong>2016</strong>


Dry Eyes and Diabetes<br />

Diabetes is one of the most common systemic<br />

diseases in the world. According to the Ministry of<br />

Health, this affects 257,776 people in New Zealand.<br />

Worldwide, 415 million people are affected and, by the<br />

year 2040, it is expected that 642 million people will be<br />

affected 1 . This metabolic disorder is associated with both<br />

microvascular (nephropathy, neuropathy, and retinopathy)<br />

and macrovascular (ischaemic heart disease, peripheral<br />

vascular disease, and cerebrovascular disease) complications.<br />

In the eye, the most well-known complication is diabetic<br />

retinopathy which, if left untreated, may lead to loss of vision.<br />

A less well-recognised complication of diabetes is dry eye<br />

disease (DED), despite the reported prevalence of 54.3% in<br />

patients with the disease 2 . Characteristic of DED is a decline<br />

in tear film function, as indicated by a reduced tear film<br />

break-up time, and ocular surface damage, as indicated by<br />

corneal staining and inflammation 3 . In diabetes, the ocular<br />

surface is already prone to recurrent corneal erosions and<br />

delayed epithelial wound healing 4,5 . The combination of<br />

both DED and diabetes can place patients at significant risk<br />

of discomfort and debilitating neurotrophic keratopathy.<br />

Identifying DED may therefore help these patients control the<br />

impact of their disease on the ocular surface.<br />

Why are people with diabetes prone to DED?<br />

• Corneal nerve density reduces in diabetes, affecting tear<br />

secretion<br />

Approximately 60%-70% of patients with diabetes will<br />

eventually develop peripheral neuropathy 6,7 . The ocular surface<br />

provides the only source of nerves that can be imaged in<br />

vivo and non-invasively. Studies of corneal nerves in diabetes<br />

reveal a loss of corneal innervation as indicated by decreased<br />

corneal nerve density and corneal sensitivity relative to healthy<br />

non-diabetic participants 8 . Interestingly, this reduction in<br />

corneal nerve density is associated with diabetic peripheral<br />

neuropathy, with suggestions being that observations of<br />

corneal nerves may be a surrogate measure of peripheral nerve<br />

changes 9,10 . Corneal nerves not only provide sensation but<br />

also provide trophic support in maintaining the structure and<br />

function of the cornea to regulate epithelial integrity, growth,<br />

proliferation and wound healing. Any impairment of corneal<br />

innervation can therefore disrupt epithelial integrity, leading<br />

to development of recurrent epithelial erosions. Significantly,<br />

this reduction in corneal nerve density disrupts the feedback<br />

mechanism that controls tear secretion 4,11 .<br />

References<br />

1. ID F. IDF Diabetes Atlas. 2015;7th Edition:http://<br />

www.diabetesatlas.org/.<br />

2. Manaviat MR, Rashidi M, Afkhami-Ardekani M,<br />

Shoja MR. Prevalence of dry eye syndrome and<br />

diabetic retinopathy in type 2 diabetic patients.<br />

BMC Ophthalmology 2008; 8: 10.<br />

3. The definition and classification of dry<br />

eye disease: report of the Definition<br />

and Classification Subcommittee of the<br />

International Dry Eye WorkShop (2007). Ocul<br />

Surf 2007; 5(2): 75-92.<br />

4. Dogru M, Katakami C, Inoue M. Tear function<br />

and ocular surface changes in noninsulindependent<br />

diabetes mellitus. Ophthalmology<br />

2001; 108(3): 586-92.<br />

5. Sanchez-Thorin JC. The cornea in diabetes<br />

mellitus. International ophthalmology clinics<br />

1998; 38(2): 19-36.<br />

6. Said G. Diabetic neuropathy--a review. Nature<br />

clinical practice Neurology 2007; 3(6): 331-40.<br />

7. Charnogursky G, Lee H, Lopez N. Diabetic<br />

neuropathy. Handb Clin Neurol 2014; 120:<br />

773-85.<br />

8. Misra SL, Craig JP, Patel DV, et al. In Vivo<br />

Confocal Microscopy of Corneal Nerves: An<br />

Ocular Biomarker for Peripheral and Cardiac<br />

Autonomic Neuropathy in Type 1 Diabetes<br />

Mellitus. Invest Ophthalmol Vis Sci 2015; 56(9):<br />

5060-5.<br />

9. Ahmed A, Bril V, Orszag A, et al. Detection<br />

of diabetic sensorimotor polyneuropathy by<br />

BY SHYAM SUNDER TUMMANAPALLI AND DR MARIA MARKOULLI*<br />

corneal confocal microscopy in type 1 diabetes:<br />

a concurrent validity study. Diabetes care 2012;<br />

35(4): 821-8.<br />

10. Pritchard N, Edwards K, Dehghani C, et al.<br />

Longitudinal assessment of neuropathy in type<br />

1 diabetes using novel ophthalmic markers<br />

(LANDMark): study design and baseline<br />

characteristics. Diabetes research and clinical<br />

practice 2014; 104(2): 248-56.<br />

11. Ishida N, Rao GN, del Cerro M, Aquavella JV.<br />

Corneal nerve alterations in diabetes mellitus.<br />

Archives of ophthalmology (Chicago, Ill : 1960)<br />

1984; 102(9): 1380-4.<br />

12. Najafi L, Malek M, Valojerdi AE, et al. Dry eye<br />

and its correlation to diabetes microvascular<br />

complications in people with type 2<br />

diabetes mellitus. Journal of diabetes and its<br />

complications 2013; 27(5): 459-62.<br />

13. Goebbels M. Tear secretion and tear film<br />

function in insulin dependent diabetics. Br J<br />

Ophthalmol 2000; 84(1): 19-21.<br />

14. Ding J, Liu Y, Sullivan DA. Effects of Insulin and<br />

High Glucose on Human Meibomian Gland<br />

Epithelial Cells. Investigative Ophthalmology &<br />

Visual Science 2015; 56(13): 7814-20.<br />

15. Yeh S, Song XJ, Farley W, Li DQ, Stern ME,<br />

Pflugfelder SC. Apoptosis of ocular surface<br />

cells in experimentally induced dry eye. Invest<br />

Ophthalmol Vis Sci 2003; 44(1): 124-9.<br />

16. Cai D, Zhu M, Petroll WM, Koppaka V,<br />

Robertson DM. The Impact of Type 1<br />

Diabetes Mellitus on Corneal Epithelial Nerve<br />

• Damage to the microvasculature of the lacrimal gland may<br />

reduce tear secretion<br />

Another potential avenue for the reduction in tear production<br />

in diabetes is damage to microvasculature feeding the<br />

lacrimal gland or reduced lacrimal innervation from<br />

autonomic neuropathy, a mechanism supported by the<br />

observation of reduced Schirmer scores in diabetes 12 .<br />

• Damage to the trigeminal nerve and the direct effects of<br />

hyperglycaemia<br />

Patients with diabetes have also been shown to have reduced<br />

conjunctival goblet cell counts, resulting in a reduction in tear<br />

film stability and tear break-up time 13 . This reduction in goblet<br />

cell count may be due to the decrease in the trophic effects of<br />

trigeminal sensory nerves on the conjunctiva and cornea 4 .<br />

The hyperglycaemia that results from diabetes may also<br />

have a direct effect on the meibomian glands. One study has<br />

shown that insulin, the factor that controls glycaemic levels<br />

in the blood, is able to stimulate meibomian gland cells,<br />

resulting in cell proliferation and the accumulation of lipids 14 .<br />

A deficiency in insulin will therefore reduce the production<br />

of lipids, affecting the quality of the tear film. Conversely, the<br />

same study found that elevated glucose causes progressive<br />

cell loss and alterations to meibomian gland cell morphology,<br />

hence being toxic for the meibomian gland epithelial cells<br />

and placing individuals with diabetes at risk of meibomian<br />

gland dysfunction, the leading cause of dry eye disease 14 .<br />

Managing diabetes-related DED<br />

Given that dry eye disease in general predisposes the ocular<br />

surface to corneal staining 15 , the co-existence of diabetes<br />

and DED places individuals at increased risk of ocular<br />

surface damage 16 . The combination of poor corneal wound<br />

healing 17,18 as a result of diabetes, combined with a poor tear<br />

film increases the risk of epithelial damage, disrupting the<br />

normal barrier function of the epithelium 19 and increasing the<br />

likelihood of infection 20,21 . It is therefore important to assess<br />

all patients with diabetes for the signs and symptoms of dry<br />

eye disease as part of their diabetic work-up. The presence<br />

of DED needs to be managed according to clinical guidelines<br />

established by the Tear Film and Ocular Surface workshops 22<br />

and patients need to be educated about the need for rigorous<br />

management. By reviewing these patients on a regular basis,<br />

the more severe ocular surface sequelae of diabetes, such as<br />

neurotrophic keratopathy, can be minimised or avoided.<br />

Morphology and the Corneal Epithelium. The<br />

American Journal of Pathology 2014; 184(10):<br />

2662-70.<br />

17. Friend J, Thoft RA. The diabetic cornea.<br />

International ophthalmology clinics 1984;<br />

24(4): 111-23.<br />

18. Yoon KC, Im SK, Seo MS. Changes of tear film<br />

and ocular surface in diabetes mellitus. Korean<br />

journal of ophthalmology : KJO 2004; 18(2):<br />

168-74.<br />

19. Gekka M, Miyata K, Nagai Y, et al. Corneal<br />

epithelial barrier function in diabetic patients.<br />

Cornea 2004; 23(1): 35-7.<br />

20. Cho BJ, Lee GJ, Ha SY, Seo YH, Tchah H.<br />

Co-infection of the human cornea with<br />

Stenotrophomonas maltophilia and Aspergillus<br />

fumigatus. Cornea 2002; 21(6): 628-31.<br />

21. Holifield K, Lazzaro DR. Case report:<br />

spontaneous Stenotrophomonas maltophilia<br />

keratitis in a diabetic patient. Eye Contact Lens<br />

2011; 37(5): 326-7.<br />

22. Management and therapy of dry eye disease:<br />

report of the Management and Therapy<br />

Subcommittee of the International Dry Eye<br />

WorkShop (2007). Ocul Surf 2007; 5(2): 163-78.<br />

* Shyam Sunder Tummanapalli is a doctoral<br />

researcher and Dr Maria Markoulli is a lecturer<br />

with the School of Optometry and Vision Science at<br />

the University of New South Wales. Dr Markoulli’s<br />

research focus is on tear film biochemistry and the<br />

ocular surface.<br />

Sex hormones and dry<br />

eye disease<br />

Dry eye is a chronic inflammatory<br />

disease affecting millions<br />

of people worldwide¹. Dry<br />

eye has been shown to be more<br />

common in women than men 2 . The<br />

prevalence of dry eye increases post<br />

menopause 3 , which equates to almost<br />

half a woman’s life suffering with<br />

the disease. Dry eye has a substantial<br />

economic impact due to days off<br />

work, medication costs and doctors’<br />

appointments 4 .<br />

Treatment for dry eye is ineffective,<br />

with a reliance on frequent instillation<br />

of lubricating eye drops. Treatment<br />

directed at the underlying cause has<br />

the potential to provide effective relief<br />

to the four million women in Australia<br />

(equivalent to approximately a third of<br />

a million women in New Zealand) who<br />

suffer from dry eye disease.<br />

The pathogenesis of dry eye is<br />

complex and as yet not completely<br />

understood. Its aetiology is<br />

multifactorial, including good evidence<br />

for a hormone-mediated contribution 5 .<br />

The role of sex hormones in dry<br />

eye 6<br />

• Androgens<br />

Androgen deficiency occurs in various<br />

physiological and disease states<br />

including general aging, menopause,<br />

autoimmune disease (including<br />

rheumatoid arthritis), the use of antiandrogen<br />

medication and complete<br />

androgen insufficiency syndrome<br />

(CAIS). Most studies support that<br />

androgen deficiency is associated with<br />

increased dry eye symptoms and signs<br />

• Oestrogens<br />

There is less known about the effect<br />

of oestrogens on dry eye, with<br />

published studies having contradictory<br />

conclusions. Many studies have<br />

examined the effects of hormone<br />

replacement therapy on dry eye; some<br />

found improvement of signs and/or<br />

symptoms, others found exacerbation<br />

of dry eye, whilst others found no<br />

effect.<br />

Current studies at UNSW looking at<br />

the effect of sex hormones on dry eye<br />

in:<br />

1. Post-menopausal women: novel<br />

ultra-sensitive methods are being<br />

developed to measure sex hormones<br />

in tears. Sex hormone levels in tears<br />

and blood will be measured and<br />

compared to signs and symptoms of<br />

dry eye to understand whether an<br />

imbalance of sex hormones causes<br />

BY EMMA GIBSON AND ARCHANA BOGA*<br />

dry eye and which hormones are the<br />

culprit<br />

2. Pre-menopausal women:<br />

continuous monitoring of ocular<br />

comfort symptoms across a complete<br />

menstrual cycle in women with a<br />

normal menstrual cycle, and those<br />

using combined oral contraceptive<br />

pills, to improve understanding of<br />

the impact of both physiological and<br />

induced hormone variations. The<br />

second stage of this study involves<br />

examining the effect of the oestrogen<br />

influx during IVF treatment on clinical<br />

signs and symptoms of dry eye<br />

The idea behind this research is to<br />

understand why women are more<br />

prone to dry eye (is it oestrogens<br />

or androgens?) and to contribute<br />

valuable information about the<br />

influence of sex hormones to enable<br />

development of effective treatment<br />

options for dry eye.<br />

References<br />

1. Schaumberg D, Sullivan D, Buring J,<br />

Dana M. Prevalence of dry eye syndrome<br />

among US women. AM J Ophthalmol.<br />

2003;136(03):318-326.<br />

2. Report of the Epidemiology Subcommittee<br />

of the International Dry Eye WorkShop. The<br />

epidemiology of dry eye disease. Ocul Surf.<br />

2007;5(2):93-107.<br />

3. Versura P, Campos EC. Menopause and<br />

dry eye. A possible relationship. Gynecol<br />

Endocrinol. 2005;20(February):289-298.<br />

4. Uchino M, Schaumberg D. Dry Eye Disease:<br />

Impact on Quality of Life and Vision. Curr<br />

ophthal reports. 2013;1(2):51-57.<br />

5. Gibson, E. J., Stapleton, F. J., Wolffsohn, J.,<br />

& Golebiowski, B. (Under review). Local<br />

synthesis of sex hormones: are there<br />

consequences for the ocular surface and<br />

dry eye. The Ocular Surface.<br />

6. Truong S, Cole N, Stapleton F, Golebiowski<br />

B. Sex hormones and dry eye. Clin Exp<br />

Ophthalmol. 2014;97:324-336.<br />

* Emma Gibson and Archana Boga are PhD<br />

candidates undertaking these studies at the<br />

School of Optometry and Vision Science at The<br />

University of New South Wales (UNSW), with<br />

supervisors, Professor Fiona Stapleton (Head<br />

of School) and Dr Blanka Golebiowski.<br />

Feast your eyes update<br />

With the importance of diet<br />

playing an ever-increasing<br />

part in the treatment of dry<br />

eye, it’s timely that a second version<br />

of the popular Feast Your Eyes-The Eye<br />

Health Cookbook is due to be published<br />

later this year by the Look for Life<br />

Foundation (previously the Genetic Eye<br />

Foundation) in Australia.<br />

Lifestyle factors are a significant<br />

contributor to the severity of genetic<br />

eye conditions and in an effort to raise<br />

awareness, the Foundation says it’s long<br />

supported the Mediterranean diet, rich<br />

in Omega-3, as a leading method of<br />

genetic eye condition prevention. The<br />

Look for Life Foundation’s Feast your Eyes<br />

cook book features more than 40 recipes<br />

donated from some of Australia’s leading<br />

chefs in an effort to promote eye health<br />

through better nutrition. It was compiled<br />

by Professor Minas Coroneo,<br />

Foundation chairman and head of<br />

the Department of Ophthalmology<br />

at the University of New South<br />

Wales, and Foundation board<br />

member and Professor Coroneo’s<br />

wife, Hellene Coroneo.<br />

Roz Sturt from the Foundation<br />

says the new version of the<br />

book is not yet available for sale<br />

but should be offered later this<br />

year through the Foundation’s<br />

website. The new version will<br />

include recipes from chefs outside<br />

Australia as well as inside, she<br />

added. “We have some excellent<br />

American chefs, and their recipes<br />

are outstanding. They include Mario<br />

Batali and Jean-Georges Vongrichten to<br />

name a couple.”<br />

The cookbook also includes<br />

informative chapters on eye health<br />

penned by Professor Coroneo. It retails<br />

for just A$25 and all proceeds go to<br />

the Foundation to help it continue its<br />

research into eye health.<br />

Add data to your insights.<br />

There is quantitative data in every eye. Uncovering this information<br />

can help guide your diagnosis and management of the ocular surface.<br />

In fact, the point-of-care TearLab Diagnostic Test provides precise<br />

and predictive information regarding tear osmolarity, an important<br />

biomarker of ocular surface health.<br />

To learn more,<br />

visit Tearlab.com<br />

or call us at<br />

+61 437 648 746<br />

TearLab®<br />

© <strong>2016</strong> Tearlab Corp. I 920275ROW REV A<br />

<strong>Oct</strong>ober <strong>2016</strong><br />

NEW ZEALAND OPTICS<br />

19


Collaborative care<br />

and practical learnings<br />

The fifth Specsavers Clinical Conference (SCC5) from the<br />

10-11 September, held for the second year in Brisbane,<br />

attracted a record 550 delegates<br />

Our first conference in Melbourne in 2011<br />

saw 130 optometrists in attendance and we<br />

felt that was a huge success,” says Charles<br />

Horner, Specsavers’ director of communications.<br />

“This year we are pleased to have seen over 350<br />

delegates attend the education sessions on the<br />

Saturday (introduced last year), and over 550 come<br />

to the main clinical conference on the Sunday.<br />

“We were delighted to also have 60 students<br />

and over 80 optometrists from practices outside<br />

of Specsavers, attend as our guests,” says Horner,<br />

adding that while some were invited in person,<br />

many signed up after hearing positive reviews of<br />

previous Specsavers’ conferences.<br />

The extra clinical education sessions on<br />

Saturday were primarily optometry-led content,<br />

while Sunday was largely ophthalmology-led.<br />

This format is based on delegate feedback from<br />

previous conferences, says Horner.<br />

There was also a chance to earn CPD points<br />

with Australian attendees able to download a<br />

comprehensive conference app, which included<br />

the ability to answer questions at the end of each<br />

session in real time, with the anonymous results<br />

posted on screens around the conference room, and<br />

which automatically earned them their points. New<br />

Zealand delegates still needed to fill in a paper form,<br />

however. The conference also included many device<br />

charging points and excellent free Wi-Fi.<br />

The event’s platinum sponsors were Alcon and<br />

Johnson & Johnson, with the team from the latter<br />

displaying their new Acuvue Vita contact lenses,<br />

which will be available to Specsavers’ owners<br />

in New Zealand and Australia exclusively from<br />

November (see p6).<br />

“There’s huge consumer demand for contact<br />

lenses and we need to make sure Specsavers<br />

practices can capitalise on that,” says Horner. “In<br />

the last 12 months, Specsavers optometrists in<br />

New Zealand have prescribed over seven million<br />

lenses – a welcome surprise that has really driven<br />

business growth”.<br />

SSC5 gold sponsors included BOC, Zeiss, Hilco,<br />

CooperVision and health insurance funding<br />

company HICAPS.<br />

Horner believes that Specsavers investment<br />

in continued professional development for both<br />

optometrists and dispensing opticians is a huge<br />

draw card for franchise holders, as is the back office<br />

management model that frees up a clinician’s time<br />

to focus on their patients. He also noted the support<br />

Specsavers is giving to the Young Optometrists (YO)<br />

network, which supports optometrists during the<br />

first ten years of their career (a New Zealand chapter<br />

is currently in the process of being established –<br />

more on this in subsequent NZ Optics’ issues).<br />

Showing this support for YO, Specsavers ran an<br />

Instagram competition at SSC5, with several prizes<br />

including the chance for one optometrist to go to<br />

Everest with the Eyes for Everest charity. Jokingly<br />

Ben Ashby, Specsavers’ optometry development<br />

manager (ANZ) told delegates that if they weren’t<br />

able to use Instagram, then they were probably too<br />

old to be Young Optometrists!<br />

As for future Specsavers Clinical Conferences,<br />

no decision has been made on where to hold<br />

next year’s – the conference is held in a different<br />

city every two years – but Auckland hasn’t been<br />

ruled out as a potential location, says Hornor,<br />

adding he’s “thrilled” by the level of participation<br />

Specsavers has from its New Zealand professionals.<br />

Peter Larsen<br />

Collaboration and better patient care<br />

Hot off the heels of the announcement regarding<br />

the memorandum of understanding between<br />

Specsavers and RANZCO (see NZ Optics’ September<br />

issue), this year’s conference included a strong<br />

collaboration theme. Peter Larsen, optometrist and<br />

Specsavers’ professional services director, opened<br />

SSC5 on Sunday with a clear focus on the need<br />

for optometry and ophthalmology to work better<br />

together to achieve more measurable outcomes.<br />

“Opinions don’t count for anything,” said Larsen,<br />

noting there was still an old guard of clinical<br />

practitioners who felt the structures RANZCO and<br />

Specsavers are working toward are unnecessary.<br />

“Measurable clinical outcomes are essential to<br />

improve best practice and patient care.”<br />

With up to 30% false-positive referral rates for<br />

glaucoma, 15% of referrals failing to attend tertiary<br />

care and 50% of glaucoma sufferers still going<br />

undiagnosed, now was the time to put politics<br />

aside, and for optometry and ophthalmology to<br />

work better together, reducing risk, increasing<br />

education, streamlining services and ultimately<br />

improving patient care, he said.<br />

A key aspect to making the collaboration<br />

with RANZCO work, ensuring it received the<br />

feedback it needed on its new referral guides, was<br />

continuing education and working toward uniform<br />

standards and processes, said Larsen. To achieve<br />

this, optometrists needed data so Specsavers is<br />

investing in a number of platforms to provide that<br />

data, he said.<br />

Having rolled out the new, secure informationsharing<br />

portal Oculo to many of its Australian stores<br />

in June this year, Larsen said he was delighted to<br />

announce Specsavers would be subsidising Oculo<br />

for franchise holders for the next six months.<br />

“We are delighted to have Specsavers continued<br />

support as we expand our network with independent<br />

optometrists and ophthalmologists,” said Oculo’s<br />

Dr Kate Taylor.<br />

Dr Russel Bach<br />

RANZCO guidelines for DED<br />

RANZCO board member Dr Russell Bach, senior<br />

medical officer, ophthalmology at the Prince<br />

Alexandra Hospital in Brisbane, reinforced Fussey’s<br />

emphasis on collaboration during his session on<br />

RANZCO’s newly drafted clinical guidelines for<br />

diabetic eye disease (DED). The guidelines, which<br />

will be formally released later this year, aim to<br />

give all optometrists a clear clinical pathway from<br />

seeing a new patient through to when to refer<br />

and how to continue caring for low-risk patients.<br />

RANZCO released its first set of guidelines on<br />

glaucoma management in August, DED is next<br />

with AMD planned for late this year.<br />

“It’s exciting to be representing RANZCO and<br />

standing in front of a large group of eager<br />

Sunday speakers Drs Russell Bach, Jesse Gale, Andrew White and Christolyn Raj, Peter Larsen, Dr Nathan Walker and Professor Stuart Graham<br />

(missing Dr Sunil Warrier)<br />

Amy Winter and Megan Glover<br />

Leilei Zhou, Jingyi Xu, Daria Kozub and Sephy Cheng<br />

Debra So and Kiwi speaker Richard Johnson with Niall McCormack and ODOB board<br />

chair Damian Koppens<br />

participants. That gives me a very positive feeling,”<br />

said Dr Bach, noting how in this day and age we<br />

are inundated with data and it is beyond the ability<br />

of the human brain to cope with it all.<br />

While this data – big data – is useful, he said,<br />

clear structures and guidelines need to be put<br />

in place to make sure patients aren’t overlooked<br />

and don’t fall out of the system. “By following<br />

these guidelines, clinical practitioners can ensure<br />

the quality and standard of care that all patients<br />

receive, and can also begin to streamline practices<br />

and prevent duplication.”<br />

Dr Bach referred to a Michigan-based study from<br />

2005 which showed that by simply introducing<br />

guidelines for patient diagnosis and care, the<br />

survival rate of acute myocardial infarction (heart<br />

attack) patients improved. “Medicine based<br />

on memory is unreliable. Guidelines improve<br />

collaborative care for the benefit of the patients.”<br />

Dr Bach went on to preview the draft guidelines,<br />

which give optometrists a clear pathway from<br />

recognising an issue through to referral and<br />

ongoing patient care.<br />

Dr Nathan Walker<br />

Vitreoretinal surgery advances<br />

Dr Nathan Walker, an ophthalmologist and<br />

vitreoretinal surgeon based on the Gold Coast,<br />

followed with a look at advances in vitreoretinal<br />

surgery. Referring to a range of common retinal<br />

conditions seen by optometrists, such as macular<br />

hole, epiretinal membrane and retinal detachment,<br />

and how they are managed by specialists postreferral,<br />

he demonstrated the vital role optometry<br />

plays in identifying, referring and following up<br />

these patients.<br />

He also reviewed ocular trauma, emphasised<br />

the importance of urgent referral and discussed<br />

indications for surgery and the essential role<br />

optometrists must play in post-operative care.<br />

Dr Andrew White<br />

Glaucoma care<br />

Dr Andrew White, a senior lecturer at the University<br />

of Sydney and consultant ophthalmologist at<br />

Westmead Hospital, focussed on glaucoma care.<br />

With the increasing volume of glaucoma patients,<br />

neither optometry nor ophthalmology are able to<br />

review them all without working together, he said.<br />

Collaboration done well allows high-risk patients to<br />

see consultants sooner, while those of moderate risk<br />

Monica Lee, Bo Kim, Renee Song and Olivia Lee, Kiwis now working in Adelaide<br />

and Queensland<br />

Kiwi presenter Dr Jesse Gale discusses swollen optic discs<br />

Hector Chang and now Fiji-based Sashi and Namita Singh<br />

can be monitored, with a clear referral pathway, by<br />

optometrists where they may otherwise have fallen<br />

out of the system. Dr White referred to a study from<br />

Stanford University, which showed compliance with<br />

medicine and keeping appointments is higher when<br />

patients are seen regularly; if people are not seen<br />

regularly by a clinician, their condition deteriorates.<br />

He ran through scenarios where patients should<br />

be seen by an ophthalmologist and noted the<br />

standard of referrals from some optometrists<br />

can be quite poor, with no visual field or even<br />

refraction notes passed on. Referring to the recently<br />

released guidelines on referrals from the Asia-<br />

Pacific Glaucoma Society, he emphasised the need<br />

for the standardisation of referrals and discussed<br />

the benefits and pitfalls of different diagnostic<br />

tools, noting an OCT won’t always give an accurate<br />

reading because of the parameters of the preprogrammed<br />

data; and that a fundus – limited as it<br />

can be in this modern technological age – offers a<br />

comparable image with that of 20 years ago or 20<br />

years into the future, as the technology does not<br />

change. Ultimately, he emphasised the importance<br />

of a practitioner’s own clinical skills – machines are<br />

only as good as their operator!<br />

Professor Stuart Graham:<br />

Glaucoma case studies<br />

In the last session before lunch, Professor Stuart<br />

Graham, head of ophthalmology and visual science<br />

at the Faculty of Medicine and Health Science at<br />

Macquarie University, discussed the circumstances<br />

under which a glaucoma patient might find<br />

themselves in surgery, when to refer and what<br />

cases are suitable for monitoring by an optometrist.<br />

He ran through several interesting case histories,<br />

including an 84-year-old male with non-specific<br />

reduced vision. Despite having a normal optic<br />

nerve, open angle and normal IOP, his visual fields<br />

were really bad. Professor Graham noted glaucoma<br />

diagnosis rarely begins with poor visual field<br />

results and this was a referral alarm bell for other<br />

conditions. If this patient walked into your clinic,<br />

it is vital more questions are asked and a full case<br />

history taken, he said, as the result for this patient<br />

was melanoma and, caught early, melanoma<br />

patients have a good outcome. Another case of a<br />

46-year-old woman with exceptionally high IOP<br />

was highlighted. Although treatment progressed<br />

normally and her disease was halted, an initial<br />

post-treatment OCT revealed very unusual results<br />

20 NEW ZEALAND OPTICS <strong>Oct</strong>ober <strong>2016</strong>


Auckland’s Philip Walsh and Cleven Cui, now living in<br />

Camberwell, Victoria<br />

Oculo’s Dr Kate Taylor celebrating Specsavers’ decision to subsidise<br />

its portal for franchise holders with Specsavers’ director Peter Larsen<br />

Ian Russell and Specsavers NZ director Graeme Edmond<br />

that did not correlate with her previous tests.<br />

It turned out this was because the wrong<br />

patient’s OCT had been saved against her<br />

name, illustrating Prof. Graham’s key message<br />

that clinicians must think beyond the norm<br />

and, if something doesn’t fit, speak to other<br />

medical professionals and refer.<br />

Dr Jesse Gale<br />

Swollen optic discs<br />

Kiwi ophthalmologist Dr Jesse Gale kicked off<br />

the afternoon sessions with the key message<br />

that “all swollen optic discs are scary and all<br />

need to be referred.”<br />

He emphasised this point with a number of<br />

pictures with multiple choice answers as to the<br />

possible cause of the swollen optic discs. The<br />

answers were all “I don’t know”, demonstrating<br />

how “crazy” it is to make a diagnosis on the<br />

discs alone. It’s important ophthalmologists<br />

and optometrists “embrace uncertainty and<br />

our inability to make spot diagnosis” because<br />

some of the most critical emergencies in<br />

ophthalmology, including papilloedema, are<br />

diagnosed with disc swelling, whereas in<br />

another context this may just be a benign,<br />

incidental thing, but without a detailed patient<br />

history and other tests, we just don’t know, he<br />

said. Other key points were measuring visual<br />

function is more important than structure;<br />

there’s no conclusive way to differentiate<br />

pseudo-swelling from truly swollen discs with<br />

an OCT; and how important it was to recognise<br />

the key features of giant cell arteritis.<br />

Dr Christolyn Raj<br />

Clinical conundrums<br />

Paediatric and retinal ophthalmologist Dr<br />

Christolyn Raj, who swapped optometry for<br />

ophthalmology and now works at the Royal<br />

Children’s Hospital in Melbourne, delivered a<br />

fascinating, interactive lecture about common<br />

clinical scenarios that aren’t always all that<br />

they seem, and how to deal with that. “Be a bit<br />

Teflon, take the history again…develop a stepwise<br />

strategy to safely assess and manage a<br />

patient to avoid missing a possible diagnosis.”<br />

Using case studies to illustrate her point, she<br />

told optometrists to be careful not to have<br />

“tunnel vision and come to only one diagnosis”<br />

for example, jumping to the conclusion with<br />

Specsavers’ Charles Hornor with Optometry Australia National CEO<br />

Genevieve Quilty and NSW CEO Andrew McKinnon<br />

Saturday speakers (L to R) Dr Geoff Sampson, Prof Alex Gentle, Ben Ashby, A/Prof<br />

Darryl Guest, Dr Shelley Hopkins, Craig Muller, Michael Yapp and Richard Johson<br />

Alcon’s Leonie Sanders and Justine Challender (standing) with<br />

Deanne Graham and Thomas Wayne (seated)<br />

patients of a certain age that it’s AMD, when<br />

in her case study it wasn’t AMD it was myopic<br />

choroidal neovascularisation (CNV); and to<br />

recognise that visual loss may be multifactorial<br />

and thus you need to “look for the second<br />

pathology”.<br />

Dr Sunil Warrier:<br />

Ocular oncology<br />

The final session by Dr Sunil Warrier, a<br />

Queensland consultant ophthalmologist and<br />

RANZCO director of training, tackled one of<br />

the most serious concerns for all delegates and<br />

eye practitioners everywhere, the diagnosis<br />

and treatment of ocular cancers. “If as health<br />

professionals we can pick this up early, we can<br />

make a huge difference to people’s lives.”<br />

Breaking his presentation down into three<br />

areas: the good, the bad and the ugly, Dr<br />

Warrier said in general good lesions are found<br />

on the iris. They need to be watched, they can<br />

normally be treated, but it’s important any<br />

changes in IOP aren’t quickly dismissed as<br />

glaucoma and the patient put on a treatment<br />

regime for glaucoma as this could lead to very<br />

serious problems, he said. Choroidal lesions<br />

in general are bad, with 50% of all choroidal<br />

melanoma sufferers likely to die, far higher<br />

than the more common cutaneous melanoma,<br />

whereas conjunctival lesions (the ugly)<br />

which is particularly common in Queensland,<br />

behaves very similarly to cutaneous melanoma<br />

and with early detection and thorough<br />

treatment can be controlled. “I have a very low<br />

threshold for taking off brown things…because<br />

if it mestasises then that’s terrible.”<br />

Dr Warrier also noted and praised new<br />

technologies making a big difference to eye<br />

and vision care today, including microinvasive<br />

glaucoma surgery (MIGS) and Optos ultrawidefield<br />

retinal imaging devices.<br />

Closing<br />

Peter Larsen, optometrist and Specsavers’<br />

professional services director, closed<br />

Specsavers Clinical Conference for <strong>2016</strong><br />

with a round of thank yous for those who<br />

attended, those who sponsored, and those<br />

who organised the event. Next year’s event<br />

will be held on 9-10 Sept at a location still to<br />

be confirmed. ▀<br />

For the second year in a row the Specsavers<br />

Clinical Conference included two parallel,<br />

afternoon optometry-led education sessions on<br />

the Saturday afternoon, prior to the conference proper<br />

on the Sunday. The success of these sessions last year,<br />

and delegates’ desire to make more of a weekend of<br />

their conference, resulted in more than 350 of the<br />

550 plus total number of delegates registering for the<br />

Saturday programme and then dividing their time<br />

between three sessions on paediatrics and three on<br />

pathology management.<br />

Paediatrics Stream<br />

A/Prof Darryl Guest<br />

Anterior eye therapeutics<br />

Associate Professor Daryl Guest, clinical and executive<br />

director, optometry and vision sciences, at the<br />

University of Melbourne, opened the paediatrics<br />

sessions with his take on kids’ eye infections. He<br />

started with the case history of Aneata, age 9, to<br />

demonstrate one of the classic problems with working<br />

with children – honesty. Aneata’s examination showed<br />

a left corneal laceration with fibrin material in the<br />

stoma and anterior chamber, which could not have<br />

been caused by an insect, despite Aneata claiming it<br />

had been. After probing for more information, Aneata<br />

admitted she had been poked in the eye with a stick<br />

by her friend who she didn’t want to get into trouble.<br />

A/Prof Guest also emphasised the need to know not<br />

only when to refer, but when to insist on the urgency<br />

of a patient being seen. He said his favourite gambit<br />

was to ring a consultant and say, “I’ve got your patient<br />

sitting in my chair, when can you see them?”<br />

He ran through the categories of drugs that can be<br />

used in pregnancy and on children and reminded the<br />

audience, when treating a minor you are responsible<br />

for your actions for seven years after the child turns<br />

18. He also noted that just because a drug is readily<br />

available, that doesn’t make it safe, offering NSAIDs as<br />

a classic example, and said that controlled drugs can<br />

also be relatively benign.<br />

With pre-schoolers, the most likely cause of infection<br />

is bacteria, with virus’ and allergies becoming more<br />

common after the age of five. If you have a very young<br />

patient, under 28 days old, A/Prof Guest suggests<br />

you should assume the cause of their infection is<br />

gonorrhoea or chlamydia from the birth canal and<br />

treat them as such until proven otherwise, unless the<br />

child was delivered by C-section.<br />

HSV conjunctivitis, he noted, is also a relatively<br />

underdiagnosed condition optometrists should look<br />

out for in pre-schoolers. A/Prof Guest also provided<br />

a useful diagnostic tool for orbital cellulitis, which<br />

can be distinguished from its less dangerous cousin,<br />

preseptal cellulitis, by asking the patient a simple<br />

question, “did you sleep well last night?” If the answer<br />

is ‘no’, they need to be urgently referred, says A/Prof<br />

Guest, as children with orbital cellulitis are unwell, will<br />

not sleep and present with a fever.<br />

Dr Shelley Hopkins<br />

Assessing children<br />

Dr Shelley Hopkins, clinic coordinator, optometry at<br />

the QUT Health Clinics in Brisbane, discussed the<br />

Australian Government Initiative Smart Eye Start,<br />

which requires children under six to have seen an<br />

optometrist before they start school. The result, she<br />

said, was there would be more four and five year olds<br />

in Australian optometry practices requiring a careful,<br />

coordinated approach to ensure a successful outcome.<br />

First, optometrists should get a clear patient history,<br />

she said. Things like developmental delays, particularly<br />

in language skills, were not just important for<br />

planning your own assessment of that child but also<br />

for assessing them holistically and understanding the<br />

role their eye health might play in the bigger picture.<br />

If they’re taking medication, such as Ritalin, that’s<br />

important to know as a side effect could be blurred<br />

vision.<br />

It’s also important to document techniques when<br />

testing visual acuity, she said, so another practitioner<br />

can understand your methods and interpret results<br />

accordingly. Conventional subjective refraction is almost<br />

impossible in pre-schoolers, so use objective measures.<br />

Static dry retinoscopy should be the first approach,<br />

moving on to cycloplegic refraction if there are additional<br />

concerns from the school nurse or parents.<br />

Dr Geoff Sampson<br />

Understanding refractive errors<br />

Dr Geoff Sampson, senior lecturer at Deakin<br />

University, ended the paediatrics stream with<br />

a question of ethics: how can you improve the<br />

diagnostic tools and treatment for hyperopia,<br />

astigmatism and anisometropia in children when<br />

you cannot perform clinical tests and trials on<br />

these groups to gain further evidence? The answer<br />

paediatrics and<br />

pathology management<br />

is simulating low levels of these refractive errors,<br />

he says, running through his PhD student’s recent<br />

research. He also reminded delegates that reading<br />

ability has a huge impact on educational outcomes<br />

and these three refractive errors in particular, require<br />

more work and understanding in order to support<br />

children post-diagnosis.<br />

Pathology management stream<br />

Michael Yapp<br />

Assessing glaucoma suspects<br />

The pathology management stream was kicked off by<br />

Michael Yapp, chief staff optometrist at the Centre for<br />

Eye Health in Sydney. He tackled the tricky subject of<br />

assessing and diagnosing glaucoma in clinical practice,<br />

stressing there are now lots of guidelines to help and<br />

delegates should “learn to love” their gonioscopes.<br />

This lively interactive session used case studies to<br />

highlight methods of integrating all of the currently<br />

available clinical information (including imaging) in<br />

the glaucoma decision process. Tips included using<br />

a history checklist, looking at right and left discs and<br />

field data side-by-side, taking disc photos for change<br />

analysis and ensuring structural imaging correlates,<br />

analysing the raw data in ocular imaging and knowing<br />

Drance haemorrhages are a significant risk factor<br />

for progression. Yapp also stressed recalls were an<br />

optometrist’s responsibility: “If your patients don’t<br />

come back because they didn’t answer your recall, it<br />

is your problem”; and finally, optometrists need to go<br />

the extra mile when attempting to diagnose glaucoma<br />

in high myopes, he said.<br />

Prof. Alex Gentle<br />

Ocular allergy diagnosis<br />

Professor Alex Gentle, associate head of school at the<br />

School of Medicine at Deakin University, discussed the<br />

significance of allergy as a public health problem and<br />

the links between systemic and ocular manifestations<br />

and the diagnosis and interventions for ocular allergy.<br />

Studies show the signs and symptoms of allergic<br />

conjunctivitis are experienced by upwards of 20%<br />

of the general population and many may never seek<br />

treatment for their allergy.<br />

“If you can’t recognise the mechanism or cause of<br />

the allergy then it can be difficult to recommend an<br />

appropriate management process,” he said, referring<br />

to a useful Spanish study by Sánchez-Hernández et<br />

al, 2015, which came up with a consensus for grading<br />

allergies after an extensive literature review.<br />

When it comes to treatment, different authors have<br />

different suggestions, said Professor Gentle, stressing<br />

that many ocular therapies only offer symptom relief<br />

so patients still need to be referred for their systemic<br />

condition. Other points included: in managing simple<br />

allergic eye disease, the complex should be excluded<br />

first; and many patients’ symptoms will be best<br />

reduced with oral or intranasal therapy supplementing<br />

their topical management.<br />

Richard Johnson<br />

Uveitis<br />

The final speaker in the pathology section was New<br />

Zealander Richard Johnson, principal optometrist<br />

at Greenlane Clinical Centre. Johnson’s session on<br />

uveitis (or perhaps Johnson himself) was obviously a<br />

powerful drawcard as the vast majority of Specscavers’<br />

Saturday afternoon delegates packed into his<br />

presentation, leaving no seat unfilled.<br />

Johnson reviewed the pathophysiology, clinical<br />

signs and symptoms of uveitis, shared evidence-based<br />

therapeutic management processes and highlighted<br />

red flags through a series of case studies.<br />

Uveitis is relatively common, especially anterior<br />

uveitis, affecting primarily those aged between 20 and<br />

50. It is rare in the very young and old, and it has many<br />

causes. Symptoms include brow ache, photophobia,<br />

redness and watering eyes developing over one to two<br />

days, and blurred vision. Undertreating uvetis can result<br />

in corneal oedema, synechiae, iris atrophy, cataracts,<br />

glaucoma, vitritis, cystoid macular oedema and ciliary<br />

body shut down. Red flags include systemic symptoms,<br />

atypical presentations, such as age, no fundal view<br />

or posterior involvement, declining visual acuity and<br />

hypopyon.<br />

An interesting complication and cause of uveitis,<br />

highlighted by Johnson, was syphilis, with an<br />

increasing number of cases in New Zealand, stemming<br />

from (primarily) British-born workers involved in the<br />

Christchurch rebuild, who contracted the disease in<br />

Britain after Europe’s extension into the Eastern Bloc<br />

caused a flood of Polish and Eastern European sex<br />

workers.<br />

Johnson ended on an amusing note, referring to his<br />

tourist status in Australia, saying if you can figure out<br />

how to use Brisbane’s public bike hire system, you can<br />

treat uveitis. ▀<br />

<strong>Oct</strong>ober <strong>2016</strong><br />

NEW ZEALAND OPTICS<br />

21


with<br />

Prof Charles McGhee<br />

& A/Prof Dipika Patel<br />

Series Editors<br />

Lamellar corneal<br />

surgery in <strong>2016</strong><br />

MOHAMMED ZIAEI*, DIPIKA PATEL, CHARLES MCGHEE<br />

Introduction<br />

Full-thickness corneal transplantation is an<br />

operation that deals with a wide variety of corneal<br />

pathologies, but the procedure has not changed<br />

significantly since Eduard Zirm successfully<br />

performed the first penetrating keratoplasty (PK)<br />

over a century ago. Lamellar keratoplasty revolves<br />

around the concept of targeted replacement<br />

of diseased corneal tissue and techniques have<br />

evolved at an astonishing speed over the past 15<br />

years. This article reviews some of the most recent<br />

developments in this field.<br />

Overview of lamellar surgery<br />

Lamellar surgery includes anterior lamellar<br />

keratoplasty (ALK) in which stromal tissue is<br />

selectively replaced, and endothelial keratoplasty<br />

(EK) which aims to replace damaged endothelial<br />

tissue (Fig 1.).<br />

Anterior lamellar keratoplasty<br />

ALK has undergone a renaissance with the<br />

dissemination of several new techniques since<br />

Arthur von Hippel performed the first successful<br />

anterior lamellar graft in 1886. This operation is<br />

the procedure of choice for a variety of corneal<br />

stromal disorders where the endothelium is<br />

healthy such as ectasia, stromal dystrophies and<br />

anterior stromal opacities. The modern version of<br />

this surgery, deep anterior lamellar keratoplasty<br />

(DALK), involves complete or near complete<br />

removal of diseased stromal tissue and perhaps<br />

the two most widely adopted techniques are<br />

Anwar’s “Big Bubble” technique (Descemetic<br />

DALK), and Melles’s “Closed manual dissection”<br />

technique (pre-Descemetic DALK).<br />

The major advantage of DALK surgery results<br />

from the retention of healthy native endothelium<br />

thereby eliminating endothelial allograft rejection,<br />

although epithelial and stromal rejection are still<br />

possible. Other advantages include a reduced<br />

need for topical steroids (15% vs 75% still on<br />

topical steroids after 12 months) and potential<br />

for earlier suture removal. Several studies have<br />

also shown that the visual quality with this form<br />

of keratoplasty is comparable to that of PK. The<br />

DALK procedure is also thought to be more cost<br />

effective when compared to full thickness corneal<br />

transplantation and reported to result in lower<br />

endothelial cell loss 1-3 .<br />

In a recent meta-analysis whilst the proportion<br />

of patients achieving best corrected visual acuity<br />

≥ 6/12 did not differ statistically between DALK<br />

and PK, the uncorrected and best corrected visual<br />

acuity levels were significantly better for PK. The<br />

Fig 1. Different types of keratoplasties (9).<br />

(A) Penetrating keratoplasty. (B) Anterior lamellar keratoplasty. (C) Endothelial keratoplasty<br />

DALK group however had a significantly lower<br />

frequency of graft rejection than the PK group 3 .<br />

It is worthwhile noting that refractive error is a<br />

significant barrier to functional vision with one<br />

long term study reporting a mean refractive error of<br />

-6.5 ± 1.7 D after pre-Descemetic DALK and -6.1 ± 1.8<br />

D after Descemetic DALK 4 .<br />

DALK does however have a steep learning curve<br />

and is technically more challenging to perform<br />

than PK. It is associated with unique potential<br />

complications such as Descemet’s membrane<br />

perforation, double anterior chamber (separation of<br />

the donor stroma tissue from the host Descemet’s<br />

membrane) and interface related issues. There are<br />

also some challenges associated with performing<br />

lamellar surgery in patients with a history of acute<br />

corneal hydrops, in individuals with a pre-existing<br />

split in Descemet’s membrane and patients with<br />

advanced ectasia.<br />

DALK makes up only 7% of corneal transplants<br />

performed in New Zealand in 2015 (unpublished<br />

data). This may reflect local population factors<br />

such as advanced ectasia or late presentation of<br />

patients. The low uptake of DALK could also be<br />

due to the fact that whilst DALK has a number of<br />

theoretical advantages over PK, long-term survival<br />

of DALK performed for keratoconus has been<br />

shown to be inferior to that of penetrating grafts in<br />

the recent Australian graft registry study.<br />

There have been some recent innovations in the<br />

field of anterior lamellar keratoplasty. One novel<br />

technique is that of femtosecond laser-assisted<br />

anterior lamellar keratoplasty (FALK) in which<br />

the depth of the recipient corneal pathology is<br />

measured using anterior segment OCT (AS-OCT).<br />

Subsequently the femtosecond laser is used to<br />

create the lamellar cut in the recipient and donor<br />

corneas and this depth can be adjusted based on<br />

the extent of the corneal pathology. The recipient’s<br />

scarred corneal tissue is then removed and replaced<br />

with the healthy donor lenticule. The lenticule<br />

can then be sutured into place or even retained by<br />

applying a contact lens in a “sutureless” procedure.<br />

Endothelial keratoplasty (EK)<br />

Charles Tillet performed the first known successful<br />

EK case in 1956 to treat corneal oedema. EK has since<br />

transformed beyond recognition and is now the<br />

procedure of choice for a variety of corneal endothelial<br />

disorders such as Fuchs’ endothelial corneal dystrophy<br />

and pseudophakic bullous keratopathy.<br />

The two most widely adopted techniques are<br />

Descemet stripping automated endothelial<br />

keratoplasty (DSAEK) in which the Descemet’s<br />

membrane endothelial complex is transplanted<br />

Fig 2. Anterior segment Optical Coherence Tomography (OCT) images of two patients who have undergone DSAEK.<br />

Note that the graft is fully attached in the top image and partially detached (arrow) in the bottom image.<br />

Fig 3. Anterior segment Optical Coherence Tomography (OCT) image of a patient following DMEK.<br />

Note the focal area of donor detachment nasally (arrow).<br />

with a sheet of stroma and Descemet’s membrane<br />

(Fig 2.), and Descemet’s membrane endothelial<br />

keratoplasty (DMEK) in which the Descemet’s<br />

membrane endothelial complex is transplanted<br />

in isolation and attached in a sutureless method<br />

through air tamponade (Fig 3.).<br />

Endothelial keratoplasty has replaced penetrating<br />

keratoplasty as the preferred technique for treating<br />

endothelial disease in the developed world, as<br />

it offers numerous advantages compared to PK.<br />

The most striking advantages of EK include the<br />

predictability and rapidity of visual rehabilitation<br />

associated with lower surgically-induced<br />

astigmatism. These advantages have driven the<br />

uptake of this technique. EK has also been shown<br />

to be more cost effective than PK as it is associated<br />

with fewer rejection episodes and requires less<br />

intensive patient follow-up. Other advantages of EK<br />

include the reduced need for topical corticosteroids<br />

and a tectonically stronger eye.<br />

In one large single centre study 50% of patients<br />

reached a best corrected visual acuity of Snellen<br />

6/12 or better, by four months following DMEK,<br />

18 months following DSAEK, and more than 24<br />

months following PK. A best-corrected visual<br />

acuity of Snellen 6/7.5 or better at 24 months<br />

postoperatively was reached in 53% after DMEK,<br />

15% after DSAEK, and 10% after PK 6 . However, in<br />

another large study, 6/12 was achieved in 60.7% of<br />

patients following DSAEK at three months, 71.0%<br />

at six months, and 85.4% at 12 months 7 .<br />

Disadvantages of EK include the technically<br />

challenging nature of surgery, the need for special<br />

instrumentation and its association with unique<br />

potential complications such as graft dislocations<br />

requiring re-bubbling (re-injection of air into the<br />

anterior chamber), and interface related issues.<br />

There are also some challenges with performing<br />

EK in patients with a history of prolonged<br />

endothelial dysfunction in which the stroma has<br />

become scarred and in the presence of other ocular<br />

co-pathology such as iris defects, aphakia and in<br />

patients with a glaucoma drainage device.<br />

EK is now the gold standard procedure for<br />

endothelial disease comprising 31% of corneal<br />

transplants performed in New Zealand in 2015<br />

(unpublished data). However, whilst there are<br />

a number of theoretical advantages over PK,<br />

long term survival of EK performed for Fuchs’<br />

endothelial dystrophy has been shown to be<br />

inferior to that of penetrating grafts in the recent<br />

Australian graft registry study 5 .<br />

This has fuelled the interest in minimally<br />

invasive procedures such as cultured human<br />

corneal endothelial cell transplantation either<br />

as a monolayer or by injection of cells into the<br />

anterior chamber. Indeed we may soon see the<br />

widespread use of medical therapy in patients<br />

where topical treatment with Rho-associated<br />

kinase (ROCK) inhibitors, a molecule that enhances<br />

corneal endothelial survival, promotes cellular<br />

proliferation, and has the potential to inhibit and<br />

even reverse endothelial cell dysfunction 8 .<br />

Conclusion<br />

Penetrating keratoplasty has long been the standard<br />

of care for treating eyes with corneal disease with<br />

up to 95% long term success in keratoconus but<br />

nonetheless, significant shortcomings. Noteworthy<br />

barriers towards functional success include<br />

prolonged refractive instability and high irregular<br />

astigmatism. Advances in surgical instrumentation<br />

and technique are improving keratoplasty outcomes<br />

and it is widely believed that selective lamellar<br />

keratoplasty is the future of corneal transplantation.<br />

Advantages of lamellar surgery include a safer<br />

surgical procedure, quicker visual recovery, less need<br />

for topical steroids and a tectonically stronger eye.<br />

However, there needs to be further innovation and<br />

refining of current surgical techniques to improve<br />

survival rates and long-term outcomes of lamellar<br />

grafts. Until such time there will likely remain a<br />

place for penetrating keratoplasty. ▀<br />

References<br />

1. Koo TS, Finkelstein E, Tan D, Mehta JS. Incremental costutility<br />

analysis of deep anterior lamellar keratoplasty<br />

compared with penetrating keratoplasty for the treatment<br />

of keratoconus. Am J Ophthalmol. 2011;152(1):40-7 e2.<br />

2. Keane M, Coster D, Ziaei M, Williams K. Deep anterior<br />

lamellar keratoplasty versus penetrating keratoplasty<br />

for treating keratoconus. Cochrane Database Syst Rev.<br />

2014;7:CD009700.<br />

3. Chen G, Tzekov R, Li W, Jiang F, Mao S, Tong Y. Deep<br />

Anterior Lamellar Keratoplasty Versus Penetrating<br />

Keratoplasty: A Meta-Analysis of Randomized Controlled<br />

Trials. Cornea. <strong>2016</strong>;35(2):169-74.<br />

4. Huang T, Hu Y, Gui M, Hou C, Zhang H. Comparison of<br />

refractive outcomes in three corneal transplantation<br />

techniques for keratoconus. Graefes Arch Clin Exp<br />

Ophthalmol. 2015;253(11):1947-53.<br />

5. Coster DJ, Lowe MT, Keane MC, Williams KA, Australian<br />

Corneal Graft Registry C. A comparison of lamellar and<br />

penetrating keratoplasty outcomes: a registry study.<br />

Ophthalmology. 2014;121(5):979-87.<br />

6. Heinzelmann S, Bohringer D, Eberwein P, Reinhard T,<br />

Maier P. Outcomes of Descemet membrane endothelial<br />

keratoplasty, Descemet stripping automated endothelial<br />

keratoplasty and penetrating keratoplasty from a<br />

single centre study. Graefes Arch Clin Exp Ophthalmol.<br />

<strong>2016</strong>;254(3):515-22.<br />

7. Khor WB, Han SB, Mehta JS, Tan DT. Descemet stripping<br />

automated endothelial keratoplasty with a donor<br />

insertion device: clinical results and complications in 100<br />

eyes. Am J Ophthalmol. 2013;156(4):773-9.<br />

8. Nakagawa H, Koizumi N, Okumura N, Suganami H,<br />

Kinoshita S. Morphological Changes of Human Corneal<br />

Endothelial Cells after Rho-Associated Kinase Inhibitor Eye<br />

Drop (Ripasudil) Administration: A Prospective Open-Label<br />

Clinical Study. PLoS One. 2015;10(9):e0136802.<br />

9. Tan DT, Dart JK, Holland EJ, Kinoshita S. Corneal<br />

transplantation. Lancet. 2012;379(9827):1749-61.<br />

About the author<br />

* Dr Mohammed Ziaei<br />

completed his ophthalmic<br />

training at Moorfields<br />

Eye Hospital in London<br />

and is currently in his<br />

second year as a cornea<br />

& anterior segment<br />

fellow at the University of<br />

Auckland.<br />

22 NEW ZEALAND OPTICS <strong>Oct</strong>ober <strong>2016</strong>


An educating evening<br />

Eye Institutes’ second educational evening<br />

of the year, and last before its conference in<br />

November, was an upbeat affair fuelled with<br />

a healthy dose of nibbles, liquid refreshments and a<br />

good turnout of optometrists from across the region.<br />

Dr Adam Watson opened the evening, promising<br />

attendees “a rich smorgasbord of education” and<br />

thanking Alcon for sponsoring the event.<br />

The subjects covered were eclectic ranging<br />

from shingles and the latest technology to be<br />

employed at Eye Institute to current thinking on<br />

endothelial and choroid diseases to an interesting<br />

and personal account from Dr Peter Ring on<br />

ophthalmology in China.<br />

The following is a summary of the evening and<br />

some of the highlights:<br />

Herpes zoster ophthalmicus<br />

Dr Watson kicked off proceedings with a look at<br />

shingles and how it can have a devastating effect<br />

on the eye. Describing the virus, Herpes zoster,<br />

as “quite a beast of a thing,” he outlined the<br />

aetiology, epidemiology and manifestations of<br />

herpes zoster ophthalmicus (HZO) and suggested<br />

how best to treat what can frequently become a<br />

severe and sight-threatening disease.<br />

Studies show there is a 34% to 76% chance of<br />

ocular complications when a patient develops<br />

shingles on their face. Complications include,<br />

most commonly, keratitis, anterior uveitis and<br />

corneal endotheliitis. Less common afflictions<br />

include neurotrophic keratopathy, corneal oedema<br />

and cranial nerve palsies. Chronic and recurrent<br />

inflammation is common, treatment is less reliant on<br />

antiviral medication than in HSV disease and, given<br />

the potential severity and effect on the eye, older<br />

patients, especially those over 60, should consider<br />

vaccination with the varicella vaccine as studies<br />

show those vaccinated have 50% less HZO and, if<br />

they do develop it, tend to have much milder effects.<br />

OCT angiography<br />

Fresh from running workshops at the popular,<br />

biennial Snowvision event in Queenstown, Dr<br />

Shanu Subbiah shared his thoughts about optical<br />

coherence tomography angiography (OCTA).<br />

OCTA is a new, non-invasive imaging technique<br />

that generates retinal and choroidal angiography<br />

images in a matter of seconds, allows close-up<br />

imaging of the retinal vasculature and has the<br />

potential to significantly change the routine<br />

assessment and characterisation of certain retinal<br />

and choroidal diseases. “Fluroscein angiography<br />

(FA) used to be the gold standard for studying the<br />

retina, now it’s OCT, but they complement each<br />

other,” said Dr Subbiah, adding OCTA takes this<br />

one step further allowing you to view a 3D image<br />

of the retinal vasculature in a non-invasive, more<br />

cost-effective manner. One limitation, however,<br />

is there’s no way of spotting fluid leakages or<br />

ascertaining how severe they may be as no dye<br />

is used. Thus OCTA is a very useful adjunct to<br />

OCT and FA, though is unlikely to replace them.<br />

However, with swept-source technology, hopefully,<br />

becoming more affordable, OCTA will become<br />

more useful for deeper scans and better choroidal<br />

visibility, he concluded.<br />

Dr Peter Ring and Roger Apperley<br />

John McLennan, Chris Earnshaw and Alastair Kyle<br />

For more about OCTA, see the review by<br />

Drs Shanu Subbiah and Peter Hadden in<br />

April’s NZ Optics.<br />

Neuro-ophthalmic emergencies<br />

Professor Helen Danesh-Meyer presented<br />

three cases which highlighted neuroophthalmic<br />

emergencies to show when<br />

diplopia is a sign of danger. Monocular<br />

diplopia is not dangerous as it’s an ocular<br />

not a neurological symptom. Whereas with<br />

binocular diplopia, if there’s more than one<br />

cranial nerve involvement then it’s always<br />

potentially dangerous, she said. Other<br />

warning signs include otherneurological<br />

symptoms associated with the diplopia,<br />

such as vomiting, headache or weakness<br />

on one side of body. Trickier, are isolated<br />

cranial nerve palsies. These should be<br />

considered dangerous, especially when the<br />

patient is young; if the diplopia progresses<br />

or doesn’t resolve; and if the patient is<br />

over 55 and has any signs or symptoms<br />

of giant cell arteritis, such as headaches,<br />

scalp tenderness or pain with chewing.<br />

Other factors to consider include a history<br />

of cancer and third, or partial-third, nerve<br />

palsy (ptosis with big pupil). In summary,<br />

said Professor Danesh-Meyer, “When it<br />

comes to diplopia, things are not always<br />

what they seem.”<br />

Anterior uveitis<br />

Dr Trevor Gray ended the first half of the<br />

evening discussing uveitis. All uveitis is potentially<br />

sight threatening and sometimes life threatening,<br />

so you need to keep your minds open and stay<br />

watchful, he said. KPs (keratic precipitates) can<br />

tell us a lot about the potential for vision loss and<br />

other complications; check distribution, colour and<br />

size. Anterior chamber cells are the key measure<br />

for uveitis activity and all patients with chronic<br />

uveitis will have chronic problems with leaky blood<br />

vessels in their iris, allowing albumin from the<br />

blood stream to flow into the anterior chamber and<br />

cause flare, he explained. There are many causes of<br />

uveitis and a number of treatments. Key treatment<br />

points include: topical steroids are only effective for<br />

anterior chamber treatment, with the exception of<br />

cystoid macular oedema; Pred Forte gets into the<br />

eye the best; Maxidex ointment is “pretty useless”<br />

because penetration of dexamethasone is much<br />

poorer in ointment than in drops form; the risks with<br />

treatments directly relate to drug concentration<br />

used; preserved drops have better penetration than<br />

non-preserved; frequency counts; don’t withdraw<br />

treatment too fast; and always document the<br />

absence and presence of complications.<br />

The choroid: source of all that’s bad?<br />

After a short break and an opportunity to refill<br />

glasses and plates, Dr Peter Hadden tackled the<br />

diagnosis and management of sight and lifethreatening<br />

diseases of the choroid, including<br />

how best to view the choroid with OCT. Given the<br />

advances with OCT, we now have a much better<br />

appreciation of the role of pathologic choroidal<br />

Dr Trevor Gray, Gary Filer, Sonia Swan and Kristine Jensen<br />

Dennis Oliver and Anne Durrant<br />

Alex Petty and Nick Mathew<br />

Cliff Harrison and Raj Maiti<br />

changes in a variety of retinal disease, he said.<br />

Choroid thickness can change in all mammals<br />

throughout the day (especially chickens),<br />

however, a “pachychoroid” (pachy-[prefix]= thick)<br />

is considered abnormal and can be a sign of<br />

disease such as central serous chorioretinopathy;<br />

choroidal osteoma (a benign tumour that<br />

can cause vision loss); choroidal metastasis;<br />

choroidal haemangioma; and chorioretinitis from<br />

toxoplasmosis. Choroidal thickness in relation<br />

to age-related macular degeneration (AMD)<br />

remains controversial, however, with some leading<br />

researchers refuting the link between thin choroids<br />

and AMD, though pathological myopia is definitely<br />

associated with thinning.<br />

Endothelial disease<br />

Professor Charles McGhee tackled endothelial<br />

disease, including presenting the endothelial<br />

life cycle in a single slide. There has been a<br />

greater understanding of the form, function and<br />

reparative capacity of the endothelium in the<br />

last decade leading to better understanding of<br />

the endothelial structure and function and the<br />

repair and replacement of the endothelium. This<br />

includes topical agents such as Rho-kinase (ROCK)<br />

inhibitors, injection of cultivated endothelial<br />

cells and the surgical replacement of layers,<br />

better known as Descemet’s stripping automated<br />

endothelial keratoplasty (DSAEK) and Descemet’s<br />

membrane endothelial keratoplasty (DMEK) –<br />

or partial thickness corneal transplants. These<br />

innovations may provide a tiered, possibly earlier,<br />

approach and more rapid recovery in common<br />

endothelial diseases encountered<br />

by optometrists, particularly<br />

Fuchs’ endothelial corneal<br />

dystrophy, explained Professor<br />

McGhee. In conclusion, he said,<br />

ROCK inhibitors promise much,<br />

but are yet to deliver; there’s been<br />

a revolution in transplantation in<br />

the last 15 years; more than 50%<br />

of surgery is now lamellar, with<br />

DALK, DSEK and DSAEK all wellestablished,<br />

and DMEK variations<br />

under study, but looking<br />

promising; and other cell-based<br />

treatments on the horizon. For<br />

more on this subject, see p22.<br />

Ophthalmology in China<br />

Dr Peter Ring shared an interesting<br />

account of his personal experience<br />

of joining the team on the Lifeline<br />

Express, a rainbow-coloured<br />

hospital eye-train that provides<br />

free cataract operations to<br />

patients in rural and semi-rural<br />

China, and The First People’s<br />

Hospital of Luoyang, which is<br />

well-known for ophthalmology. In<br />

conclusion, he said it was, “a very<br />

enlightening experience” and he’ll<br />

be back to help again next year.<br />

Cystoid Macular Oedema<br />

Dr Nick Mantell brought the<br />

evening to a close with a look at<br />

Hannah Kersten, Chelsey Wood and Samantha Simkin<br />

Emilie Langley and Jason Dhana<br />

Professors Helen Danesh-Meyer and Charles<br />

McGhee<br />

cystoid macula oedema (CMO). CMO is when fluid<br />

and protein deposits collect within the macula,<br />

leading to thickening and swelling which distorts<br />

central vision. It’s a common, non-specific response<br />

to a number of different ocular diseases, including<br />

diabetic retinopathy, vascular occlusions, postsurgical<br />

conditions (post-cataract is the most<br />

common cause) and uveitic diseases. Diagnosis is<br />

relatively easy with OCT, but without, the patient’s<br />

history and changes to visual acuity are critical, as<br />

is a thorough retinal exam. Monitoring is best done<br />

with OCT, measuring visual acuity changes and,<br />

as a lot of these patients are being treated with<br />

steroids, monitoring changes in intraocular pressure<br />

over time. For the most part treatment of CMO is<br />

relatively easy and effective. Optometrists should<br />

retain a high level of suspicion when it comes to<br />

CMO, especially post-surgery, so it can be diagnosed<br />

quickly and treated, he said. ▀<br />

Eye Institute’s next educational event will be their<br />

annual scientific conference 5-6 November <strong>2016</strong>,<br />

now incorporating workshops for optometrists<br />

and special educational opportunities for optical<br />

dispensers and optometry staff on Saturday 5<br />

November.<br />

Product recall<br />

– diabetic<br />

patients<br />

Novo Nordisk is recalling two batches of<br />

GlucaGen HypoKit in New Zealand. The<br />

GlucaGen HypoKit is indicated for the<br />

“treatment of severe hypoglycaemic reactions<br />

(low blood sugar), which may occur in the<br />

management of diabetic patients receiving<br />

insulin or oral hypoglycaemic agents”. Novo<br />

Nordisk found a small number (0.006%) of<br />

needles were detached from the pre-filled<br />

syringe supplied in certain batches of the<br />

HypoKit, so it’s recalling affected batches from<br />

wholesalers, pharmacies and patients in New<br />

Zealand. The recalled GlucaGen HypoKit batch<br />

numbers and expiry dates are: batch-FS6X537,<br />

expiry-31 August 2017; and batch-FS6X873,<br />

expiry-31 August 2017. The company has<br />

asked health professionals to ask their diabetic<br />

patients and their carers to check the batch<br />

number of any GlucaGen HypoKit in their<br />

possession to see if it’s affected. The product<br />

can be returned to their pharmacy where it will<br />

be replaced. ▀<br />

<strong>Oct</strong>ober <strong>2016</strong><br />

NEW ZEALAND OPTICS<br />

23


Virtual reality in everyday practice<br />

Jai Breitnauer finds out what virtual reality (VR) can offer<br />

practices and gives the new Nautilus a whirl<br />

The “Year of VR” is the<br />

name many tech experts<br />

dubbed <strong>2016</strong>. With the<br />

long-awaited launch of the<br />

virtual reality headset, Oculus<br />

Rift, plus other offerings to the<br />

market, like Google cardboard<br />

and the new Samsung Gear<br />

headset, <strong>2016</strong> is living up<br />

to its geek moniker. But<br />

if you thought VR was all<br />

about gaming, you’re sorely<br />

mistaken.<br />

“In medicine as a whole, VR<br />

systems have been used for<br />

some time as a surgical training<br />

tool. This trend will likely<br />

continue as the resolution of<br />

the displays, as well as methods<br />

to portray tactile sensation,<br />

improve over time,” says Dr<br />

Philip Turnbull, an optometrist<br />

and research fellow from<br />

the School of Optometry & Vision Science at The<br />

University of Auckland, noting the multitude<br />

potential uses of the technology. “There are already<br />

amblyopia treatment VR ‘games’ on the market,<br />

and it is not inconceivable that an eye-tracking VR<br />

system will be able to measure a range of clinically<br />

useful visual function in the near-future.”<br />

Dr Turnbull cites increased consumer computing<br />

power and cost reductions, from sharing<br />

technology elements with the cell phone industry,<br />

as driving forces behind the accessibility of VR.<br />

VR and AR (augmented reality, where digital<br />

devices add computer-generated images to<br />

real situations – think Pokémon Go) have many<br />

applications within optometry and ophthalmology,<br />

and headsets are now beginning to find their<br />

way into high street practices. Hoya are currently<br />

working on a VR Vision Simulator system, which is in<br />

a beta stage of development. “It’s a great dispensing<br />

tool that simulates the multifocal experience for<br />

patients,” said Hoya’s national customer services<br />

manager Sara Leonard at this year’s O-Show. While<br />

Essilor released its own VR headset called Nautilus<br />

in July, with 20 headsets being snapped up within<br />

the first week they were available.<br />

“We are pleased with the positive response;<br />

it’s been very well received,” says Kumuda Setty,<br />

marketing manager for Essilor New Zealand.<br />

Virtual reality in reality<br />

Paterson Burn have jumped on board the Nautilus<br />

ship, investing in headsets for all seven of their<br />

practices.<br />

“We’ve had it since early July and we’ve had a<br />

good response so far,” said dispensing optician<br />

Alisha Walker when I popped into her practice in<br />

Newmarket. “At first, we used it on everybody, but<br />

we’re now starting to learn what types of patients<br />

benefit from it the most. We’ve found myopes<br />

respond better to it than those with hyperopia,<br />

who can be quite sensitive. It’s also great for<br />

displaying the different sun care products we have,<br />

such as Transitions lenses.”<br />

The Nautilus itself is a light weight plastic unit,<br />

sealed on all but one side. A flap at the front opens<br />

to enable an iPhone to be placed in the front. An<br />

Alisha Walker demonstrates Nautilus’ capabilities to a client<br />

app on the iPhone demonstrates the different<br />

types of lenses to the user, who can look through<br />

the open side, and it is controlled by a linked iPad.<br />

“Most people are quite excited when we bring<br />

it out,” Walker explains as she sets the unit to my<br />

prescription. “It’s quite good fun to use.”<br />

The first set of lenses Walker demonstrates are<br />

Transitions. I’m able to look at two different scenes,<br />

a village square and a colourful marketplace,<br />

while the lenses scroll through the different tints<br />

available. An area around my peripheral vision,<br />

where my lenses wouldn’t reach in real life, allows<br />

me to compare the Transitions lenses to the view<br />

with a clear lens or naked eye.<br />

“The XtraActive lens is for driving; it’s a lighter<br />

tint,” explains Walker, changing my view so I’m<br />

looking at a street over a dashboard and through a<br />

windscreen. “In this one, you can see a reflection of<br />

a man in the rear view mirror that shows you what<br />

the lens colour looks like to other people.”<br />

We’ve moved away from static images now, and<br />

into video. I’m being shown the Xperio polarising<br />

lens and at first I’m driving a car along a highway,<br />

then I’m hiking in the mountains and finally I’m<br />

skiing down an alpine slope. With each lens change<br />

I am able to clearly the see the benefits and pitfalls<br />

of the lens, which allow me to make an informed<br />

choice before purchase.<br />

“Everyday annoyances can be quite intangible,”<br />

says Walker, as she demonstrates the Optifog and<br />

Crizal lens settings. “Things like steamed up lenses<br />

or moisture on your lenses are hard to imagine. This<br />

is where the Nautilus is really helpful.”<br />

I only have a single prescription lens need, but<br />

Walker is keen to talk me through the progressive<br />

lens showcase on the Nautilus.<br />

“People can be quite worried about going into<br />

progressives, they may have heard bad things,”<br />

says Walker, as she demonstrates an entry level<br />

lens that makes me feel like I’ve just got off a<br />

rollercoaster. “By showing them these products in<br />

different settings, and also walking up and down<br />

stairs – which can be a problem with progressives<br />

– clients can see how far the lenses have come and<br />

make a choice that is right for them.”<br />

Understanding the benefits of coatings, different<br />

standards of lenses and even different shade of<br />

tints can be hard without the ability to experience<br />

the lens, says Walker, and with the Nautilus fixed<br />

to my face, I can’t help but agree.<br />

“Nautilus really aides that conversation,” she says.<br />

“A big issue for the optics industry is that the only<br />

tangible part is the frame. Previously we worked off<br />

a chart to demonstrate lens differences. It’s easier<br />

with VR, and we can take into account a patient’s<br />

lifestyle before we make a recommendation.”<br />

VR certainly seems like it has a role to play in<br />

today’s practices, particularly in helping to convey<br />

the benefits of progressive lenses or the multitude<br />

of different lenses out there. Walker hopes that in<br />

VOSO TONGA <strong>2016</strong><br />

Mãlõ e lelei from the<br />

Kingdom of Tonga!<br />

The <strong>2016</strong> Voluntary<br />

Ophthalmic Services Overseas<br />

(VOSO) trip to Nuku ‘Alofa, Tonga<br />

this August included a Kiwi team<br />

of two ophthalmologists (Dr<br />

Andrew Riley from Auckland and<br />

Dr Jean-Paul Blanc now based<br />

in Hervey Bay, Queensland)<br />

and two optometrists (Richard<br />

Johnson and myself, both from<br />

Auckland). Although I had<br />

previously visited the Pacific<br />

Islands, this was my first trip<br />

to Tonga. I was reminded of<br />

the relaxed and stress-free<br />

lifestyle within my first hour<br />

when my taxi driver, en-route<br />

to my hotel, stopped to buy<br />

taro and thereafter went to<br />

a supermarket for his weekly<br />

shopping!<br />

Our working week was spent at Vaiola Hospital,<br />

in the Japanese government-built eye clinic.<br />

This involved a walk-in clinic service for patients<br />

requiring an eye exam or glasses, recalls for<br />

diabetic screening and lists of mostly pre-booked<br />

cataract surgeries. In total we saw 225 patients<br />

who were refracted and screened for diabetes<br />

and general ocular health.<br />

Most days we had finished with patients around<br />

4pm, so I spent some of my spare time in theatre<br />

watching Dr Riley complete a series of complex<br />

cataract extractions – the majority of which were<br />

SICS (Small-Incision Cataract Surgery). Interesting<br />

cases we came across included a child with a<br />

possible rhabdomyosarcoma, a sebaceous cell<br />

carcinoma, a dislocated crystalline lens in the<br />

vitreous and, as expected, keratoconus, diabetic<br />

retinopathy and dense cataracts. In particular,<br />

though there were many diabetes patients, there<br />

wasn’t much evidence of diabetic retinopathy,<br />

something VOSO has also noted from previous<br />

visits. Perhaps they’re all great at controlling their<br />

blood glucose levels!<br />

The local nurses are well-trained and are now<br />

experienced, so VOSO is moving into more of<br />

a supportive role where we supplement their<br />

training and assist in cases where needed.<br />

Initially the weather was not in our favour;<br />

very wet yet a comfortable 24 degrees with<br />

low humidity. Through the week the weather<br />

BY JASON DHANA*<br />

Jason Dhana refracting a patient in Tonga<br />

the future it could help with diagnostics as well.<br />

“It is likely that the ‘virtual’ reality headsets in<br />

the market today (which close off the real world,<br />

and can be isolating) will be replaced with ‘mixed’<br />

reality (eg. Google Glass, Microsoft Hololens),<br />

where virtual images are overlaid on the real<br />

world,” says Dr Turnbull, stressing VR is far from<br />

a fad and will continue to rise in popularity.<br />

“Combined with other emerging technologies<br />

such as real-time eye tracking and machine<br />

object-recognition, VR will provide a mechanism to<br />

enhance the world around us, to simulate/correct<br />

vision loss or, for mixed reality headsets, to be a<br />

tool for the vision impaired.” ▀<br />

improved, however, and the combination of fresh<br />

papaya and coconuts, fresh fish, and after-work<br />

wharf-jumping and snorkelling left us with a<br />

sense that we were actually on holiday. I’ve also<br />

learnt that diving masks and beards do not go<br />

well together, so I guess that means I won’t be<br />

snorkelling again! The coastline of the main<br />

island of Tongatapu is stunning, and is one of the<br />

few places in the world where Humpback whales<br />

migrate to breed in the warm Tongan waters.<br />

To top off the holiday feeling, toward the end<br />

of our visit, the clinic staff treated us to a night<br />

of entertainment, including traditional Tongan<br />

dancing and a local feast.<br />

The assistance from foreign governments is<br />

evident, however, and basic healthcare in Tonga<br />

still has a long way to go. Thankfully, there are<br />

numerous medical teams from Australasia<br />

helping our neighbours in need. This was my<br />

first VOSO trip and I couldn’t have asked for a<br />

better team to go with. It was truly a rewarding<br />

experience and the locals with their grateful<br />

smiles made it even better – I look forward to<br />

returning!<br />

For more information, visit VOSO’s Facebook page<br />

or website at www.voso.org.nz ▀<br />

* Jason Dhana splits his week between emergency and<br />

glaucoma clinics at Greenlane Hospital and as a Professional<br />

Teaching Fellow within the School of Optometry and Vision<br />

Science, University of Auckland.<br />

For more personalised eye care<br />

talk to Dr Hussain Patel<br />

Consultant Ophthalmologist<br />

MBChB, MD, FRANZCO<br />

SERVICES INCLUDE:<br />

Glaucoma Specialist / Refractive Cataract Surgery<br />

General Ophthalmology / Acute & Emergency Eye Care<br />

Available throughout Auckland<br />

and also in Hamilton<br />

Phone 0800 750 750 or Fax 09 282 4148<br />

info@eyesurgeryassociates.co.nz or<br />

Dr Patel at: patel@glaucoma.co.nz<br />

www.eyesurgeryassociates.co.nz<br />

Eye Surgery Associates are a Southern Cross Health Society Affiliated Provider<br />

Support VOSO and have a good night out at Merediths in Auckland, which has chosen VOSO as its Charity of the Month for <strong>Oct</strong>ober<br />

24 NEW ZEALAND OPTICS <strong>Oct</strong>ober <strong>2016</strong>


Obituary: Johan Steeman 10/11/1929 – 10/08/<strong>2016</strong><br />

BY KATHRYN STEEMAN<br />

Johan (John) Steeman was born at the<br />

beginning of the Depression on 10 November<br />

1929 in Den Helder, northern Netherlands. He<br />

was the younger and weaker of twins born to his<br />

Polish mother and Dutch father. Johan was born a<br />

‘blue’ baby and his parents did not think he would<br />

survive, but little Johan was stubborn, determined<br />

and possessed a strong will to live and he made it<br />

through. These were traits that would stay with<br />

him for life.<br />

Johan’s early years were dramatically changed<br />

in May 1940 when the Germans invaded and<br />

occupied the Netherlands. Life was hard during<br />

the war with little food, and Johan’s family hid<br />

three Jewish people, so needed to feed extra<br />

mouths. One evening, German troops burst in<br />

and demanded to know why there were three<br />

dark haired people amongst all the blond ones.<br />

Johan’s mother was quick thinking and took the<br />

photo of her older son from her first marriage,<br />

whom had been unwillingly conscripted into the<br />

German army. She said the soldier in this photo<br />

was that woman’s husband, and that was their<br />

little boy and the older woman was his mother-inlaw.<br />

This satisfied the officer and they left. Johan<br />

said he had never been so scared as the Germans<br />

would have had no qualms about taking everyone<br />

outside and shooting them. He learnt from his<br />

mother to be quick thinking and always find a<br />

way around a problem.<br />

At the end of the war, the Jewish residents<br />

left only to find most of the people they had<br />

known were no longer alive. They were so<br />

grateful to Johan’s parents that they gave them<br />

enough money to pay for their children’s further<br />

Johan Steeman’s ‘Alien’ passport, which he was required to carry until the late 1970s as a noncommonwealth<br />

passport holder<br />

education. Johan went to technical college in<br />

1946 to obtain his engineering certificate. After<br />

graduating, Johan was called up for National<br />

Service, but as the youngest of five sons, he had<br />

the option not to go. He stayed in Den Helder<br />

where he worked as a civilian engineer at the<br />

navel harbour workshop.<br />

This job only lasted for a short while as returned<br />

servicemen were being employed. Johan then<br />

went to work as a plumber’s mate but was eager<br />

to see something of the world. His twin had<br />

finished his National service in Indonesia and had<br />

gone on to Australia to work in the Queensland<br />

sugar cane fields. Johan said he would meet him<br />

there, but Australian migrant recruiters said he<br />

would need to show five years’ work experience<br />

and Johan only had two and a half years. Luckily<br />

the NZ migrant recruiters only required two years’<br />

work experience.<br />

Johan was on one of the first four boats of<br />

Dutch immigrants to arrive in New Zealand in<br />

1952. He could not speak much English and found<br />

the first 18 months very hard. Luckily his twin<br />

– who had now moved to New Zealand – could<br />

speak better English and he got Johan his first job<br />

in Christchurch at engineering company Andrews<br />

& Bevan where he worked until 1954, when he<br />

went to work for another equally well known<br />

engineering company, CWF Hamilton. Johan met<br />

his English wife Evelyn in 1954 and they married<br />

in December 1955.<br />

Johan worked for CWF Hamilton on night shift<br />

until 1966 and it was during this time he had his<br />

first contact with the optical side of things. During<br />

the day his own small engineering business was<br />

doing machine repair work for Standard Optical.<br />

Johan’s good friend Eddie Turner was working for<br />

them and had recommended<br />

Johan for his quality of<br />

workmanship.<br />

In the early 1970s Johan<br />

found himself without a job<br />

after the camping equipment<br />

manufacturer he worked for<br />

since 1968 was unexpectedly<br />

dissolved. Whilst deciding<br />

which direction to go next, his<br />

friend Eddie Turner mentioned<br />

a new company were starting<br />

up in Christchurch and needed<br />

someone with engineering<br />

knowledge.<br />

The company turned out to be<br />

the contact lens manufacturing<br />

business Corneal Lens<br />

Corporation. Johan got the job<br />

of laboratory manager and was<br />

sent to Australia for training. He<br />

became a pioneer in the contact lens field and very<br />

forward thinking. In the early 1970’s importing<br />

goods was not easy and very expensive. So Johan,<br />

after much trial and error, made up most of the<br />

polishing ‘pitch’ compounds and polish mixtures<br />

required for the different PMMA and early soft lens<br />

materials in use. He was instrumental in making<br />

some of CLC’s first polishing machines, and other<br />

equipment, that was easy to service and replace<br />

and more financially viable.<br />

CLC’s ‘Generator’ machine, which was the<br />

equipment used at the time to cut the Conoid<br />

lens design, was a temperamental and tricky<br />

piece of equipment that required a talented<br />

engineer like Johan to keep it under control. It<br />

was the bane of many a Steeman family weekend<br />

outing as Johan was forever having to go in to<br />

reset the machine ready for Monday. Knowing<br />

how to produce a good final product from a<br />

machine like this required a talent few had but<br />

Johan possessed. Johan worked at CLC until 1977.<br />

After this he went back to engineering and<br />

worked as a tool and die maker, but his dream<br />

was to open his own contact lens laboratory. He<br />

decided that if he could make equipment for his<br />

previous employer then why not for himself. So<br />

over the next three years, in his weekends and after<br />

work, Johan, with the permission and generous<br />

use of his current employers milling machine and<br />

lathes, made his own polishing and engraving<br />

machines and two contact lens lathes. In June<br />

1980 he finally fulfilled his dream, and Precision<br />

Contact Lenses Ltd began manufacturing. I joined<br />

my father at the end of 1981 and my brother Neil<br />

joined in 1986 – a true family affair.<br />

Johan wanted to help young newly graduated<br />

optometrists and so he provided his trial sets<br />

free of charge and encouraged them to try fitting<br />

customised contact lenses to their patients by<br />

making all parameters available no matter what<br />

they wanted. He did not make stock lenses as<br />

he felt this restricted the fit for the patient.<br />

Johan also re-introduced a design from the late<br />

1960’s at the request of a practitioner friend in<br />

Dunedin. The practitioner wanted to keep the<br />

BCOR spherical but needed some toricity only<br />

in the secondary/peripheral curves. So Johan<br />

developed what was to be known as the TSP<br />

Curve lens design and another generation of<br />

practitioners had the experience of giving their<br />

patients a better-fitting lens if needed. Johan was<br />

encouraged by the feedback he received from<br />

practitioners who said patients often asked if the<br />

lens was still in their eye, or said that they could<br />

see like a hawk. Johan also used his engineering<br />

skills to make a range of his own plastic products,<br />

Tweezer, Contact Lens Catcher and various<br />

packages and cases. He had his own milling<br />

Johan Steeman in recent times<br />

machine and lathe and enjoyed creating injection<br />

moulds for these products.<br />

Johan’s personal health had moments of<br />

upheaval; in 1984 he was diagnosed with diabetes,<br />

in 1994 he had a heart attack at Hamner hot pools<br />

and in 1995 he battled prostate cancer. He had<br />

further problems with his heart and circulation<br />

and in 1999 he had a triple bypass. This gave him<br />

a new lease of life, but his diabetes was getting<br />

harder to control with just tablets so in 2005 he<br />

was put on insulin. Too high sugar levels due to<br />

an under dose of insulin shortly after left him in<br />

a coma. Doctors didn’t think he would make it,<br />

but that stubborn, determined, strong will to live<br />

kicked in and he pulled through. Afterwards Johan<br />

took things slower and left the day-to-day running<br />

of the business to myself and Neil.<br />

The earthquake of February 2011 nearly<br />

shattered Johan’s dream of owning his own<br />

laboratory. It was a tense three months before it<br />

was known whether or not the laboratory would<br />

survive. Luckily PCL managed to salvage all their<br />

equipment and after much TLC and overhauling<br />

managed to keep going and the company is still<br />

trading today.<br />

Johan’s final ‘occupation’ was that of funloving<br />

and generous Grandad, one that he<br />

enjoyed very much. He had many dreams in<br />

life and on reflection fulfilled most of them. He<br />

battled through the last six weeks of illness but<br />

unfortunately did not win and it was his time to<br />

finally rest.<br />

Johan is survived by his children Kathryn, Neil<br />

and Martin and his three grandchildren. ▀<br />

Retina NZ workshop<br />

BY SALLY ROSENBERG*<br />

Introduced by Mike Smith and hosted by the<br />

Blind Foundation, Hamilton, a workshop<br />

hosted by Retina NZ in August was attended<br />

by participants from around New Zealand. The<br />

two presenters and facilitators, Dieu Nguyen and<br />

Vildana Praljak from Vision Australia showed their<br />

style from the outset of the meeting.<br />

The team in the room varyingly knew or didn’t<br />

know each other so the process of introductions<br />

took on a special flavour. We did the usual ‘roll<br />

call’ but with a twist – each person had to add an<br />

alliterative adjective to their name. So we had the<br />

pleasure of meeting Reliable Ricky, Peaceful Peter,<br />

Adaptable Amy and Sincere Sue, amongst others.<br />

I’ve been to many events, endured many ‘ice<br />

breaker’ moments and I have to say that this was<br />

one of the most effective I’ve experienced, bridging<br />

the gap between professional and personal<br />

through the reflective choice of descriptor.<br />

The purpose of the workshop was to explore<br />

services that are available to the low vision<br />

people of New Zealand, those where the criteria<br />

for support through agencies and the Blind<br />

Foundation have not quite met yet. The approach<br />

taken by Dieu and Vildana was a mixture of<br />

group discussion, ‘around the house’ individual<br />

statements, small group work to explore<br />

solutions for problems outlined in scenarios, and<br />

a bit of role playing to offer differing viewpoints<br />

of a pertinent challenge.<br />

Key messages and challenges from the day<br />

include the perceived gap between a clinician’s<br />

view of risk in the landscape of low vision<br />

conditions and that of the person being affected<br />

by low vision. In the ideal world there would be a<br />

person-centred approach to support for low vision<br />

patients and collaboration between clinicians,<br />

providers, organisations, patients and their family.<br />

The anecdotal barriers in New Zealand to this<br />

being successful and available ubiquitously are<br />

time and money.<br />

However, these are not insurmountable –<br />

improvement in the processes and approaches<br />

to low vision support can improve the personcentred<br />

outcome. Provision of guiding questions<br />

for clinicians to ensure that assumptions about<br />

accessible services don’t derail a holistic approach<br />

could help.<br />

Even within the room of interested individuals<br />

there was a mismatch of knowledge – the option<br />

of using occupational therapists and social workers<br />

as part of the whole equation was discussed, for<br />

example. The Waikato DHB’s Disability Support<br />

Services carries out in-home assessments of need<br />

and can offer support in novel ways. Prevention of<br />

falls is a strong driver for the provision of support<br />

and if adding resources and aids to the home of a<br />

person with low vision reduces the likelihood of<br />

falls then this support can be accessed.<br />

Another area of support not commonly offered,<br />

and this was backed up by several participants with<br />

low vision themselves, is counselling to assist a<br />

person manage the emotional and psychological<br />

impact of a diagnosis of low vision and a prognosis<br />

of gradual (or rapid) blindness as a result of their<br />

condition. This is an area of improvement that<br />

could be added to the suite of tools in a clinician’s<br />

treatment and management regime.<br />

The topic that took us to the role play was the<br />

return to work of a person with low vision after an<br />

absence from the workforce of some ten years. Dieu<br />

stated that employment is the greatest symbol of<br />

social inclusion in modern urban life. People are<br />

judged on output and employment status and this<br />

links strongly to our sense of self-worth. A survey of<br />

Australian employers conducted by Vision Australia<br />

found that only 17% would employ a vision-impaired<br />

person.<br />

Five teams role-played the differing influencers<br />

in a ‘return to work’ situation – the person herself,<br />

friends and family, the employer and support<br />

agencies. The consensus was that “Rachael” would<br />

confirm her place in the workforce, that she would<br />

be supported and assisted to return to meaningful<br />

work with additional help from technology that<br />

wasn’t available ten years prior. As a group we<br />

clearly had a bias towards a positive outcome (and<br />

I quietly left the meeting with a slight smugness<br />

that if we surveyed New Zealand employers we’d<br />

achieve better than 17%!)<br />

After lunch, the focus of the workshop shifted<br />

specifically to innovative ways for agencies to work<br />

together. As practice manager of Hamilton Eye<br />

Clinic duty called so the bridge was built without<br />

a view from private ophthalmology, however<br />

mine is just one view. Others in the meeting<br />

included optometrists, a post graduate student<br />

of low vision, executive members of Retina NZ,<br />

Blind Foundation representatives, occupational<br />

therapists and nurses, so the innovation pathways<br />

were well seeded with diverse inputs.<br />

Key messages from the day included:<br />

• Strength-based conversations with people<br />

facing low vision challenges which don’t (yet)<br />

meet the Blind Foundation criteria are a necessary<br />

part of a management plan for each person<br />

• Blind Foundation, Disability Support Link and<br />

allied health services are all accessible, at least<br />

for enquiry, in the holistic support of a low vision<br />

person<br />

• Making time or taking time for a ‘joined up’<br />

approach to low vision care is the most personcentric<br />

mode for treatment and management –<br />

the challenge of insufficient time can be mitigated<br />

somewhat if we understand what the available<br />

options are and can access information easily ie.<br />

sharing our knowledge and knowledge of each<br />

other as providers.<br />

And Mike Smith – I’ll pick you to order the lunch<br />

any day!!!!! ▀<br />

<strong>Oct</strong>ober <strong>2016</strong><br />

* Sally Rosenberg is practice<br />

manager at the Hamilton Eye<br />

Clinic which she manages<br />

alongside other consulting<br />

work. Prior to this she worked<br />

in senior roles predominantly<br />

in the dairy and agriculture<br />

sectors. Personal interests<br />

include choral singing,<br />

rudimentary fitness (no<br />

marathons) and sailing, which<br />

is a challenge in the land-locked<br />

Waikato!<br />

NEW ZEALAND OPTICS<br />

25


Style-Eyes<br />

BY JO EATON*<br />

On reflection<br />

Some years ago, during my first work experience at a spectacle shop, I had<br />

an interaction with a customer that brought me to tears. A woman came<br />

in looking for new glasses. She’d left it too long and she really needed a<br />

new pair in her updated prescription. We picked out a few pairs for her to<br />

try on. When it came to putting them on and looking in the mirror, it was<br />

obvious she didn’t want to look at herself. She screwed up her face at the<br />

first sight of her reflection, looked away quickly, mumbled, “Not these ones”<br />

and reached for the next pair, only to have the same reaction. The thing is,<br />

she looked great. All of the frames complemented her face shape and the<br />

colours we’d chosen made her eyes pop. I told her this, but because I was<br />

trying to sell her something, she told me, “You have to say that.”<br />

I was so surprised that I didn’t know how to respond. I was thinking, “Well,<br />

I’m new to this job and I really don’t have to say those things. I don’t earn<br />

commission. I’m not going to sell you something that I don’t think looks<br />

right on you or works for your prescription.” But I didn’t know how to say<br />

that without sounding rude. So we moved on. She chose some frames, but<br />

I could tell she didn’t love them. She left and I went into the back room to<br />

tell the optometrist and I felt my eyes prick with tears. I wanted to know<br />

why she couldn’t see what is beautiful about her. Why couldn’t she see her<br />

beautiful eyes, brightened by the frames we’d picked?<br />

There’s something beautiful about everyone<br />

I soon discovered that this is not unusual. The optometrist told me she had<br />

seen similar situations quite often over the years. I wanted to know how<br />

I could make people feel comfortable looking at themselves. I wanted to<br />

know how I could help them see the beauty that I see in them.<br />

Lights, cameras…<br />

There are some practical things you can do to help when words fail<br />

you. Lighting should be considered. No one looks their best under harsh<br />

fluorescent tubes. If your store has these, then perhaps consider upgrading<br />

to more flattering lighting options. A low-cost alternative is to take out<br />

or turn off some of the tubes and get some decent free-standing lamps<br />

(without fluorescent bulbs) near your mirrors and angle them correctly.<br />

The last store I worked in had very flattering lighting, but I often like to<br />

encourage customers to go out onto the street with a hand mirror to look at<br />

themselves in natural sunlight if they’re expressing concerns. Of course, this<br />

is also great for trying on sunglasses.<br />

People who dislike looking in the mirror often equally dislike having their<br />

photo taken. Even so, if you can encourage them to get out their phone to<br />

take some selfies (or take photos of them yourself) trying on frames, these<br />

photos can be sent to family or friends who can help them make decisions<br />

and send some positive reinforcement that they look great. This comes<br />

with a warning though – often family and friends will disagree with the<br />

customer and dispenser’s choice!<br />

Ask the professionals<br />

Geraldine Booth from Geraldine Booth Optical in Wellington says that it’s<br />

important to get to know a patient before you offer opinions on how a<br />

frame looks on them, “If I don’t know a patient at all, then I will [initially]<br />

hold back on a cosmetic opinion. I know that can be hard but hold off on it!<br />

Fit is of prime concern, but as you see how people react to frames it starts<br />

to reveal their personality. I often tell them that any feedback is good –<br />

negative and positive. Again it reveals more of their personality... So much<br />

comes down to the individual and you have to find your way of ‘unpeeling<br />

the layers’ to establish the best plan of attack.”<br />

When they’re having trouble looking in the mirror, she says, “I think<br />

it’s all part of coaxing them along until they have confidence in you and<br />

know you’re not there to sell. Optical practices do not fit a retail model.<br />

Remember we ‘sell’/dispense what’s termed ‘optical appliances’ in formal<br />

speak. We are governed by strict government-enforced professional<br />

standards. We’re not just selling a commodity, so exercising your<br />

professional role is paramount.”<br />

Great advice!<br />

Dealing with this situation is something that I’m still learning. When my<br />

greatest pleasure in this role is helping someone look fantastic, it’s hard if a<br />

customer can’t recognise the beauty you see in them.<br />

How do you deal with this? I’d love to hear! Email me: jo@eyeheartglasses.<br />

com<br />

* Jo Eaton is an optical dispensing student at RMIT. Originally from Wellington, Jo became<br />

interested in eyewear after discovering she was myopic at the age of 14. In 2008, many years<br />

after deciding to make unusual glasses her ‘thing’, she founded eyewear fashion blog ‘Eye Heart<br />

Glasses’. When she’s not immersed in the world of spectacles, she works in digital marketing,<br />

DJs, volunteers for community radio and is a director of feminist music organisation LISTEN.<br />

Visique Oamaru’s new look<br />

Oamaru Visique’s team Dave Roberts, Barb Bain and Nicky Hay<br />

They say a change is as good as a holiday, and Visique<br />

Oamaru Eyecare have certainly embraced this<br />

philosophy, revamping their interior to reinvigorate the<br />

practice.<br />

Last fitted out in the 1990s, while under the name Peter<br />

Dick Optometrists, current owners Dave and Debbie Roberts,<br />

who took over the practice in<br />

2007, felt the time was right for<br />

a change.<br />

“We needed to use our<br />

space better,” says Dave. “It<br />

was originally set up as a one<br />

optometrist, part-time practice.<br />

We are now full-time and had<br />

outgrown the previous layout.<br />

We needed another testing<br />

room to accommodate another<br />

part-time optometrist.”<br />

Working with a local builder<br />

and interior designer, Dave and<br />

Debbie had a ‘Steampunk light’<br />

vision for the interior, to reflect<br />

Oamaru’s local heritage and<br />

embrace the Steampunk trend.<br />

“Steampunk is described as<br />

a mixture of Victoriana and<br />

science fiction,” says Dave.<br />

“Oamaru is the self-proclaimed<br />

‘capital of steampunk’ and we<br />

wanted to incorporate the light<br />

industrial side of it.”<br />

The practice was completely<br />

Statuesque, intelligent and fiercely independent, it’s hard to<br />

image Dame Maggie Smith even having a cold, let alone a more<br />

serious condition. The truth is that formidable actress Maggie<br />

Smith was diagnosed with Graves’ Disease in 1988, which required<br />

optical surgery for Graves ophthalmology – the characteristic<br />

raised lids, bulging eyes and redness that affect sufferers of the<br />

autoimmune disorder.<br />

Understanding more about eye conditions than others, Dame<br />

Maggie became a patron of the International Glaucoma Association<br />

in 2012, and more recently it has emerged that she has glaucoma<br />

herself. “Forgive me for looking at you like this. It’s because I’m blind<br />

in one eye, not being furtive”, she said to a reporter for the Daily<br />

Telegraph during a recent interview. The award-winning star of<br />

stage and screen is now 80 and still ploughing through a selection<br />

of wonderful roles, such as the beloved Professor McGonagall in the<br />

Harry Potter franchise and Mary Shepherd in Alan Bennett’s The Lady<br />

in the Van. The fact she is able do this with a visual impairment (and<br />

the need for a hip replacement) can surely only win this formidable<br />

star more adoration. ▀<br />

gutted and remodelled more efficiently, to incorporate two<br />

testing rooms and a room for the Medmont, which used<br />

to be in the hallway. They now also have a kitchenette and<br />

a sink, with hot running water – which has caused much<br />

excitement!<br />

“We used to have to boil the kettle and fill a bucket to do the<br />

dishes,” says Debbie.<br />

They’ve also doubled their<br />

retail space and upgraded their<br />

operating systems, moving to<br />

a cloud-based server and VOIP<br />

phone system.<br />

“(The new fit out is) great for the<br />

customers. It’s warmer, we have a<br />

wider range of frames, the lighting<br />

is better, and it gives more privacy,”<br />

says Dave “It has allowed us to<br />

grow our business and see our<br />

patients more quickly.”<br />

Local patients have given<br />

the new-look practice an<br />

overwhelmingly positive response,<br />

says Debbie.<br />

“We’ve had people just pop in to<br />

have a look because someone told<br />

them about the refurbishment.<br />

Someone even said they felt<br />

they had popped into a shop in<br />

Parnell. It was absolutely worth<br />

the investment and the inevitable<br />

stress that goes along with a<br />

renovation.” ▀<br />

Stars and their eyes: Dame Maggie Smith<br />

William Morris’<br />

new campaign<br />

William Morris has<br />

launched its European<br />

autumn/winter<br />

fashion campaign, with stylish<br />

images shot in some of London’s<br />

trendiest spots.<br />

Using locations around Notting<br />

Hill, and featuring a canine<br />

companion named Quincy, the<br />

iconic British eyewear brand<br />

aims to showcase their sense<br />

of humour and patriotic eye as<br />

well as their new designs, the<br />

company said in a press release.<br />

Alongside the parent collection<br />

is the all-new Wills collection,<br />

aimed at stylish teens. Subtle<br />

re-workings of popular classics<br />

for younger, more petite face<br />

shapes, open up a range of<br />

on-trend styles to a more<br />

junior, but no less demanding<br />

audience. The company is also<br />

using lighter yet more durable<br />

materials, it said.<br />

William Morris is distributed<br />

in New Zealand by Phoenix<br />

Eyewear. ▀<br />

26 NEW ZEALAND OPTICS <strong>Oct</strong>ober <strong>2016</strong>


Alcon launches<br />

DT1 multifocal<br />

The Alcon roadshow for the launch of its new Dailies Total1<br />

Multifocal contact lenses arrived in Auckland in August,<br />

with special guest speakers Tim Grant, Alcon ANZ’s regional<br />

professional affairs manager, and Mark Koszek, a therapeuticallyqualified<br />

Australian optometrist with a special interest in contact<br />

lenses, orthokeratology and dry eye.<br />

Chairing proceedings at the Crowne Plaza Hotel in Auckland,<br />

Karen Fowler, Alcon Vision Care ANZ country head, said New<br />

Zealand is second only to Australia to launch Alcon’s new multifocal<br />

version of its popular, premium Dailies Total1 contact lens (CL)<br />

range. While Grant added that New Zealand was the first country in<br />

the world to actually sell the product to a patient.<br />

Described by Alcon as the “first and only multifocal water gradient<br />

contact lens,” Grant provided an in-depth look at the science and<br />

technology behind Dailies Total1 and the new multifocal lens.<br />

According to Alcon, “The Dailies Total1 water gradient<br />

technology reduces end-of-day dryness, as the water content<br />

approaches nearly 100% at the outermost surface of the lens. The<br />

hydrophilic (water-loving) surface of the lens is almost as soft as<br />

the surface of the cornea to enhance comfort, while the innovative<br />

optical design of this new multifocal lens offers a smooth<br />

progression of power designed to provide a seamless experience<br />

between distant, intermediate and near vision.”<br />

In Alcon studies, compared with similar lenses, 8/10 people<br />

reported better end-of-day comfort with the new Dailies Total1<br />

lenses and 9/10 said upon trying it that it was not like wearing a<br />

contact lens at all. Research supported by clinical studies conducted<br />

on Dailies Total1, in comparison with other silicone hydrogel daily<br />

disposable contact lenses, by the Optometry and Vision Science<br />

Department at the University of Waterloo in Ontario, Canada, which<br />

looked at both the comfort response and the clinical performance,<br />

Richard Chinn, Jeremy Wong and Darryl Eastabrook<br />

including lens surface deposits, wettability, pre-lens non-invasive tear<br />

breakup time, lens movement and centration.<br />

Bringing the proceedings back to multifocals, Grant explained<br />

how monovision lenses are on the decline, while multifocals are<br />

on the up, as new technology comes into play. “In practices every<br />

day we are talking to patients about adaptation…adaptation is<br />

another term for ‘it takes time’, it takes time to have that delight our<br />

patients wish for.”<br />

Alcon’s “Precision Profile Design” technology features smooth<br />

progression of power gradients, with the ability to push-plus<br />

without adversely affecting distance vision, he said.<br />

The lens is particularly aimed at people with presbyopia, as an<br />

alternative to reading glasses or bifocals, though it suits progressive<br />

Renata Watene and Jared Neame from Occhiali with Alcon’s Karen Fowler (centre)<br />

lens wearers equally well too, said Koszek.<br />

It also makes economic sense to encourage more CL patients, he<br />

added, referring to a study he conducted in his own practice. His study<br />

found that his average CL wearing-patient spent A$1,340 over four<br />

years, compared with an average non-CL patient who spent A$656 over<br />

the same period. Plus, on average, his CL patients remained patients for<br />

11.4 years, while non-CL patients stayed for just nine years.<br />

In conclusion Koszek, who referred extensively to the Waterloo<br />

University studies, said he’d actively recommend the new multifocal<br />

from Dailies Total1, that optometrists should introduce it to<br />

potential patients (myopic and presbyopic) early, they should “push<br />

the plus in hyperopes”, closely monitor patients and sell the science<br />

to get buy-in and trial. ▀<br />

PORSCHE DESIGN<br />

EYEWEAR<br />

Hirdesh Nair and guest speaker Mark Koszek<br />

Bhavna Patel, Rochelle Yukich and Roger Apperley<br />

CASUAL ELEGANCE IN TITANIUM<br />

www.porsche-design.com<br />

For more information, please contact BTP<br />

or visit BTP stand at Visionz Conference.<br />

T: 64 7 307 2410 | E: info@btpid.co.nz<br />

BTP | 58 McAlister St, Whakatane 3158 | PO Box 604, Whakatane 3158 |www.btpid.co.nz<br />

Paula Farrar, Robert Ng, Kristine Jensen and Tony Cradwick<br />

<strong>Oct</strong>ober <strong>2016</strong><br />

NEW ZEALAND OPTICS<br />

27


DISPENSING OPTICIAN<br />

HAVELOCK NORTH<br />

Grant & Douglas Optometry & Eyewear are seeking a qualified<br />

Dispensing Optician (or someone who is currently training to be<br />

a Dispensing Optician). We are a busy independent Optometry<br />

practice providing excellent eye care and eye wear solutions<br />

tailored to our customer’s individual needs.<br />

This role will be based mainly in our Havelock North practice<br />

however you may occasionally be required to work in our<br />

Hastings practice.<br />

This is a great opportunity for a confident, versatile individual<br />

who has the following attributes:<br />

• Experience in customer service with a proven track record for<br />

a high level of customer satisfaction.<br />

• Excellent communication and sales skills.<br />

• Shows initiative, is reliable and honest.<br />

• Strong computer literacy.<br />

• Good standard of personal presentation.<br />

• Able to work cohesively and productively within a team.<br />

Monday to Friday, approx 30 - 40 hours per week (Negotiable)<br />

Please email your CV and cover letter outlining your skills and<br />

experience to Anna Byers abyers@grantanddouglas.co.nz<br />

OPTOM PLATE FOR SALE<br />

The personalised plate OPTOM is for sale after 18 years. Asking<br />

price is $3000+GST or make an offer. Additional fees apply to<br />

change or remove message and have the plate made.<br />

Contact stuart.warren@nsoptom.co.nz<br />

AUCKLAND PRACTICE FOR SALE<br />

Finally, a bustling, central Auckland practice for sale!<br />

The current owner is looking to retire and would like to find<br />

someone to take over this profitable, independent practice and<br />

their loyal customers. There’s tremendous scope for growth for the<br />

right owner who has the skills and the energy, drive and marketing<br />

know-how to make this practice stand out.<br />

This practice is ideally suited to an optometrist who yearns to be<br />

truly independent and is ready to run their own business, make<br />

their own decisions and reap the rewards from the hard work they<br />

put in. Or perhaps you’re overseas and looking to move or return to<br />

New Zealand?<br />

Situated in a very sought after suburb with good schools and<br />

amenities close by, with many high-value customers and a great<br />

team, this practice has it all, and you’ll receive the full support of<br />

the current owner in a comprehensive handover process.<br />

If this sounds like you, please email, in strictest confidence,<br />

info@nzoptics.co.nz, quoting code PFSB20<br />

RETAIL/OPTICAL ASSISTANT<br />

PART-TIME<br />

Optik Eyecare Pukekohe Ltd are looking for a part time retail/<br />

optical assistant. The position would include reception and<br />

general optical duties. Starting immediately.<br />

All enquires please email admin@optik.co.nz<br />

MANUAL VERT NEEDED<br />

Do you have an old manual lens meter lying around gathering<br />

dust? Why not sell, or rent it to a training DO? If you can help,<br />

please email mgr.pukekohe.nz@specsavers.com<br />

PART-TIME DO/OPTICAL ASSISTANT<br />

Nicholls Optometrists in Browns Bay are looking for a part-time<br />

Dispensing Optician or Optical Assistant to provide maternity<br />

cover for 12 months from November <strong>2016</strong>. Days required are<br />

Mon & Fri 8.30-5.30 and Sat 8.30-1.30. You will become part of an<br />

experienced team in a well resourced independent practice. Please<br />

contact Bruce Nicholls in confidence at nicholls4@gmail.com<br />

D/O TO COVER MATERNITY LEAVE<br />

We require a dispensing optician for a one year fixed-term<br />

contract to cover maternity leave in sunny Gisborne. Hours and<br />

days worked flexible, either part-time or full-time. Contact either<br />

Steve Stenersen or Sue Kain (06) 867 5465, 027 486 7540 or<br />

steve@sko.co.nz<br />

Whether you are looking for new staff, to sell your practice or buy<br />

some equipment, NZ Optics classified page connects you.<br />

For all your advertising needs email<br />

Lesley@nzoptics.co.nz or<br />

(for classifieds only) do it online at<br />

www.nzoptics.co.nz<br />

C<br />

M<br />

Y<br />

CM<br />

MY<br />

CY<br />

CMY<br />

K<br />

Thinking of selling your practice - we have buyers<br />

Considering buying - we’ll give you all the options<br />

OpticsNZ specialises in optometry practice sales,<br />

we've helped dozens of Optometrists buy and sell their practices<br />

For more information contact Stuart Allan on: 03 546 6996<br />

027 436 9091 stu@opticsnz.co.nz www.opticsnz.co.nz<br />

• Locum Service<br />

• Recruitment Services<br />

• Practice Brokering<br />

• Business Consultants<br />

28 NEW ZEALAND OPTICS <strong>Oct</strong>ober <strong>2016</strong>

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