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2 NEW ZEALAND OPTICS October 2016

Lensworx in liquidation 

Auckland-based optical lens manufacturing 

laboratory Lensworx was placed into 

liquidation on 23 August. 

Managing director Albie Hanson emailed creditors 

and customers on 26 August explaining the company 

had been dealing with shareholder issues for the 

past two years, which had affected the company’s 

ability to operate. “It was restricting our ability to 

gain appropriate financial and banking services as 

would be expected for operating a company of our 

size on a daily basis. The frustration this has been 

causing has made it extremely difficult to expand 

the business and its NZ Kodak Lens and Safety 

eyewear lines. As this problem has been ongoing 

without satisfactory resolution today it was decided 

to voluntary liquidate Lensworx as it is becoming 

too difficult and personally very costly to manage 

the company properly.” 

According to Companies Office records’ the 

current shareholders of Lensworx are Hanson, with 

a fifth share, stock breeder and feed supplier Karyn 

Maddren, also with a fifth, and Crystal Sand Limited, 

owned by Christopher James Taylor of Kohimarama, 

who owns three fifths of the company. 

The news came as a surprise given that Lensworx 

had begun the rollout of its long-anticipated Kodak 

Lens Vision Centres (KLVCs) retail programme for 

independent optometrists earlier this year. 

First mooted in February 2015, the programme 

offered independent optometrists the opportunity 

to partner with Kodak and use the brand, which 

is owned under license by Californian company 

Signet Armorlite. Under the programme, 

independent optometrists can choose to 

incorporate the Kodak brand into their practices 

as a concession, or whole-of-premises branding, 

(effectively a franchise), without the associated 

fees. Practices commit to a level of Kodak lens 

sales in return for marketing and branding support 

and use of the Kodak name. In May, four practices 

had agreed to join the programme, with six more 

expected to sign up by the end of June. 

Talking to NZ Optics after announcing the 

liquidation, Hanson remained committed to the 

Kodak programme. “Even though Lensworx has 

chosen to liquidate, we feel the outcome will 

be better for Signet Armorlite and the Kodak 

branding for independent optometrists. Lensworx 

management still feels this is the best model 

internationally for supporting independent practices 

with the world leading Kodak brand and will do all it 

can to see this continues to be available to the New 

Metabolites and AMD? 

New findings suggest that oxidative stress stemming from a 

growing accumulation of visual cycle adducts may play an 

important role in the pathogenesis of AMD, said Dr Janet 

Sparrow, Anthony Donn professor of ophthalmic science at Columbia 

University, New York. “There are a number of genes that have 

been implicated in AMD and there are likely multiple modifiable 

environmental factors at work,” she continued in an article in 

Ophthalmology Times. Non-genetic risk factors include smoking, 

diet and exposure to sunlight. The protective effects of smoking 

cessation, increased intake of antioxidants, and sunglasses all play 

roles in reducing oxidative stress in the visual system, particularly in 

RPEs. All cells are subject to oxidative stress, she said, but the visual 

system appears to be particularly vulnerable. ▀ 

Jeremy Ang and Chien Chiang from Signet Armorlite flank Albie Hanson 

from Lensworx in happier times earlier this year 

Zealand independent practitioner.” 

However, given no buyer stepped forward in the 

limited time allotted by the liquidators Meltzer 

Mason, Signet Armorlite has closed its account 

with Lensworx and transferred all existing and 

ongoing Kodak work and commitments to 

Independent Lens Specialists (ILS) in Christchurch. 

The move was a “natural fit”, said Chien Chiang, 

managing director of Signet Armorlite AMERA, 

based in Singapore, as ILS distributed Kodak lenses 

in the South Island and the two organisations 

have had a long-standing relationship. “We do not 

wish for Kodak Lens customers to be left in limbo. 

Therefore, for the time being, all of the customers 

and jobs, which were going to Lensworx are being 

routed through ILS in Christchurch.” 

Chiang also reiterated his company’s 

commitment to rolling out the Kodak brand and 

supporting independent optometrists in New 

Zealand. “We would also like to communicate 

to the optical trade that we are committed to 

promoting and supporting the brand in the region. 

The demise of Lensworx was not due to the lack of 

support for Kodak Lens from the trade/consumer 

nor due to a lack of support from Signet’s side. As 

our retail program was off to a promising start, our 

ambition will continue as planned.” 

Glenn Bolton, ILS director, said both he and 

business partner John Clemence were very 

surprised and saddened by the news, especially 

for Lensworx’s loyal staff. “We have obviously 

worked closely over the years with the Kodak 

Lens brand and have continued this supply to 

Lensworx’s customers.” 

Lensworx was formed in 

2005 as a full wholesaler and 

specialist prescription optical lens 

manufacturing laboratory. It gained 

the Kodak Lens agency in 2007 

and was certified for processing 

prescription safety eyewear. 

According to the liquidators’ 

report, at the time of liquidation 

the company owed $33,541 to 

secured creditors, $496,000 to 

unsecured trade creditors and 

$718,293 to an unsecured “related 

party”. With no buyer on the 

horizon, the remaining assets of 

the company are expected to be 

sold by public auction in October. 

Disclosure: NZ Optics is a 

creditor of Lensworx ▀ 

Earthquake shakes East Coast 

On 2 September at 4.37am, a magnitude 

7.1 earthquake struck off the coast of 

the eastern cape of the North Island. 

Optometrist Steve Stenersen in Gisborne said he 

felt they were lucky this time. 

“Although the earthquake was quite large and 

sent us all out of bed diving to the floor, it was not 

too bad here. It was more rolling, although still 

violent, as opposed to the sudden jolts which cause 

more damage. We only had the odd thing fall over, 

no breakages.” 

Other locals also described it as a strong, rolling 

quake. It was located 130km north-east of Te 

Araroa, was 55kms deep and lasted for around 

30 seconds. Locals reported some minor damage 

including toppling chimney’s, artwork falling 

from walls and products dislodged from shelves 

in local businesses. A Tsunami alert was issued 

afterwards, and with many local schools and 

businesses closed, residents of coastal towns 

such as East Cape, Hicks Bay and Tologa Bay 

headed for higher ground. 

Stenersen said he was thankful the effects 

weren’t worse as the magnitude 6.7 Gisborne 

earthquake of 2007 caused major disruption 

and cost him around $150,000 in repair bills. 

“We’ve learned a lot about insurance since 

then,” he said. 

Aftershocks have continued in the cape area, 

with Geonet predicting they could last for up to 

two years. With the earthquake having changed 

the stresses in the Hikurangi Subduction Zone, 

Geonet experts said there is a small chance of a 

very major event occurring, similar to the Tohoku 

earthqauke in Japan in 2011, however, they added 

this is very unlikely. ▀ 

Highs, lows and dry eye 

This month has been a 

roller coaster of highs and 

lows. The biggest high 

was completing our second, 

even better, Dry Eye Special 

Feature (see pages 9-19). The 

wonderful A/Prof Jennifer 

Craig, NZ’s international dry eye 

superstar, helped us to decide, 

curate and review the material 

for this feature which, I’m sure 

you will agree, covers a wealth 

of information on dry eye from 

the latest research here and 

across the ditch to views on the 

latest technology and thinking 

in areas as diverse as hormones 

and bacteria to contact lenses 

and triage. There’s even a 

little tip for making your own 

tearscope with a ping pong ball! We can’t thank 

all the DryEye contributors enough, both for the 

time they’ve taken to put their articles together, 

and for their enthusiasm when asked to share 

their knowledge and experiences with the wider 

industry. 

Lows include the sad news about the passing 

of Emeritus Professor Leon Frank Garner and 

Precision Contact Lens founder Johan Steeman, 

each ably remembered by those who knew 

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

daughter Kathryn (p25) respectively. Then there 

was the earthquake in Gisborne – glad to hear 

it was just the crockery that got hurt! And the 

liquidation of Lensworx, whose creditor list 

sadly reads like a who’s who of the company 

side of the industry (see news story, this page). 

In another sort of passing, we say goodbye to 

columnist Alan Saks who has decided to focus 

on other projects. We wish him well, and are in 

the process of introducing a new column that 

will most definitely get you talking! 

Other highs include the Eye Institute’s 

entertaining and educating evening (check out 

the smiling faces on p23) and Specsavers annual 

EDITORIAL 

clinical conference (SSC5), which was supported 

by a number of New Zealanders, including many 

who now live in Australia but were delighted to 

shout about their Kiwiness for NZ Optics while 

we were in Brisbane. SSC5 was also packed 

full of useful and practical information, the 

highlights of which we’ve distilled for you on 

p20-21. 

And finally, by the time you read this, I’ll be in 

Paris for my first Silmo fair! Yes, it is fair to say 

I am a tad excited! Silmo will be covered in our 

November issue, along with our Summer and 

Sun special, and an ever so amusing take on 

the bad side of homemade scleral lenses by our 

wonderful speciality CL columnist Alex Petty. So 

don’t miss it; it’s going to be another bumper 

issue! 

Au revoir 

Lesley Springall, publisher, NZ Optics 

Charity Fundraiser A day at the Ellerslie Races 

Saturday 18 th February 2017 

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

is a treatment that can stop its progression. MDNZ is committed to slowing this epidemic. 

Please support this fundraising event and help us save the sight of thousands of New 

Zealanders. Funds raised will support awareness campaigns, education, information and 

support for those with Macular Degeneration, their families and carers. 

Donate an 

auction item 

We welcome any 

item for the live or 

silent auction. 

Philip Walsh, Damien Koppens and our own Jai Breitnauer at SCC5 in Brisbane 

How you can help: 

Purchase 

a table 

Invite 10 guests to be at 

your personal table for 

a fabulous day including 

a gourmet buffet lunch, 

celebrity guests, auctions, 

raffles, horse racing at its 

best and more! 

Sponsor 

a race 

Naming rights to a race 

on the day comes with 

wide brand exposure 

and VIP opportunities. 

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

October 2016 

NEW ZEALAND OPTICS 

3

News 

in brief 

DRUG DISPENSING CONTACT LENSES 

Researchers at Harvard Medical School are developing drugdispensing 

contact lenses that could offer new hope to glaucoma 

patients at risk of going blind. The lenses, which are designed to 

deliver medication gradually, may improve the treatment of patients 

who struggle with eye drops, which can be imprecise and difficult 

to self-administer, said Dr Joseph Ciolino, an ophthalmologist at 

Harvard Medical School. “Based on our preliminary data, the lenses 

have not only the potential to improve compliance for patients, but 

also the potential of providing better pressure reduction than the 

drops.” 

OCULAR SURFACE EVALUATION IN GLAUCOMA 

In a study, published in Optometry and Vision Science, patients with 

ocular surface disease (OSD) and open-angle glaucoma (OAG) taking 

anti-glaucoma medication showed greater reductions in tear lipid 

layer thickness than those without OAG; plus the total duration of 

anti-glaucoma medication use significantly correlated with tear lipid 

layer thickness. A total of 85 eyes in 85 patients were included, with 

34 in the control group (OSD without OAG). “Results suggest that 

greater tear lipid layer damage, represented as a thinning of lipid 

layer thickness, can be characteristic of OSD associated with topical 

anti-glaucoma medication use,” researchers concluded. 

RETINAL CHANGES MAY SIGNAL PARKINSON’S 

Retinal changes may serve as a marker for Parkinson’s disease, a new 

study in mice suggests. “We show that rosiglitazone can efficiently 

protect retinal neurons from the rotenone insult, and that systemic 

administration of liposome-encapsulated rosiglitazone has an 

enhanced neuroprotective effect on the retina and central nervous 

system,” wrote Eduardo Maria Normando of Imperial College London, 

UK, and colleagues in Acta Neuropathologica Communications. 

Previously researchers observed that intracytoplasmic inclusions 

called Lewy bodies, characteristic of Parkinson’s, appear not just in 

the brain, where they damage cells that produce dopamine, but 

throughout the central nervous system, including the retina, which 

led to the mouse study. Animal trials, administering rosiglitazone, 

also showed promise in protecting against the effects of rotenone as 

it appears to promote an anti-inflammatory response and to reverse 

inhibition of monoamine oxidase, a crucial enzyme for dopamine 

metabolism, said researchers. 

COOPERVISION HONOURED 

CooperVision has been honoured by the Puerto Rico Manufacturers 

Association (PRMA) with a series of prestigious environmental, 

health and safety awards, which recognise advancements in its 

Puerto Rico high volume production facility, culminating with 

PRMA’s Environmental Innovation Project of the Year award. The 

company reported a reduction of 12.4% in its use of alcohol, a 55% 

decrease in water and significantly reduced landfill disposal at its 

Puerto Rico facility. The reductions are expected to result in cost 

savings of more than US$8.5 million by the end of 2017. 

PIG-VISION 

Scientists in China are developing transplant alternatives for those 

suffering from cornea damage. Long waiting lists and the halting 

of a controversial programme that allowed organ transplants from 

executed prisoners, has led to government support for alternative 

donors – pigs. More than five million people in China are estimated 

to need a cornea transplant, so researchers from China Regenerative 

Medicine International (CRMI) are trialling the use of pig corneas 

– a bi-product of the meat industry that is readily available and 

cost effective. Several 

transplants have 

already taken place at 

Zhongshan University, 

in the southern city of 

Guangzhou. CRMI has 

also been producing 

bio-engineered pig 

corneas for human 

use since approval was 

given in April 2015. 

DIY MEDICINE RESEARCH ON THE RISE 

Almost four out of five Australians (78%) report looking for 

information about medicines on the internet, while 58%, and 

79% of 18-34 year olds, admitted looking up information about 

health conditions on the internet to avoid going to see a health 

professional, according to a survey released during Australia’s Be 

Medicinewise Week from 22-28 August. This compares to just one 

in three people who said they were likely to search the internet for 

information about their symptoms before they visited their doctor 

in a 2012 survey by NPS MedicineWise. 

ESSILOR INNOVATION 

Essilor has again been named one of the world’s “Most Innovative 

Companies” by Forbes in its prestigious, annual 100 Most Innovative 

Companies list. This is the sixth year in a row Essilor has earned a 

spot on the list, which recognises publicly traded companies that 

have been identified by investors as being innovative now and 

in the future. “Innovation has always been a cornerstone of our 

strategy. We have one goal: to push back the frontiers of poor vision 

worldwide,” said Jean Carrier, chief operating officer for Essilor 

International. ▀ 

Obituary: Emeritus Professor 

Leon Frank Garner 

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

Originally from Melbourne, Professor 

Leon Garner held positions in 

Canada and Malaysia before 

moving to New Zealand with wife, Rosie. 

They arrived in Auckland in 1978 and in 

his 25 years with the University, Leon’s 

achievements were remarkable. 

His drive led the development of the 

discipline of optometry from its early roots 

in 1965 as a section hosted within the 

Department of Psychology. Leon added vision 

science content to the Diploma of Optometry 

enabling the formation of the four-year 

Bachelor of Optometry degree in 1982. By 

1987 Leon had developed resources, research, 

staffing and activities to the point that the 

establishment of a separate Department of 

Optometry and Vision Science was agreed. 

During this period Leon was the quiet 

driving force behind the creation of the 

New Zealand Optometric Vision Research 

Foundation which, with generous and 

ongoing donations from industry and the 

New glaucoma 

test 

Researchers from the University of New South Wales 

(UNSW) have developed a new test that could 

detect glaucoma four years earlier than current 

available techniques. 

The new diagnostic test asks patients to look at small 

dots of light of specially chosen size and light intensity. An 

inability to see them indicates blind spots in the eye and 

early loss of peripheral vision – a precursor to glaucoma. 

A study assessing the new technique on 13 patients 

was recently published in the journal Ophthalmic and 

Physiological Optics, and further trials are ongoing. 

“The researchers have presented results using a new 

paradigm for visual field testing using the Humphrey 

visual field analyser,” explained glaucoma specialist, Dr 

Hussain Patel from Eye Surgery Associates in Auckland. 

“Instead of a single target size to test sensitivity at each 

point, multiple targets of varying size are used.” 

Glaucoma is one of the leading causes of irreversible 

blindness in the world and in the early stages patients 

usually have no symptoms and are not aware they are 

developing permanent vision loss, said Professor Michael 

Kalloniatis, director of the UNSW Centre for Eye Health. 

“The cause of the disease is unknown and there is no 

cure, but its progression can be slowed with eye drops or 

surgery to lower pressure in the eye. So, early detection 

and early treatment is vital for prolonging sight.” 

The UNSW diagnostic test has been patented in the 

US and EU, with the inventors named as Professor 

Kalloniatis, Dr Sieu Khuu of the UNSW School of 

Optometry and Vision Science and Dr Noha Alsaleem, a 

former Masters student at UNSW. 

Ray-Ban honoured 

Luxottica brand, Ray-Ban, distributed through Luxottica 

companies’ OPSM and Sunglasses Hut, has been named 

Brand of the Year by the US Accessories Council, a not-for 

profit organisation that includes the world’s leading brand names, 

designers, publications, retailers and associated providers for the 

accessories, eyewear and footwear industries. Each year, the Council 

pays homage to those brands, designers and businesses that have 

had a big impact on the accessories industry by assigning the 

Accessories Council Excellence Awards. Over the past 12 months, 

Ray-Ban announced the fusion of its Round and Clubmaster styles 

that led to Clubround, and the new campaign #ittakescourage that 

focuses on Ray-Ban’s theme: the courage to be yourself. 

profession, still supports NZ research in 

optometry and vision science today. Leon 

was appointed the Foundation Professor of 

Optometry in 1989. 

His research focus was optics including 

the development of refractive error. Specific 

populations within New Zealand, its Pacific 

neighbours and also in Nepal where myopia 

was uncommon, provided ideal groups 

for study. Comparison of the dimensions 

of components of eyes from these groups 

with measurements from cultures where 

myopia was a growing problem provided 

publications which are the foundation of 

today’s research into causes of myopia. 

Leon had a principle that guided his 

decisions and work at Auckland throughout 

his 25 years and this principle was that the 

good of optometry and the Department was 

foremost. He was an incisive thinker and a 

greatly respected academic. 

Leon was appointed Emeritus Professor 

of the University of Auckland in recognition 

Professor Leon Garner 

of his achievements on his retirement in 

2003. Following his retirement, Leon and his 

wife Rosie moved to Australia to be closer 

to their children and families. They had 

originally planned to settle in Queensland 

but one fateful day in 2004 they drove 

past a granite house on a stud estate, 

called Roseleigh, in Victoria, and Rosie 

immediately fell in love with the property. 

Together they established Garners Heritage 

Wines on the property and produced many 

award winning wines. 

Leon Frank Garner died on 31 August after 

battling cancer, aged 75. 

Leon, his family and his achievements 

will be remembered warmheartedly by the 

University, the profession and the many 

individuals on whose careers and lives he 

was an important influence. ▀ 

Pharmac reviews anti- 

VEGFs 

There has been a lot of debate 

about the three most widelyused 

injectable anti-vascular 

endothelial growth factor (anti-VEGF) 

drugs to treat wet age-related macular 

degeneration (AMD) – ranibizumab 

(brand name Lucentis), aflibercept 

(Eylea) and bevacizumab (Avastin) 

– with anecdotal feedback in New 

Zealand suggesting that, given the costs and effectiveness, Avastin is the 

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

Fitt, director of operations at Pharmac, about the current funding situation. 

“These are medicines primarily given in a hospital setting. Pharmac didn’t 

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

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

the Hospitals Medicines List (HML).” 

Ranibizumab is a second line medication after Avastin, she said, adding 

that Pharmac has not received any negative feedback regarding Lucentis. 

“Patients on a second line medication are perhaps less likely to be responsive, 

so perhaps that could be the issue.” 

That said, however, Pharmac is currently considering its anti-VEGF 

treatments for wet AMD. 

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

to PTAC (Pharmacology and Therapeutics Advisory Committee) and 

the ophthalmology subcommittee for review and PTAC gave us the 

recommendation to run a competitive process” said Fitt. 

The request for proposals (RFP) process closed about a month ago with 

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

the information and decide on if and which treatments we can fund. We are 

assessing all factors at the moment.” 

Fitt was keen to stress the process takes time, but Pharmac is hoping to be 

able to offer some news around anti-VEGF funding soon. ▀ 

Ray Ban Clubround campaign 

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those of NZ Optics (2015) Ltd. 


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0800 447 272 

EYESRIGHT.CO.NZ 



5

Specsavers rolls out “value” lens 

Johnson & Johnson (J&J) has teamed up with 

Specsavers in Australia and New Zealand to 

roll out its new “value-conscious” monthly 

contact lens, Acuvue Vita this year. 

“It’s for the value-conscious patient, so it fits 

Specsavers’ business model well and it allows 

us to help optometrists add Acuvue to their 

portfolio,” says Dr Emma Gillies, professional 

affairs manager at J&J Vision Care ANZ. 

In recent surveys of monthly contact lens 

(CL) wearers, J&J found more than two-thirds 

of respondents experienced comfort-related 

issues with their lenses at some time during the 

month; 84% of these patients used compensating 

behaviours such as re-wetting drops or taking 

breaks from wearing their CLs; and 73% said they 

did not plan to tell their optometrist about their 

lens wearing experience because most considered 

their comfort issues “normal”, with some raising 

concerns they were worried they would be taken 

out of CLs if they mentioned it. 

Though J&J maintains a shorter-wearing 

cycle is better for contact lenses, the studies 

demonstrated an unmet need in the monthly 

category, says Dr Gillies. 

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

J&J claims to have solved many of the monthly 

comfort-related issues with Acuvue Vita’s 

HydraMax technology, which employs a noncoated 

silicon hydrogel formulation to maintain 

hydration over the month. Dr Gillies says this is 

different to J&J’s HydraLuxe technology used 

in the manufacture of its Acuvue Oasys 1-Day 

lenses, though both focus on maintaining and 

working with the natural tear film. According 

to the marketing material, the HydraMax 

technology in Acuvue Vita helps maximise lens 

hydration by integrating the maximum amount 

of hydrating agent, polyvinylpyrrolidone (PVP), in 

the lens and then maintaining hydration through 

optimal density and distribution of beneficial 

lipids throughout the lens. Costs are kept down 

through changes to the manufacturing process, 

says Dr Gillies. 

The lens was launched to the Australasian 

market at the Specsavers Clinical Conference 

(SCC5) in Brisbane in September and will be 

available for sale through Specsavers’ stores from 

November. It will be rolled out to the rest of the 

eye care market from early 2017. ▀ 

For more about SCC5 go to p20. 

EVF heads south 

The Essilor Vision 

Foundation (EVF) has 

conducted its first school 

screening in the South Island at 

New River Primary School. The 

decile one, Southland school 

is the first of many taking part 

in the screening programme, 

thanks to the involvement of 

Ria Bond, the New Zealand First 

List MP based in Invercargill. 

“I’m pleased that the 

children in our community 

will be screened as part of 

this programme and have the 

opportunity to address any 

potential issues with their 

sight,” said Bond in a statement. 

“There is a clear link between 

eye issues and academic achievement, so to be 

able to rectify any problems at this stage will help 

even the playing field for these children.” 

Claire Martin, from Martin and Lobb Eyecare in 

Invercargill, volunteered her time to help with the 

screening on 18 August. “Although most children 

have a basic eyesight test when they start school, 

their eyes don’t mature until around the age of 

nine. At that stage our equipment can identify 

previously undiagnosed vision conditions. 

New River Primary principal Elaine McCambridge 

said she was delighted the school had been asked 

to take part. “Ensuring our students can make 

progress and achieve to the best of their ability 

is always our priority. We are constantly looking 

for barriers to learning. As a group of educational 

professionals, we may have suspicions that a 

child’s vision is problematic to their learning, 

but we have to rely on parents taking action or 

following up, and this doesn’t always happen. 

“The Essilor Vision Foundation have provided 

an amazing opportunity for us to have our year 

three to year six students checked. An important 

aspect of this process is that we will have some 

control over the follow-up testing and will ensure 

it happens for each child that has been identified. 

Such a practical and effective programme, provided 

by a very dedicated group of community-minded 

people, could change the course of a child’s life.” 

The EVF was officially launched in January this 

Marnie Lankow from Martin and Lobb Optometrists at New River Primary School, Invercargill 

year after a pilot programme in Hawke’s Bay. It 

provides eye tests and follow-up care for children 

in decile 1 and 2 schools. Essilor’s platinum partner 

optometrists volunteer to help run the screening 

programmes, while the school’s commit to taking 

any referred children to follow up appointments 

and glasses fitting. Glasses not covered by a 

community services card are paid for by the 

Foundation and all students are “awarded” their 

glasses in a graduation ceremony so it’s seen as 

an exciting privilege. The first EVF graduation was 

held at South Auckland’s Rowandale school in July 

and attracted significant general media coverage. 

“Let’s face it, sometimes kids can be teased for 

wearing glasses, but I liken it to the fact these 

children aren’t just wearing glasses, they’re 

superheroes!” said Rowandale’s deputy principle 

Lois Hawley-Simmons, adding the graduation 

ceremony helps remove any stigma around 

wearing spectacles. 

So far EVF has facilitated screenings in 10 

schools, testing around 200 children at each 

school. Kumuda Setty, Essilor NZ’s marketing 

manager and EVF coordinator, said the aim is to 

have screened more than 3,000 children by the 

end of this year. Data collected from screenings 

and follow ups is being used by Massey University 

to compile accurate figures around eye problems 

and its impact on Kiwi children’s educational 

achievement. ▀ 

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6 NEW ZEALAND OPTICS October 2016 

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2/09/16 11:32 AM 

TPA optometrists to 

issue Standing Orders 

TPA optometrists are now authorised to 

issue Standing Orders, written instructions 

that allow timely access to medicines in 

situations where an authorised prescriber is not 

available. 

In October 2015, the Ministry of Health 

consulted on a proposed amendment to the 

Medicines (Standing Order) Regulations 2002 to 

authorise nurse practitioners to issue standing 

orders. The NZ Association of Optometrists 

(NZAO), supported by the Optometrist and 

Dispensing Opticians Board (ODOB), then 

put a case to the Ministry for an amendment 

to authorise both nurse practitioners and 

optometrists (with therapeutic endorsement) to issue standing orders, 

which was accepted. 

The new regulations, the Medicines (Standing Order) Amendment 

Regulations 2016, allowing TPA optometrists and nurse practitioners to 

issue standing orders under the same conditions that apply to medical 

practitioners and dentists, came into effect on 17 August 2016, 

Dr Lesley Frederikson, NZAO national director, says this new 

amendment rectifies an anomaly brought about by the previous wording. 

“The previous exclusion of nurse practitioners and optometrists from 

being able to issue standing orders is a legal anomaly arising after the 

2013 amendment of the Medicines Act 1981 which was not intentional. 

“Post-amendment, the Medicines Act already defined a Standing 

Order as a written instruction issued by a practitioner, registered 

midwife, nurse practitioner or optometrist in accordance with any 

applicable regulations. However, the Medicines (Standing Order) 

Regulations 2002, definition of practitioner included only dentists and 

medical practitioners thus defeating the intent of the primary Act. 

“All parties recognise that healthcare demand is increasing and costs 

are rising so it makes sense to enable these two groups of authorised 

prescribers (TPA optometrists and nurse practitioners) to work to their full 

scope of practice. Authority to issue a Standing Order permits therapeuticsendorsed 

optometrists to provide more efficient and safe care by enabling 

other non-prescribing practitioners in the primary healthcare team to 

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

in specified circumstances without a prescription.” 

Dr Frederickson says issues of safety are covered in the Ministry of 

Health guidelines for Standing Orders and they are quite specific and 

very comprehensive. “Enabling TPA optometrists to issue Standing 

Orders will improve teamwork and efficiency between therapeuticsendorsed 

optometrists, doctors, non-prescribing optometrists and 

registered nurses in a variety of community settings.” 

RANZCO’s new digital museum 

As an industry, ophthalmology 

is often very focussed on 

the future – what is new? 

Cutting edge? Smart? How can we 

evolve and do things better? But 

Confucius said, “Study the past 

if you would define your future,” 

and to that end, RANZCO has been 

collecting and cataloguing artefacts 

and memories since the 1950s. 

“It began as a small collection 

of discarded instruments by 

Dr Geoffery Serpell,” says Dr 

David Kaufman, a full-time 

ophthalmologist and volunteer 

curator of the museum. “It 

began to grow with private 

collections being donated and 

artefacts passed on from trade. A 

large collection was donated by 

(Melbourne ophthalmologist and 

former RANZCO president) Dr Ken 

Howsam, and it was all stored at 

the Royal Victorian Eye and Ear 

Hospital in Sydney.” 

The previous curator, Dr Jim 

Martin, spent 12-years painstakingly 

cataloguing the collection, but it wasn’t 

very accessible. 

“We have two small rooms at the 

RANZCO offices in Sydney,” explains Dr 

Kaufman. “And we put on an exhibition 

at the RANZCO Congress each year. 

Otherwise, it’s all in storage. When I took 

over in 2012, I decided I wanted to make it 

more accessible to ophthalmologists and 

the public; more useful.” 

Dr Kaufman realised that with 

the profession spread across a wide 

geographical area, the best way to display 

the collection was digitally. 

“I moved the collection to a storage 

facility near me in Melbourne. It’s bigger 

and easier to move around in. Then I 

invested in electronic museum software, 

the type that is used by many major 

institutions to catalogue collections.” 

With the help of an assistant, Dr 

Kaufman has spent a day each week for 

the last few years photographing artefacts 

and writing their entry to be displayed 

online. He has come across many 

interesting and amazing items. 

“There are lots of curious instruments, 

things that ophthalmologists had 

made off the back of some crazy idea. 

You wouldn’t find them in any modern 

catalogue! One of the most unusual items 

we have is a cute little pocket dispensary. 

They were popular in the 1920s. We have 

about six and one is particularly beautiful 

with a snake skin cover. They’re about half 

the size of a matchbox with room inside 

for a small tube of pellets that could be 

dissolved and made into eye drops.” 

One of the museum’s biggest selling 

points are the digital memories. 

“We’ve got oral archives recorded 

between 1990 and 2000, memories from 

eminent ophthalmologists. We’ve also got 

some video, including Barbara McKay’s 

account of being an ophthalmic nurse in 

the 1950s.” 

The museum also offers a list of notable 

people, catalogues of diagnostic tools and 

journals, and welcomes the opportunity 

to share private collections through 

this platform. Much of the work on the 

museum, and the development of the 

website, has been made possible by a 

large donation from Dr (Charles) Neville 

Banks, who passed in 2010. 

“We’ve been well supported by senior 

colleagues, and also younger volunteers,” 

says Dr Kaufman. “Not a week goes by 

without a new donation. I just want to 

try and inform people. I want people to 

be able to use it as a resource and also to 

link with other websites. Our collection is 

expanding and evolving constantly.” 

You can now visit the new RANZCO digital 

museum at www.ranzco.edu/museum ▀ 

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7

Saving Sight celebrates 50 years 

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

Hannah Kersten and Dr Aaron Wong 

DFV’s Ralph Thompson demonstrates the IC100 Tonometer on Alex Petty 

BY DR AARON WONG* 

Celebrating 50 years since its foundation, 

the Save Sight Society hosted its annual 

conference on 26 August. For me, this 

meeting is all about great local speakers, a variety 

of clincally relevant topics and a good catch-up 

with colleagues. The fact this years meeting was 

set on the shores of Tauranga harbour made it all 

the more enticing. Dr Sam Kain co-ordinated an 

engaging programme that reflected the everyday 

clinic dilemmas of a general ophthalmologist or 

optometrist. 

Associate Professor Dipika Patel kicked off the 

day with an update on the research that the Save 

Sight Society has funded over the last year. It was 

particularly encouraging to see that donations 

and money raised from conferences like this one 

allows New Zealand researchers to perform cutting 

edge clinical and lab-based eye research. Some of 

the projects suported by the Save Sight Society 

have even gone on to garner further funding from 

overseas. The Save Sight Society has an important 

role to provide a launchpad for our researchers in 

rapidly advancing areas such as ocular genetics. 

Since less than 10% of applications for funding 

came from outside of Auckland this year, A/Prof 

Patel also took the opportunity to encourage 

researchers from all regions of New Zealand to 

apply. 

Everyone was intrigued to hear Dr Neil Murray 

explain why SIC (small incision cataract) surgery 

could be more aptly named ‘SLICK’ surgery. This 

phaco-less version of cataract surgery is more 

commonly performed in the developing world for 

cost reasons. Dr Murray presented his experience 

with SIC surgery in Rotorua. His audit found that in 

the right hands, SIC surgery has similar outcomes 

to phacoemulsification – with the exception of 

slightly more surgically-induced astigmatism in SIC 

surgery patients. He advocated for the use of SIC 

surgery in more challenging cases such as those 

with dense cataracts. 

In contrast to Dr Murray’s talk about less 

technology in cataract surgery, Professor Charles 

McGhee spoke about a shift towards more 

technology in cataract surgery. More specifically, 

the role of femtosecond laser-assisted cataract 

surgery in New Zealand. Although the initial 

excitement around femtosecond laser-assisted 

cataract surgery has subsided, there is no doubt 

the technology can offer better capsulorhexis 

centration, less phaco time and less endothelial 

cell damage during cataract surgery. 

Hans Vellara an optometrist and PhD candidate 

at the University of Auckland talked about an 

innovative technique to measure orbital compliance 

in thyroid eye disease. Using the Corvis ST noncontact 

Scheimpflug tonometer they were able to 

diagnose thyroid eye disease with a 92% sensitivity 

and 84% specificity in a group of 20 patients. 

After lunch, and a break to take in the 

Tauranga sea breeze, Dr Jo Sims gave a talk 

about sympathetic ophthalmia. This potentially 

blinding form of uveitis can attack a patient’s 

good eye weeks to years after an eye injury or even 

significant eye surgery. Fortunately a majority of 

the patients in her series of 12, maintained good 

visual acuity, largely due to prompt recognition 

of the condition and aggressive treatment with 

immune modulating medication. 

Dr Shenton Chew, a glaucoma specialist from 

Auckland gave an update on the current protocols 

for peripheral iridotomy for angle closure. He 

mentioned that these protocols are in for an 

update as soon-to-be-published trials such as ZAP 

and EAGLE seem to indicate a greater role for lens 

extraction in the management of angle closure. 

There is hope yet for sufferers of macular atrophy 

as Dr Mike O’Rourke explained. The CentraSight 

magnifier lens implant is a 4.4mm telescope 

that can be implanted instead of an intraocular 

Angela James, Margaret Riordan and Ruth Mangnall 

lens during cataract surgery or even replace an 

existing intraocular lens during lens exchange 

surgery. A magnified image means that the 

patients central scotoma takes up less area in 

objects around fixation. The CentraSight however 

requires very careful patient selection: those 

with bilateral central vision loss, healthy corneal 

endothelium and who respond well to a simulation 

magnification device. 

The 2016 Save Sight Society meeting delivered 

on all my expectations and more. In fact, it was 

so good even NBA star Steven Adams decided to 

make a fleeting appearance. Although he may 

have been lost looking for the bathroom whilst 

at the venues hotel. Or maybe he heard there 

was free food? At any rate, the Save Sight Society 

and all the sponsors should be congratulated for 

hosting another fantastic meeting. ▀ 

* Dr Aaron Wong is an ophthalmology trainee at the University of 

Auckland and father to eight-week-old baby Dylan (aka the cute 

baby who made brief appearance at lunch time). 

Dr Sarah Welch and John Kelsey 

Dr Stephen Guest and Dr James McKelvie 

Hans Vellara, A/Prof Dipika Patel and Akilesh Gokul 

Chantal O’Rouke, Dr Mike O’Rouke and Kay Evans 

Convenor Dr Sam Kain 

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 


SPECIAL FEATURE: DRY EYE 

Dry eye: a hot topic 

A 

week doesn’t go by without someone 

issuing a press release or circulating a paper 

where dry eye diagnosis or treatment is the 

topic. More and more companies are developing 

new technologies or introducing software 

upgrades to tackle the thorny issue of dry eye. 

There’s still much debate, however, about what 

works and what doesn’t as will become evident in 

the following articles in this special feature. 

But knowledge about dry eye has grown 

exponentially over the past decade, fuelled by 

research following the internationally-renowned 

Tear Film & Ocular Society’s Dry Eye Workshop 

(DEWS), which was instrumental in bringing the 

problem to the fore by developing a common 

starting platform from which organisations 

could develop products and researchers could 

undertake new research. Out went the old 

definitions, deemed inadequate, and in came a 

new consensus definition: 

Dry eye is a multifactorial disease of the tears 

and ocular surface that results in symptoms 

of discomfort, visual 

disturbance and tear film 

instability with potential 

damage to the ocular 

surface. It is accompanied by 

increased osmolarity of the 

tear film and inflammation of 

the ocular surface. 

It’s pleasing to note how 

New Zealand, together with 

our trans-Tasman neighbour, 

is leading a lot of the research 

out there and there’s more 

to come with the results 

of DEWS II, the second Dry 

Eye Workshop, expected 

in the next few years, with 

preliminary results being 

discussed at the TFOS meeting 

in Montpellier in France, 

ongoing at the time of this 

feature’s publication. 

EDITORIAL BY LESLEY SPRINGALL 

Acknowledgements 

With that in mind, NZ Optics would like to thank 

the authors of all the contributed articles in this 

feature for updating us about their research, 

their progress and their interesting and personal 

take on the treatments and diagnosis of dry eye 

and the tools available (as well as some of their 

own invention – see Greg Nel’s article about his 

ping pong ball tearscope on p14). Their stories 

provide a breadth of understanding about where 

we’re at with dry eye and where we’re going and 

it’s a privilege to be able to curate and present 

these articles here. 

Special thanks must also go to New Zealand’s 

own dry eye expert, Associate Professor Jennifer 

Craig, vice-chair of DEWS II and passionate 

researcher into all things dry eye, who was 

instrumental in helping to curate and review the 

following articles, which we both hope will serve 

to enlighten and inform current thinking on the 

increasingly hot topic of dry eye. 

TFOS imagery used to launch the now highly anticipated DEWS II 

TFOS, OSL and where we are 

with dry eye 

BY ASSOCIATE PROFESSOR JENNIFER CRAIG* 

The Tear Film and Ocular Surface Society 

(TFOS) is a non-profit society created in 

2000 with a network that extends to more 

than 85 countries. As such, it represents a global 

community whose mission is to advance the 

research, literacy and educational aspects of the 

scientific field of the tear film and ocular surface. 

Since the initial International Conferences on the 

Lacrimal Gland, Tear Film and Dry Eye Syndromes 

in 1992 and 1996 in Bermuda, the incorporated 

TFOS Society has continued to organise meetings, 

initially every four years and now every three, with 

the latest meeting held as this article goes to press 

in Montpellier, France. These vibrant meetings 

provide a forum for critically appraising current 

knowledge and the latest research on the ocular 

surface, and promoting international exchange 

of information and ideas between scientists, 

academic clinicians and industry representatives 

dedicated to understanding the field and 

ultimately to improving patient care. 

At the time of writing, the current meeting is 

shaping up to be the best yet, with an impressive 

line-up of presenters promising to provide insight 

into the unique challenges and unmet needs for 

the treatment of ocular surface disease across the 

different regions of the globe; and many topical 

matters such as sex-differences in dry eye and the 

role of neuropathic pain in the disease. Debates 

provide insight into topical concepts and around 

250 posters will be presented across the three full 

days of the meeting. 

Beyond the conferences, TFOS is undoubtedly 

best known for the International Workshops it has 

sponsored; the Dry Eye Workshop (DEWS, 2007), the 

Meibomian Gland Dysfunction Workshop (MGDW, 

2011) and the Contact Lens Discomfort Workshop 

(CLDW, 2013). Critical to these workshops has been 

an evidence-based approach to achieving global 

consensus, with open communication, dialogue 

and transparency. It is with this charge, that 150 

clinical and scientific experts have come together, 

under the organisation of Associate Professor 

David Sullivan, TFOS founder and Harvard senior 

scientist, and the 

leadership of Dr 

Dan Nelson, chair of 

the Workshop, and 

myself, as vice-chair, 

to compile DEWS 

II, an update on dry 

eye from the 10 

years of research 

published since the 

original DEWS. 

The conference in 

Montpellier is the 

first opportunity to 

hear some of the 

DEWS II findings 

presented in an 

Associate Professor Jennifer Craig 

vice-chair of DEWS II 

open forum. So it’s pleasing to see that there will 

be a sizeable Australasian contingent attending, 

reflecting the volume and quality of research being 

conducted in dry eye within Australia and New 

Zealand. In particular, there will be representation 

from the University of New South Wales (UNSW) 

research group, which includes Dr Maria Markoulli 

and Dr Laura Downie’s laboratory in Melbourne 

(see stories later in this feature), as well as 

from the Ocular Surface Laboratory within the 

Department of Ophthalmology at the University of 

Auckland in New Zealand. 

Ocular Surface Laboratory (OSL) update 

The last year or so has seen significant expansion 

in the size of the OSL team, which now comprises 

12 full-time and part-time individuals that include 

registered PhD students, MSc students and Honours 

students (in medicine, optometry and physics), 

as well as postgraduate optometrists (including 

Grant Watters – see story p14) and undergraduate 

medical students who undertake collaborative 

research projects in their spare time, under the 

guidance and leadership of post-doctoral researcher 

Dr Isabella Cheung and myself. Cheung brings a 

wealth of laboratory research skills to the team, to 

complement the clinical research expertise. 

CONTINUED ON PAGE 10 

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9


CONTINUED FROM PAGE 9 

For the first time this year, clinical exposure, that can contribute 

to the requirements for a Clinical MSc, has been offered through 

the Laboratory, in collaboration with the University’s School of 

Optometry and Vision Science (SOVS). The Clinical MSc programme, 

coordinated by senior lecturer, Dr Nicola Anstice, provides 

postgraduate optometrists with an opportunity to expand their 

knowledge and clinical skills in an area of interest. Sang Hoo Lee is 

the inaugural Clinical MSc student in the OSL, where he has been 

focussing on advanced dry eye diagnosis and management. 

Researching dry eye in New Zealand… 

In addition to the blepharitis and Demodex projects described by 

the individual team members in the following article, the Ocular 

Surface group has an interest in better understanding dry eye 

development and its risk factors. Published in The Ocular Surface 

journal this year, the group, including medical student, Michael 

Wang who has co-authored a number of papers with the team, 

described novel findings that highlighted differences in the 

morphology of the meibomian glands between the Asian eye and 

the Caucasian eye in a cohort of University students. Over the next 

year, the group, with the help of medical student Ji Soo Kim and 

optometry student Alicia Han, will be continuing to investigate 

this apparent ethnic predisposition to dry eye in other age groups, 

with particular interest in the possible link identified between 

incomplete blinking and meibomian gland morphology. 

…and overseas as part of a global study 

To address limitations posed by the lack of normative data on 

meibomian gland morphology across different age groups and 

ethnicities, the OSL in Auckland is collaborating with researchers in 

the UK and around the world, in a global epidemiology study. Leslie 

Tien, a Part V BOptom student, has been contributing to this, while 

evaluating age effects on the tear film and ocular surface in a local 

cohort, for her Honours project this year. Medical student Joevy 

Lim, like Ji Soo, plans to take a year away from her medical studies 

to undertake a BMedSci Honours project, during which she too will 

be developing and expanding this work next year. 

Dissemination 

Dissemination of research findings is critical so researchers at 

the Laboratory are encouraged to write up their research findings 

whenever possible and to present findings at national and 

international conferences. PhD students Sanjay and Ally have 

already travelled to meetings in Barcelona, Spain and Beijing, 

China, respectively within the last year to present their work and 

will be heading to Montpellier with me. Both also have aspects of 

their research in review or published already. 

I am also planning to travel to Anaheim, California later in 

the year for the American Academy of Optometry meeting, to 

present the results of an international multicentre clinical trial 

involving the Ocular Surface Laboratory and New Zealand-based 

ophthalmology practices, Eye Institute and Auckland Eye. Targeting 

patients with aqueous deficiency, the Oculeve device uses 

intranasal neurostimulation to encourage tear production from the 

lacrimal gland. Positive preliminary results have led to Allergan, 

which acquired the Oculeve company in July 2015, currently 

seeking FDA approval for the device (see p16). 

* Associate Professor Jennifer Craig is head of the Ocular Surface Laboratory at the 

University of Auckland. She chaired the TFOS Workshop Subcommittee on “Contact Lens 

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

initiative DEWS II (Dry Eye Workshop II), which will update the original DEWS report 

of 2007. 

Dry Eye & Allergy 

Centre of Excellence 

123 Remuera Rd, Remuera 

0800 393 527 

info@eyeinstitute.co.nz 

DED research update 

from the University 

of Auckland 

The following is a summary of just some of the research 

into dry eye disease (DED) currently being undertaken by 

researchers from the Ocular Surface Laboratory (OSL) and 

other departments at the University of Auckland. 

Blepharitis and Demodex studies 

Justin Sung, Varny Ganesalingam, Dr Isabella Cheung and Andy Kim 

Blepharitis is one of the most commonly observed ophthalmic 

conditions, with an impact on quality of life that is both 

significant and life-long, requiring patients to commit to ongoing 

management. Performed regularly, eyelid hygiene is an effective 

first-line management option for anterior blepharitis, helping to 

rid the lashes of crusting and reducing the bacterial load around 

the lid margins. As such, it is well established as a clinical mainstay. 

Controversy exists, however, between recommendations for use 

of diluted baby shampoo as a cost-effective remedy versus more 

expensive, custom-designed, commercial lid cleansers. Anecdotal 

reports have suggested a tendency for baby shampoo, as a nonophthalmic 

product, to induce ocular surface inflammation in 

some patients, by stripping the ocular surface of essential tear film 

lipids, as well as the troublesome lash crusts and debris. Evidence 

in the literature, however, is inconclusive. 

Medical student Justin Sung, who is presently undertaking 

a BMedSci Honours programme in the OSL between the fifth 

and sixth years of his medical degree, has been addressing 

this conundrum by performing a paired-eye, double-masked, 

randomised controlled trial to directly compare diluted baby 

shampoo against a leading commercial lid cleanser in terms of 

ocular surface inflammation levels pre and post-treatment. It’s 

hoped the results will help to guide clinicians in providing sound, 

evidence-based recommendations for patients affected by this 

highly prevalent condition. 

Blepharitis and Manuka honey 

While the pathophysiology of blepharitis is complex and its 

etiology uncertain, current research continues to find bacteria and 

inflammation as key contributing features. Because of this link, a 

topically-applied lid treatment embracing the unique antibacterial 

and anti-inflammatory properties of New Zealand Manuka Honey 

has been under development by collaborating researchers within 

the Department of Ophthalmology and Department of Molecular 

Medicine and Pathology. The resulting formulation – Manuka 

Honey with CycloPower microemulsion (MHCPME) – contains 

Manuka Health New Zealand’s proprietary combination of Manuka 

honey with cyclodextrin, a naturally occurring type of sugar, to 

increase its efficacy. 

Optometrist Varny Ganesalingam has been conducting laboratorybased 

research, as a part-time MSc student within the OSL, under 

the supervision of Associate Professors Jennifer Craig and Trevor 

Sherwin. Her study forms part of a larger investigation objectively 

assessing the tolerance of the human eye to the novel MHCPME 

product. Ganesalingam was responsible for evaluating RNA 

expression of three biomarkers of inflammation; MMP-9, IL-6 

and MUC5AC, from ocular surface tissue samples collected by 

impression cytology before and after a two-week treatment period 

on 23 healthy participants. After conducting preliminary studies 

to develop and refine the methodology, she subjected the samples 

to gene quantification analysis using real-time qPCR. The levels 

of all three genes of interest were found not to alter significantly 

following eyelid treatment with the Manuka honey-based emulsion. 

The results of her investigations, together with similarly favourable 

outcomes from the clinical component of the safety and tolerability 

trial, indicate that the treatment is suitable to progress towards the 

next and current phase, in which efficacy in patients with signs of 

chronic blepharitis is being tested. 

In addition, post-doctoral researcher Dr Isabella Cheung is 

evaluating the effectiveness of three months’ nightly use of this 

cyclodextrin-complexed Manuka honey formulation on the eyelids, 

as well as on the tear film and ocular surface, of individuals affected 

by blepharitis in an investigator-masked trial. The paired eye 

evaluation will be supported by clinical testing and with sensitive, 

laboratory-based quantification of the levels of inflammation. 

With scientific evidence demonstrating its effectiveness in treating 

blepharitis, this cyclodextrin-complexed Manuka honey preparation 

could become commercially available. This study is currently at the 

recruitment stage, so practitioners are encouraged to refer patients 

with blepharitis who might be interested in participating to the OSL 

for further information and to have their eligibility to participate 

confirmed. 

Blepharitis and Demodex 

Cheung is also supervising a 

novel study being undertaken 

by BMedSci Honours student, 

Andy Kim, who is between the 

third and fourth years of his 

medical degree, and who is 

also under the joint supervision 

of A/Profs Craig and Sherwin. 

Kim’s project concerns 

Demodex mites (see Fig 1.) 

which have been shown to be a 

significant contributing factor 

Fig 1. Demodex folliculorum can cause 

anterior blepharitis 

CONTINUED ON PAGE 12 


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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 

in Vision and Ophthalmology Annual Meeting; May 2-6, 2010; Fort Lauderdale, FL. 2. Christensen, M, Martin, A, Meadows, D. An Evaluation of the Efficacy and Patient Acceptance of a New 

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 

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 

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 

Gland Dysfunction: Report of the Subcommittee on Management and Treatment of Meibomian Gland Dysfunction. IOVS. 2011;52(4):2050-2064. Alcon Laboratories (Australia) 

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October 2016 NEW ZEALAND OPTICS 

11


CONTINUED FROM PAGE 10 

Fig 2. Cylindrical collarettes are suggestive of Demodex 

infestation 

in blepharitis. Unfortunately, there are 

major deficits in our ability to diagnose 

ocular demodicosis in the clinical 

setting, which impacts upon the timely 

instigation of appropriate treatment. 

Currently clinicians rely on high 

magnification microscopic examination 

of epilated lashes to confirm Demodex 

presence (see Fig 2.), but inaccuracies 

in this technique, that complicate 

diagnosis, are recognised to exist due to 

variations in mite numbers between an 

individual’s lashes, and the potential for 

obscuration of mites by crusts around 

the lash base. In order to overcome these 

difficulties, Kim has helped develop a 

polymerase chain reaction (PCR)-based 

assay that detects and amplifies a 

Demodex-specific sequence from the 

16s ribosomal RNA gene; the presence 

and quantity of which can be visualized 

using gel electrophoresis. He is also 

working with the team to develop a latex 

agglutination assay using chitinase and 

wheat germ agglutinin which binds to 

chitin, the main constituent of Demodex. 

This in-clinic diagnostic test will enable 

practitioners to determine whether the 

patient has Demodex infestation at a 

clinically significant level to indicate need 

for treatment and may have benefits in 

future epidemiological studies. 

Microbial keratitis studies 

Sanjay Marasini 

Microbial keratitis (MK) describes a 

potentially devastating acute corneal 

infection that can be caused by a variety 

of pathogens including bacteria, virus, 

fungi and protozoans, with dry eye 

disease being a common predisposing 

factor. Despite improving diagnostic 

approaches and management options, 

however, MK remains a difficult disease 

to treat, and disease incidence has been 

rising steadily. Sanjay Marasini, a PhD 

student within the OSL, has recently 

completed a retrospective review of 

hospitalized cases of MK (2013-2014) 

at Greenlane Clinical Centre (GCC), 

Auckland. In his review, he identified 

increasing disease due to more virulent 

bacterial species, such as Pseudomonas 

aeruginosa. Contact lens use was the 

most common risk factor leading to MK in 

Auckland followed by pre-existing ocular 

surface disease of varying aetiology. 

Consistent with previous literature, 

gram-negative bacteria, most frequently 

Pseudomonas aeruginosa, were more 

common among contact lens wearers. 

Increasingly, inefficacy of commonly used 

antibiotics, against such virulent bacteria, 

has been predicted as a major threat. In 

Maransini’s recently published paper on 

this Auckland-based retrospective review, 

he noted that, in laboratory testing 67% 

of gram-negative bacteria exhibited 

resistance to cefuroxime, one of the 

most frequently prescribed antibiotics for 

bacterial keratitis during the 2013 to 2014 

period. (For more on how bacteria affects 

dry eye see p14). 

Tackling antibiotic resistance 

Concerning antibiotic resistance 

statistics, such as these, provide 

impetus for the pharmaceutical industry 

to develop the next generation of 

antibiotics, but they also make the quest 

for alternative bactericidal therapies 

increasingly attractive. In this context, 

the OSL – in collaboration with patentholder, 

ophthalmologist Dr Simon Dean 

– is continuing to explore the potential 

of ultraviolet C (UVC) radiation to treat 

corneal infection. Marasini’s pre-clinical 

research, investigating the minimum 

safe dose of UVC that is effective in 

halting bacterial growth, has shown 

interesting preliminary results. These 

are being translated to the next phase 

of his study, which will be completed 

over the next year and will involve the 

use of bioluminescent bacteria. With 

the prevalence of visual impairment 

secondary to infectious keratitis on 

the rise globally, the potential for UVC 

to contribute to the safe and effective 

management of corneal disease, either 

alone or as an adjunct therapy, is an 

exciting prospect which, if successful, 

could be extended to other branches of 

medicine. 

Youʻre 

leaving me… 

arenʻt you? 

Tackling dry eye treatment dilemmas 

BY JAGRUT LALLU* 

Many companies claim their drop is ideal for dry 

eye, but the reality of deciding which drop to use, 

when, is not simple. There are a myriad of tests 

that dry eye specialists employ prior to prescribing. 

We are currently developing a comprehensive dry eye tool 

that uses what we have available in terms of testing and 

treatment to help practitioners simplify the diagnosis and 

prescribe effective treatment. Plus, the data collected can 

be used by research teams to more effectively develop 

algorithms using online infrastructure for practitioners. 

Currently, the process for effective patient care employs 

a series of questionnaires, as no one questionnaire fulfills 

all needs. Examples include: OSDI, McMonnies and SPEED. 

Ours includes a patient/practitioner portal and treatment 

tool/algorithm and employs all three questionnaires, with 

two being repeated prior to each follow-up/review. 

A brief summary of the diagnostic tests (not all) that 

our tool will include are: 

• Phenol red thread test – if less than 10mm dry eye 

indicated 

• Tear Lab – measures tear film osmolarity. In general, 

an increase in osmolarity is a marker for increased 

inflammation. If the results indicate a measurement >308 

= dry eye present;

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Founder & CEO, AFT Pharmaceuticals 

0800 423 823 

www.aftpharm.com 



13


Characterisation of the ocular surface microbiome 

BY GRANT WATTERS* 

Understanding and managing ocular surface 

disorders such as anterior blepharitis, 

meibomian gland dysfunction and 

dry eye disease remains challenging. Many of 

these conditions, being chronic, recurrent and 

debilitating, frustrate patients and clinicians alike 

with a plethora of treatments that are, at best, 

usually only partially effective¹. 

As in the intestine, there is a growing belief that 

dysregulation of the normal ocular commensal 

microbiota population may contribute to many of 

these conditions, so understanding the resident 

ocular surface microbiome in normal and diseased 

states may give us some clues as to whether we 

could more accurately regulate these microbe 

populations as a therapeutic strategy². 

Extensive research into the role that bacteria 

have in eyelid disease began with Thygeson’s work 

in the early half of the 20th century. He identified 

gram-positive (gm+) Staphylococcus aureus (S. 

aureus) as the organism most frequently isolated 

from the lid margins of blepharitis sufferers. 

Author(s); 

(year published) 

Albietz & Lenton 

(2006) 

Graham et al 

(2007) 

Bowman et al 

(1987) 

Dougherty & 

McCulley (1984) 

Groden et al 

(1991) 

Watters et al 

(2016) 

Country N C-N S 

(%) 

S.Aureus 

(%) 

P.acnes 

(%) 

Corynebact. 

sp.(%) 

Subsequent studies showed that while S. aureus 

was more common in blepharitis, coagulasenegative 

Staphylococcus (C-NS) was the most 

prevalent organism. Anaerobic gram-positive 

Proprionibacterium acnes (P. acnes) was also found 

to be more prevalent in eyes with lid disease 3,4 . 

We* have recently completed a study across 

three departments here at Auckland University 

to characterise the ocular surface microbiome 

present in New Zealanders with and without 

eyelid disease. Inferior lid margin swabs were 

collected from 157 randomly selected subjects 

subdivided into three categories: no lid disease 

(normal: n= 66); mild-to moderate lid disease (n= 

41), and moderate-to severe lid disese (n= 50). 

We also compared contact lens (CL) wearers and 

non-CL wearers. All subjects were analysed for 

aerobic isolates and 87 subjects were additionally 

investigated for anaerobic bacteria (P. acnes) 5 . 

Table 1. summarises our results in New Zealand 

normal eyes compared to relevant overseas 

studies. Of note is our sample exhibited a relatively 

higher percentage of individuals with S. aureus, a 

slightly lower incidence of C-NS, and an absence 

of Corynebacterium 

Streptococcus 

sp.(%) 

Australia* 18 84.0 6.0 22.0 6.0 0 6.0 

Ireland* 12 81.0 0 19.0 19.0 6.0 6.0 

Texas USA* 21 100.0 13.0 31.0 69.0 6.0 9.0 

Texas USA* 47 95.7 8.5 87.2 63.8 - - 

Florida USA* 160 87.5 15.6 73.7 45.0 - 4.3 

New 

Zealand* 

39 64.1 48.7 25.6 0 0 5.1 

Rubio (2004) Spain # 4366 56.8 6.4 - 30.2 7.5 6.2 

Hsu et al (2013) 

de Kaspar et al 

(2005) 

Capriotti et al 

(2009) 

Karthika et al 

(2014) 

Missouri 

USA # 

California 

USA # 

Sierra Leone 

(Rural) # 

India 

(Rural) # 

183 74.8 4.9 - 7.6 0.9 9.4 

162 76.0 11.7 - - 4.9 6.8 

276 28.6 19.9 - - - 16.0 

100 32.0 10.0 - 11.0 2.0 - 

Gm neg. rods inc. 

Pseudomonas (%) 

Table 1. Comparison of the ocular microbiome in different countries. 

(-) denotes not measured; (*) denotes normal subjects in studies comparing normal and dry eye subjects; 

(#) denotes consecutive and randomised “healthy” subject selection from the general population 

spp. This could be due 

to unique climatic 

and environmental 

conditions in New 

Zealand affecting the 

relationships between 

these different 

species. For example, a 

Queensland, Australia 

study showed higher 

C-NS and lower 

S. aureus counts 

than New Zealand, 

presumably due to 

the warmer and more 

humid climate 6 . 

Anaerobic P. acnes has 

previously been linked 

with blepharitis and, 

in our study, was the 

second most prevalent 

microorganism 

isolated in subjects 

For Longer Dry-Eye Relief 

Try Thera Tears 

Staphylococcus aureus is the most frequently isolated bacteria from the 

lid margins of blepharitis sufferers 

with blepharitis after C-NS. This suggests that the 

synergistic relationship between S. aureus, C-NS 

and P. acnes changes between normal and diseased 

states. We also found this was the case with CL 

wearers, and other studies have found similar results 

(7,8) 

. Again our New Zealand cohort exhibited a 

notable absence of Corynebacterium spp. 

Further work is now being undertaken by 

our group to target therapeutic treatments to 

re-regulate the ocular surface microbiome for 

the management of blepharitis, including the 

development of a novel medical Manuka honeybased 

extract acting as an antimicrobial and a mild 

anti-inflammatory agent, (see P10). 

BY GREG NEL* 

Dysfunctional tear films have always 

tormented me. The clinical signs of dry eye 

disease (DED) and patient symptoms don’t 

always seem to fit very well in my chair. Patients 

who stain with lissamine and fluorescein aren’t 

always the unhappy ones and vice versa. Even 

more curious, contact lenses-associated dry eye 

symptoms have some patients preferring to wear 

the most illogical choices of lenses on occasion. 

The worst part of everything is that, as 

optometrists, we are supposed to be the ones 

that know what is going on. I didn’t feel up to the 

job and in the mid-noughties I declared war on 

dry eye and made it a pet project. 

The 2007 DEWS report (www.tearfilm.org/ 

dewsreport/pdfs/TOS-0502-DEWS-noAds. 

pdf) helped identify a couple of key factors, 

evaporation and osmotic change in particular, 

but I needed to look at more than staining to 

evaluate what was happening on the eye. 

Critical signs included tear film meniscus 

height, meibomian function and the meibomian 

glands themselves. The lipid film thickness and 

properties are also excellent predictors and 

generally agree with the tear film surface quality 

assessment (TFSQ) module on the Medmont 

topographer. I had read papers on evaluating 

the lipid film and that interference fringes could 

be used to evaluate its thickness and character, 

but hadn’t thought of this as clinically useful 

To create your ping pong ball tearscope, cut the ball so that one 

slit allows it to sit over the diffuser lens in front of the mirror 

and another slit so that the widest beam illuminates the mirror 

(brightest light) 

References 

1. Nelson JD, Shimazaki JM, Benetez-del-Castillo JM, Craig JP, 

McCulley JP, Den S, Foulks GN. The International Workshop 

on Meibomian Gland Dysfunction: Report of the Definition 

and Classification Subcommittee. IOVS 2011; 52: 1930-37 

2. Zegans ME, Van Gelder RN. Consideratons in 

understanding the ocular surface microbiome. Am J 

Ophthalmol 2014; 158: 420-422 

3. Lee SH, Oh DH, Jung JY, Kim JC, Jeon CO. Comparative 

ocular microbial communities in humans with and 

without blepharitis. IOVS 2012; 53: 5585-93 

4. Miller D, Iovieno A. The role of microbial flora on the 

ocular surface. Curr Opin Allergy Clin Immunol 2009; 9: 

466-70 

5. Watters G, Craig JP, Swift S, Petty A, Turnbull P. 

Characterisation of the ocular surface microbiome present 

in New Zealanders with and without eyelid disease. Brit. J 

Ophthalmol (in press) 

6. Albietz JM, Lenton LM. Effect of antibacterial honey on 

the ocular flora in tear deficiency and meibomian gland 

disease. Cornea 2006; 25: 1012-19 

7. Dougherty JM, McCulley JP. Comparitive bacteriology of 

chronic blepharitis. Brit. J Ophthalmol 1984; 68: 524-28 

8. Graham JE, Moore JE, Jiru X, Moore JE, Goodall EA, Dooley 

JSG, Hayes VEA, Dartt DA, Downes CS, Moore TCB. Ocular 

pathogen or commensal: a PCR-based study of surface 

bacterial flora in normal and dry eyes. Invest.Ophthalmol. 

Vis.Sci 2007; 48: 5616-23 

* Grant Watters, MScOptom, a practicing Auckland optometrist 

and a lecturer and researcher with the University of Auckland, 

worked with Simon Swift PhD, Alex Petty BOptom, Philip 

Turnbull PhD, BOptom and Associate Professor Jennifer 

Craig PhD, MCOptom on the study. The researchers spanned 

three departments: the Department of Ophthalmology, the 

Department of Molecular Medicine and Pathology and the 

Department of Optometry and Vision Science at the University 

of Auckland, New Zealand. 

Evaluating, treating DED and ping pong balls! 

because tearscopes weren’t common outside the 

research arena until a mis-focussed image of the 

corneal endothelium yielded a spectacular image 

of the tear film lipid layer. Experimentation and 

improved cellphone cameras make this simple 

to record on a regular basis. You get a great view 

of the tear lipids by also using a ping-pong ball! 

Incidentally, the modern ping pong ball is larger 

than it used to be in an attempt to slow the game 

down – even better for us! So, for just 75 cents at 

your local sports shop (or mine anyway), you can 

make your own tearscope. Just mount your ping 

pong ball on your slit lamp’s diffuser after cutting 

a couple of perpendicular slots in it with a Dremel 

Tool or hacksaw blade – one to fit the diffuser and 

one to get the slit beam to the diffuser. 

Retroilluminating the lid with a transilluminator 

and playing with the colour sliders in the slit lamp 

camera software also gives great views of the 

meibomian glands, superior to some of the infrared 

systems I’ve tried. Encysted glands and gland 

dropout and atrophy are far more common than I 

had presumed. Imaging this is an excellent way of 

convincing people of the need to actively manage 

their lids on a day-to-day basis! 

Another useful assessment is the use of 

questionnaires; they are more sensitive as regards 

symptoms in my opinion – we use the SPEED 

(Standardised Patient Evaluation of Eye Dryness) 

questionnaire, especially as your slit lamp diagnosis 

is very situational, an “at-the-moment” snapshot. 

IPL treatment has been a game changer for 

many patients, both for dry eye symptoms and 

contact lens intolerance. My criticism of this 

quite futuristic intervention, however, is twofold. 

Firstly, we still have to try it and see. As a 

single intervention its success rate is impressive 

and doesn’t hinge on patient diligence, but 

exactly who benefits most remains as fractal as 

dry eye disease itself. Patients with neuropathic 

dry eye (mostly post-LASIK) and significant 

meibomian gland dropout seem to have the 

CONTINUED ON P15 

a 

b 

Transilluminator meiboscopy 

For further information call 0800 954 536 or email whitney@corneal-lens.co.nz 

c 

Examples of interference fringes: (a) thick, (b) disorganised and 

unstable, (c) not too bad – some debris, (d) thin – notice vertical bands 

d 

Pre and post-IPL TFSQ over a MyDay contact lens in a symptomatic 

patient, with improvement shown by the shallower gradient 

indicating less rapid destabilisation 


To IPL or not? 

BY ALLY XUE* 

The current mainstay therapies for 

meibomian gland dysfunction (MGD) are 

either palliative, providing only transient 

relief from dry eye symptoms, or they are 

unsuitable for long-term use in chronic cases. 

One novel treatment to emerge in recent years, 

however, is intense pulsed light (IPL), which was 

discovered, serendipitously, to provide relief 

from symptomatic MGD, around a decade ago. 

Despite the dearth of scientific evidence 

supporting its anecdotal positive ocular effects, 

IPL therapy is now being offered in more than 

100 practices across Australasia. The rising 

popularity of IPL as a treatment for evaporative 

dry eye prompted the Ocular Surface Laboratory 

(OSL) at The University of Auckland to conduct 

the first randomised, double-masked, placebocontrolled 

pilot study (published in IOVS last 

year). The research team, led by Associate 

Professor Jennifer Craig, demonstrated 

significant and cumulative improvements 

to the lipid quality and stability of the tear 

film, as well as reduced symptoms following 

IPL application. However, it was deemed that 

further study was necessary to establish the 

underlying mechanism(s) and determine 

applicability in different patient sub-groups to 

improve prognostic value and enable further 

therapeutic refinements. 

CONTINUED FROM P14 

poorest prospects in my opinion. My other 

criticism is that it is actually expensive for 

patients in an unsubsidised environment. I 

had visions of using it more often, and I find it 

frustrating that I don’t use it more frequently. 

I probably need sales training! 

References 

Differentiation of Lipid Tear Deficiency Dry Eye by 

Kinetic Analysis of Tear Interference Images; Eiki Goto, 

MD; Scheffer C. G. Tseng, MD, PhD; Arch Ophthalmol. 

2003;121:173-180 

Assessment of the Tear Film; Jane Veys MSc MCOptom 

FBCLA FAAO, Education Director, Vision Care Institute 

Classic meibomian gland dysfunction 

In a few weeks’ time, under the supervision of 

A/Prof Craig, I will begin conducting a second 

IPL study to validate the promising results 

demonstrated by the prospective pilot trial. 

The aim is to refine and expand upon the pilot 

research methodology by tracking its efficacy 

over a longer time period and collect data 

to help investigate the potential underlying 

mechanisms. Specifically, myself and the other 

researchers will be evaluating the effects of IPL 

therapy on neurobiological and inflammatory 

pathways, eyelid microflora and the tear film 

lipidome. The OSL is currently recruiting eligible 

dry eye patients with symptomatic MGD 

from Auckland optometric clinics, and it is 

expected that recruitment will be ongoing until 

December 2016. In exchange for a few hours 

of their time, participants are offered free IPL 

treatments and a contribution towards travel 

costs. Therefore, if you believe your patient may 

be a suitable candidate for this study, please 

send referrals to me at a.xue@auckland.ac.nz 

or email me for further information. 

*Ally Xue is a PhD student with OSL. 

Johnson & Johnson Vision Care: www.jnjvisioncare. 

co.uk/sites/default/files/public/uk/tvci/eclp_ 

chapter_4.pdf 

Computer-Synthesis of an Interference Color Chart of 

Human Tear Lipid Layer, by a Colorimetric Approach; 

Eiki Goto, Murat Dogru, Takashi Kojima and Kazuo 

Tsubota; IVOS. Nov 2003: 44:11 

Tear film dynamics and lipid layer characteristics— 

Effect of age and gender; Cécile Maïssa, Michel 

Guillon, Contact Lens and Anterior Eye; August 2010, 

Volume 33, Issue 4, Pages 176–182. 

* Greg Nel has practiced optometry in both South Africa 

and New Zealand and is a partner with Total Eyecare. 

He is passionate about specialised contact lens fitting, 

corneal refractive therapy (CRT) and paediatric/ 

development optometry, plus he’s a keen photographer, 

surfer and home-brewer. 

Dry eye in NZ 

With our aging population, the 

current state of dry eye disease 

(DED) diagnosis and management in New 

Zealand needs to be examined. Recently, 

an anonymous, web-based questionnaire 

was distributed to New Zealand eye 

care clinicians (optometrists n=614, 

ophthalmologists n=113). The questionnaire 

sought information about practitioners’ 

interest in DED, their practice experience, 

practice modality, preferred diagnostic and 

management strategies and the evidencebase 

they use to guide patient care. 

The survey revealed both professions 

(optometrist response rates: 26%, 

and ophthalmologist: 26%) possess 

similarly strong knowledge of tear film 

assessment. Consistent with evidencebased 

guidelines, New Zealand eye care 

professionals use subjective and objective 

techniques to diagnose DED. Almost all 

respondents considered patient symptoms 

and meibomian gland evaluation as the 

most valuable and commonly performed 

diagnostic techniques. However, 

standardised grading scales and validated 

dry eye questionnaires were infrequently 

adopted. 

Most respondents indicated eyelid 

hygiene and non-preserved lubricants 

as the mainstay therapies, nevertheless 

DED management was tailored to disease 

severity. There’s increased recommendation 

for omega-3 fatty acids intake (see p18), 

topical corticosteroids and systemic 

tetracyclines in moderate to severe DED 

relative to mild disease, highlighting 

recognition of inflammation as a feature 

associated with dry eye, particularly in more 

advanced cases. 

Lastly, it was concluded that dissemination 

of research evidence relating to clinical bestpractice 

for DED could be further improved, 

potentially through mechanisms focussed 

upon continuing education conferences, as 

this was the preferred method to inform their 

management approach, clinicians report. 

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15


Contact lenses and dry eye 

Dry eye is one of the most common 

conditions seen by eye care practitioners 

around the world. It is estimated that 

25% of patients will report symptoms of dry 

eye¹. For our contact lens (CL) patients this 

frequency is likely higher due to the effects that 

an in situ contact lens can have on the tear film 

and ocular tissue. Reported rates of contact lens 

discontinuation internationally vary from 15% 

to 31%². Consistently, discomfort and dryness 

are rated as the top reasons for this dropout 3 4 5,6 . 

However, certain types of contact lenses can also 

be an important management option for patients 

with mild to severe dry eye. This article will briefly 

explore why contact lenses cause dry eye, explain 

what can be done to reduce the incidence of dry 

eye symptoms in contact lens wearers and describe 

some of the contact lens options available to 

patients with existing dry eye disease. 

Why do CLs cause dryness? 

In 2013 the Tear Film and Ocular Surface Society 

(TFOS) international workshop on contact lens 

discomfort carried out a robust investigation into 

this question. Helmed by our very own Associate 

Professor Jennifer Craig, the TFOS report on tear 

film stability in contact lens wearers suggested 

that contact lens induced dryness stems from the 

alteration of the tear film into pre- and post-lens 

layers (Fig 1.) 7 . The resulting pre-lens tear film has 

reduced lipid layer thickness, reduced tear volume 

and an increased evaporation rate compared 

to the normal tear film 8 . As a result of this 

compromised tear film, previously asymptomatic 

patients may begin to experience discomfort and 

dry eye symptoms 9 . Another school of thought 

suggests decreased corneal sensation from contact 

lens wear leads to a ‘neurotrophic state’, which 

promotes inflammation and compromises the 

signal for tear production 10 . 

Lid wiper epitheliopathy (LWE) is a clinical sign that 

is gaining in popularity amongst practitioners when 

describing dry eye. LWE refers to disruption of the lid 

margin that ‘wipes’ across the anterior eye surface or 

contact lens during blinking (Fig 2.). Studies suggest 

BY ALEX PETTY* 

Get to the main 

cause of dry, 

irritated eyes* 

that the presence of LWE is highly associated with 

discomfort in contact lens wearers, occurring in 

80% of symptomatic contact lens patients versus 

13% for asymptomatic wearers 11 . LWE is a sign of 

increased friction with each blink; expected in a 

dry eye or with the use of a poorly wetting contact 

lens. Efron et al.’s recent comprehensive review 

of LWE states there is consistent evidence of a 

relation between contact lens surface friction and 

wearing comfort 12 . 

Improving dry eye symptoms in CL 

patients? 

The presence of LWE in CL patients has 

highlighted the importance of having a slippery 

lens surface to decrease friction and discomfort. 

Coles and Brenan showed that contact lenses 

with a higher lubricity tend to be more 

comfortable 13 . CL companies have been quick to 

release a number of excellent products that serve 

to increase the lubricity of patient’s lenses. These 

include Alcon’s Dailies Total1 water gradient 

lens and Bausch and Lomb’s “MoistureSeal” 

technology, incorporated in their Ultra range 

of lenses. We should not forget, however, that 

silicone hydrogels are naturally more hydrophobic 

than hydrogels due to their siloxane components, 

and may lead to decreased wettability, and 

therefore lubricity in certain wearers 14 . In 

these instances, hydrogel materials such as 

B+L’s Biotrue ONEday daily and Coopervision’s 

Proclear family (incorporating zwitterionic PC 

technology; still the only FDA material approved 

for patients that experience dryness with contact 

lens wear) may be useful. Alcon have also recently 

incorporated ‘Hydraglyde moisture matrix’, 

a hydrophilic compound that embeds onto a 

lens and decreases friction, into their hydrogen 

peroxide cleaning solution, AOSept, as well as their 

PureMoist multi-purpose disinfecting solution. 

Rigid lenses too can benefit from technologies 

to improve wettability. This includes the use of 

materials such as Optimum Extra with its very 

low wetting angles, and plasma-treatment of 

rigid lenses to decrease the hydrophobicity of 

4UP TO 

HOURS 

RELIEF 2 

CLINICALLY PROVEN 

the surface 15 . We should 

not forget to encourage all 

CL patients to use artificial 

tear drops as needed for an 

immediate improvement 

in lens lubricity, especially 

after longer-wear time. 

To avoid exacerbating any 

inflammatory aspects of 

dry eye, non-preserved 

formulations should be 

recommended. 

Options if the patient 

still cannot wear CLs 

comfortably? 

Despite advances in 

technology some patients, 

especially as they age and 

their tear volume naturally 

decreases, will continue 

to experience discomfort 

with soft contact lens wear. 

In this case sometimes no 

lens is better than any lens. 

Orthokeratology can be an 

excellent modality for patients 

who experience regular 

contact lens discomfort 

but otherwise only show 

mild signs of dry eye. One 

study showed that patients 

refitted from SiHy lenses 

into orthokeratology wear 

had a statistically significant 

increase in goblet cell density 

and improvement in dry eye 

symptoms after one month 16 . 

Anecdotally I have looked after 

a number of very satisfied 

orthokeratology patients that 

were previously unhappy with 

their SCL comfort. 

Scleral CLs 

A report on dry eye and 

contact lenses would not be 

complete without discussing 

scleral contact lenses. Sclerals 

are mainly reserved for 

patients with severe dry eye, 

such as Sjogren’s syndrome 

and graft-vs-host disease 

(GvHD), that do not find 

relief with other treatments. 

They are effective as the lens 

shields the eye and allows 

the post-lens fluid reservoir 

to bathe the compromised 

ocular surface during wear. Scleral lenses, 

including the PROSE lens (Prosthetic Replacement 

of the Ocular Surface Ecosystem; an impressive 

sounding scleral lens treatment that really just 

refers to onsite custom fitting at the B+L contact 

lens laboratory), have been shown to improve the 

visual function in patients with ocular surface 

disease over a five-year period 17 . 

A colleague of mine from the States, Dr 

Nate Schramm, a scleral lens expert from Fort 

Lauderdale, shared this relevant case with me 

recently: a 21-year-old man presented to his 

practice with severe dry eye symptoms. He has 

psoriasis and low testosterone and due to his 

programming occupation spent 75% of his day in 

front of a computer screen. He had been treated 

with meibomian gland probing and punctal 

cautery three months before and given a course 

of topical cyclosporin, however his symptoms did 

not improve. Examination showed instantaneous 

tear breakup, stagnant meibomian glands and 

Fig 1. Tear film structure with a soft contact lens 

Fig 2. Moderate lid-wiper epitheliopathy present on an everted upper lid margin, stained with 

lissamine green. Courtesy of OSL 

Fig 3. Central corneal OCT scan of the scleral lens fit for the dry eye patient case described 

Another SCL patient of mine with punctate epitheliopathy due to mild dry eye. I refitted her into 

hyperopic orthokeratology lenses and after a month her epitheliopathy had resolved and daytime 

comfort was much improved. Note the lack of corneal staining 

scattered corneal epitheliopathy. MGD treatments 

were initiated, including Lipiflow, and a scleral lens 

was fitted in conjunction with autologous-serum 

drops in the lens bowl during insertion (Fig 3). 

Despite initial difficulties with handling, this 

patient noticed immediate improvement in 

comfort when wearing his sclerals. After a year’s 

treatment the patient commented the only 

treatment that decidedly helped his dry eye were 

his scleral lenses. 

In summary, technologies for managing dry 

eye are improving each year, with contact lens 

advancements helping our patients achieve 

freedom from spectacle wear in an increasingly 

comfortable and safe manner. It should not be 

forgotten that certain contact lens modalities 

provide important dry eye therapies and should be 

considered in recalcitrant cases. 

CONTINUED ON P17 

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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: 

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 

FDA and Oculeve 

Allergan has filed a de novo application with the US Food and Drug Administration (FDA) for its 

Oculeve Intranasal Tear Neurostimulator Device. The de novo classification process is a rapid 

regulatory pathway for novel, low- to-moderate-risk medical devices that are deemed to be 

first-of-a-kind. 

The neurostimulator was acquired by Allergan last year, when it bought Oculeve for US$125 

million cash. Allergan has openly stated that dry eye is a priority area. “The Oculeve Intranasal Tear 

Neurostimulator is an exciting potential option for patients suffering from dry eye disease, and we 

are pleased to have filed the de novo application with FDA that will allow patients to gain access to 

this novel medical device,” said David Nicholson, Allergon’s chief R&D officer in a statement. 

The device is a non-invasive nasal neurostimulation that stimulates tear production. An element 

is inserted into the mucous membrane of the nasal cavity and another under the skin below the 

eyebrow, allowing the patient to manually adjust the rate of tear delivery using a wireless controller. 

Just prior to filing the application, Allergan announced two pivotal trials (one of which involved the 

University of Auckland’s OSL team) of the neurostimulator each met their effectiveness endpoints. 


CONTINUED FROM P16 

References 

1. O’Brien, P, and Louis, C. “Dry eye: diagnosis and current 

treatment strateg ies.” C urrent allergy and asthma 

reports 4.4 (2004):314319. 

2. “New Data on Contact Lens Dropouts: An International 

Perspective.” Rumpakis, J. 2016. < https://www. 

reviewofoptometry.com/article/newdataoncontactlensdrop 

outsaninternationalperspective 

3. Research in dry eye: report of the Research Subcommittee 

of the International Dry Eye WorkShop (2007). Ocul Surf. 

2007Apr;5(2):17993. 

4. Pritchard N, Fonn D, Brazeau D. Discontinuation of 

contact lens wear: a survey. Int Contact Lens Clin. 1999 

Nov;26(6):15762. 

5. Weed K, Fonn D, Potvin R. Discontinuation of contact lens 

wear. Optom Vis Sci. 1993;70(12, suppl.):140. 

6. Richdale K, Sinnott LT, Skadahl E, Nichols JJ. Frequency of 

and factors associated with contact lens dissatisfaction 

and discontinuation. Cornea. 2007;26(2):16874. 

7. Craig, JP et al. “The TFOS International Workshop on 

Contact Lens Discomfort: Report of the Contact Lens 

Interactions With the Tear Film Subcommittee Report on 

Interactions With Tear Film.” Investigative ophthalmology 

& visual science 54.11 (2013): TFOS123TFOS156. 

8. Nichols, JJ et al. “The TFOS International Workshop on 

Contact Lens Discomfort: Executive SummaryExecutive 

Summary.” Investigative ophthalmology & visual science 

54.11 (2013): TFOS7TFOS13. 

9. Nichols, JJ, and Sinnott, L. “Tear film, contact lens, and 

patient related factors associated with contact lens– 

related dry eye.”Investigative ophthalmology & visual 

science 47.4 (2006): 13191328. 

10. Cox, S and Nichols J. Contact Lens Dry Eye: Neurotrophic 

Disease or MGD? Contact Lens Spectrum, Volume: 31 , 

Issue: July 2016, page(s): 3235 

11. Korb, D.R., Greiner, J.V., Herman, J.P., Hebert, E., 

Finnemore, V.M., Exford, J.M., Glonek, T., Olson, M.C., 2002. 

Lidwiper epitheliopathy and dryeye symptoms in contact 

lens wearers. CLAO J. 28, 211216. 

12. Efron N , Brennan NA , Morgan PB , Wilson T Lid wiper 

epitheliopathy. Prog Retin Eye Res. 2016 Jul;53:14074. 

doi:10.1016/j.preteyeres.2016.04.004. Epub 2016 Apr 14. 

13. Coles, C.M.L., Brennan, N.A., 2012. Coefficient of friction 

and soft contact lens comfort. Optom. Vis. Sci. 88. 

Eabstract 125603. 

14. Jones, L. Editorial: Hydrogel contact lens materials: Dead 

and buried or about to rise again? Contact Lens Update. 

October 7 2013. http://www.contactlensupdate.com/ 

15. http://www.gpli.info/labconsultantmaterialstreatments/ 

16. Carracedo, Gonzalo et al. Effect of overnight 

orthokeratology on conjunctival goblet cells. Contact Lens 

and Anterior Eye,Volume 39 , Issue 4 , 266 269 

17. Agranat JS, Kitos NR, Jacobs DS. “Prosthetic replacement 

of the ocular surface ecosystem: impact at 5 years.” Br J 

Ophthalmol 2016; 100 :11711175 

*Alex Petty is a New Zealand optometrist based in Tauranga with 

a particular interest and knowledge in speciality contact lenses, 

ortho-k and myopia control. 

Dry eyes and allergy: a common association? 

BY DR ADAM WATSON* 

Dry eye and allergy problems are usually 

considered as separate entities and, if 

there is consideration given to both, it 

is usually in terms of differential diagnosis: “is 

this a dry eye or an allergy problem causing the 

patient’s symptoms?” 

But the two may co-exist and there may be a 

causative relationship between the two in many 

cases. 

Dry eye problems are common, affecting up to 

15% of people over 50 with a greater proportion 

of women affected. Ocular surface allergy is 

also common with around 20% of people having 

some degree of seasonal or perennial allergic 

conjunctivitis. When both are present, a tailored 

management strategy that takes both into 

account is desirable. 

Symptom overlap 

The symptoms of dry eye include burning, 

stinging, tired eyes and grittiness sensation. 

Vision may be variably affected by ocular surface 

disturbance and poor tear film quality. Allergy also 

frequently causes burning, stinging and irritated 

sensations, while vision may be variably affected 

by mucus production and tear film abnormalities. 

A cardinal symptom of allergy, however, is 

itching of the eyes due to histamine release 

– itching is very suggestive of an allergic 

component to the ocular surface disease. 

Dry eye and allergy association – evidence 

Inflammation has been recognised as a key 

component of dry eye disease. More than likely 

this has multifactorial causation including 

tear film instability, hyperosmolarity of the 

tear film and meibomian gland related factors. 

Inflammation is also the underlying cause of 

ocular surface allergy symptoms and signs – 

type I hypersensitivity, in the case of seasonal or 

perennial allergic conjunctivitis; type IV cellmediated 

response in vernal and atopic disease. 

Studies in children with both type I and 

type IV (vernal) allergic disease have shown a 

significantly decreased tear breakup time leading 

to variable dry eye symptoms. 

In atopic keratoconjunctivitis, the earlier age 

of onset is associated with poorer Schirmer and 

Rose Bengal scores, presumably as a result of the 

more prolonged inflammation worsening ocular 

surface damage and inducing dryness. 

Among other risk factors including age, 

rheumatoid arthritis and depression, the 

presence of any allergy, asthma and eczema 

(atopy) were significantly associated with dry eye 

disease in a large study of female twins in the 

UK. Additionally, in a study of 689 adults using 

a validated questionnaire, most patients with 

symptoms consistent with allergic conjunctivitis 

(57%) also had dry eyes. 

Management suggestions 

When combined allergy and dry eye disease is 

suspected, treatment should ideally address 

both conditions. However, there is probably 

room to rationalise the approach to simplify 

what otherwise can be a veritable onslaught of 

intervention. 

Since both conditions involve inflammation 

of the ocular surface, rational therapy includes 

treatment or prevention of inflammation as 

part of the approach. This may be helpful in 

stabilising the tear film, thereby assisting in the 

management of dry eye. Therefore, an initial 

strategy may be the use of olopatadine (Patanol) 

eye drops twice daily for their mast cell stabilising 

and anti-histamine effect; and the addition 

of a (preservative-free) lubricant drop to help 

augment the tear film and to flush away ocular 

surface allergens 

Reviewing this after a couple of weeks will tell 

you whether you’re on the right track. If the itching 

and inflammation have improved, but dry eye 

symptoms are still a feature, incorporating more 

frequent preservative-free lubrication, eyelid 

therapy including heat treatment, doxycycline 

or azithromycin, and possibly punctal plug 

placement may be appropriate. 

If inflammation is a more prominent feature, 

then a tapering course of a topical steroid 

(fluorometholone or non-preserved prednisolone 

or methylprednisolone) while continuing 

olopatadine may be a useful strategy to optimise 

the ocular surface. Again, attention to meibomian 

gland dysfunction (MGD) may be an important 

component of treatment. 

Other modalities such as intense pulsed 

light (IPL) therapy may play a part. More 

severe allergic inflammation (vernal or atopic 

keratoconjunctivitis) can be effectively treated 

with topical cyclosporine or tacrolimus that often 

help the dry eye problems as well. 

In summary, dry eye and allergic eye conditions 

are likely often present in combination, with 

the link between them being ocular surface 

inflammation. Control of the inflammation is an 

important first step in managing both. 

References: 

DEWS Report. Ocular Surface. 2007;5:65-204 

Chen et al. High incidence of dry eye…Acta 

Ophthalmologica. May 2016 (epub) 

Villani et al. Dry eye in vernal keratoconjunctivitis. 

Medicine(Baltimore). 2015;94:e1648 

Hon et al. Allergic conjunctivitis and dry eye syndrome. Ann 

Allergy Asthma Immunol. 2012;108:163-6 

Vehof et al. Prevalence and risk factors of dry eye disease… 

Br J Ophthalmol. 2014;98:1712-7 

Onguchi et al. The impact of the onset time of AKC on the 

tear function… Am J Ophthalmol. 2006;141:569-71 

* Dr Adam Watson works at Eye Institute in Auckland. He has 

subspecialist interests in ocular surface disease, cataract, 

corneal and refractive surgery and oculoplastic surgery. 

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17


New dry eye drug 

launched 

Shire’s dry eye drug Xiidra (lifitegrast ophthalmic solution) went 

on sale in the US market at the end of August, just weeks after 

its approval by the US Food and Drug Administration (FDA) 

for the treatment of signs and symptoms of dry eye disease. Xiidra 

is the first medication in a new class of drugs, called lymphocyte 

function-associated antigen 1 (LFA-1) antagonist approved by the 

FDA for dry eye disease. 

“Normal tear production is needed for clear vision and eye health. 

This approval will provide a new treatment option for patients 

with dry eye disease,” said Dr Edward Cox, director of the Office of 

Antimicrobial Products at the FDA’s Centre for Drug Evaluation and 

Research, in a statement. 

The safety and efficacy of Xiidra was assessed in more than a 

thousand patients, aged 19 to 97, with 76% being women, in four 

separate, randomised, controlled studies. Patients were randomised 

equally to receive either Xiidra eyedrops or placebo eyedrops, which 

were used twice a day for twelve weeks. The studies found groups 

treated with Xiidra demonstrated more improvement in both the 

signs and the symptoms of eye dryness than the groups treated 

with placebo. The most common side effects of Xiidra include 

eye irritation, discomfort or blurred vision and an unusual taste 

sensation (dysgeusia). 

Xiidra is Shire’s first FDA-approved medicine in ophthalmics and 

the first significant new drug to enter the dry eye market in more 

than a decade. It is expected to severely effect sales of Allergan’s 

Restasis (cyclosporine ophthalmic emulsion 0.05%), which was 

approved in 2003. 

Omega-3 for 

treating DED 

BY DR LAURA DOWNIE* 

Dry eye disease (DED) is a highly 

prevalent condition that has a 

significant, negative impact upon 

quality of life. Although the pathogenesis 

of DED is not fully understood, the 

condition involves an immune-based 

inflammation of the anterior eye 1 . DED is 

characterised by an abnormal elevation of 

tear film tonicity, known as a state of tear 

hyperosmolarity 2 , which promotes ocular 

surface inflammation 3 . Tear hyperosmolarity 

leads to corneal and conjunctival epithelial 

cell apoptosis and inflammatory events that 

culminate in the loss of mucin-secreting 

goblet cells 4 . Together, these changes are 

recognised to promote tear film instability 

and perpetuate a chronic, pro-inflammatory 

cycle. 

Given the prominent role of inflammation 

in the pathogenesis of DED, antiinflammatory 

agents are often prescribed 

to reduce the signs and symptoms of the 

condition. As an alternative to traditional 

anti-inflammatory therapeutics, such as 

corticosteroids, oral omega-3 (Ω-3) essential 

fatty acid (EFA) supplements can be used 

to modulate ocular inflammation. EFAs are 

termed ‘essential’ as they are required for 

optimal general health 5 . As EFAs are unable 

to be synthesised directly within the body, 

they must be derived from dietary sources. 

The two main types of EFAs are the omega-3 

(Ω-3) and omega-6 (Ω-6) fatty acids, which 

are found in different food sources. Omega-3 

EFAs occur in relatively high concentrations 

in oily fish (eg. tuna, salmon, sardines) and 

some plant-based foods (eg. chia seeds, 

walnuts). Foods rich in Ω-6 EFAs include 

meat, poultry and eggs. 

The ratio of consumed Ω-3 to Ω-6 EFAs 

has a direct effect on the inflammatory 

status of the body 6 . In contemporary 

Western diets, 

the ratio of 

Ω-6:Ω-3 intake 

is often as high 

as 15:1, whereas 

an ideal ratio is 

considered 4:1 or 

less 7 . Omega-3 

EFAs bias systemic Dr Laura Downie 

prostaglandin 

metabolism towards the production of 

anti-inflammatory eicosanoids, which limit 

and resolve inflammation 7 . In contrast, 

the Ω-6 fatty acid metabolic pathway 

primarily promotes the production of proinflammatory 

mediators. 

As summarised in a recent systematic 

review and meta-analysis 8 , several small 

clinical trials have investigated the use 

of oral Ω-3 EFA supplements for treating 

DED. Together, these investigations report 

promising findings in terms of reducing dry 

eye symptoms and improving tear stability, 

however the mechanism(s) underlying 

the potential clinical benefits are not well 

understood. Furthermore, there is a need 

for improved scientific understanding into 

the optimal dosage, duration of treatment 

and form of Ω-3 EFA supplements for 

treating DED. 

The Downie ‘Anterior Eye, Clinical Trials 

and Research Translation Unit’, based in 

the Department of Optometry and Vision 

Sciences at the University of Melbourne, 

has recently completed a double-masked, 

randomised, placebo-controlled clinical trial 

investigating the safety and efficacy of two 

different forms of Ω-3 EFA supplements 

for treating mild-to-moderate DED. 

Findings from this study will be available 

over the coming months and will provide 

novel clinical insights into how Ω-3 EFA 

supplementation modulates the clinical 

expression of DED. 

References 

1. Calonge M, Enrique-de-Salamanca A, Diebold 

Y, et al. Dry Eye Disease as an Inflammatory 

Disorder. Ocul Immunol Inflamm. 2010;18:244- 

253. 

2. The definition and classification of dry 

eye disease: report of the Definition 

and Classification Subcommittee of the 

International Dry Eye WorkShop (2007). Ocul 

Surf. 2007;5(2):75-92. 

3. Jackson D, Zeng W, Wong C et al, Downie 

LE. Tear interferon-gamma as a biomarker 

for evaporative dry eye disease. Invest 

Ophthalmol Vis Sci. 2016; In press, July 2016. 

4. Baudouin C, Aragona P, Messmer EM, et al. 

Role of hyperosmolarity in the pathogenesis 

and management of dry eye disease: 

proceedings of the OCEAN group meeting. 

Ocul Surf. 2013;11(4):246-258. 

5. Simopoulos AP. Omega-6/omega-3 essential 

fatty acids: biological effects. World Rev Nutr 

Diet. 2009;99:1-16. 

6. Calder PC. N-3 polyunsaturated fatty acids 

and inflammation: from molecular biology to 

the clinic. Lipids. Apr 2003;38(4):343-352. 

7. Simopoulos AP. The importance of the ratio of 

omega-6/omega-3 essential fatty acids. Biomed 

and Pharmacother. 2002;56(8):365-379. 

8. Zhu W, Wu Y, Li G, Wang J, Li X. Efficacy 

of polyunsaturated fatty acids for 

dry eye syndrome: a meta-analysis of 

randomized controlled trials. Nutrition Rev. 

2014;72(10):662-671. 

* Dr Laura Downie is a senior lecturer and 

National Health and Medical Research Council 

Translating Research Into Practice (TRIP) fellow 

at the Department of Optometry and Vision 

Sciences at the University of Melbourne. She leads 

the specialty Cornea Clinic and heads her own 

research laboratory, the ‘Downie Anterior Eye, 

Clinical Trials and Research Translation Unit’. 


Dry Eyes and Diabetes 

Diabetes is one of the most common systemic 

diseases in the world. According to the Ministry of 

Health, this affects 257,776 people in New Zealand. 

Worldwide, 415 million people are affected and, by the 

year 2040, it is expected that 642 million people will be 

affected 1 . This metabolic disorder is associated with both 

microvascular (nephropathy, neuropathy, and retinopathy) 

and macrovascular (ischaemic heart disease, peripheral 

vascular disease, and cerebrovascular disease) complications. 

In the eye, the most well-known complication is diabetic 

retinopathy which, if left untreated, may lead to loss of vision. 

A less well-recognised complication of diabetes is dry eye 

disease (DED), despite the reported prevalence of 54.3% in 

patients with the disease 2 . Characteristic of DED is a decline 

in tear film function, as indicated by a reduced tear film 

break-up time, and ocular surface damage, as indicated by 

corneal staining and inflammation 3 . In diabetes, the ocular 

surface is already prone to recurrent corneal erosions and 

delayed epithelial wound healing 4,5 . The combination of 

both DED and diabetes can place patients at significant risk 

of discomfort and debilitating neurotrophic keratopathy. 

Identifying DED may therefore help these patients control the 

impact of their disease on the ocular surface. 

Why are people with diabetes prone to DED? 

• Corneal nerve density reduces in diabetes, affecting tear 

secretion 

Approximately 60%-70% of patients with diabetes will 

eventually develop peripheral neuropathy 6,7 . The ocular surface 

provides the only source of nerves that can be imaged in 

vivo and non-invasively. Studies of corneal nerves in diabetes 

reveal a loss of corneal innervation as indicated by decreased 

corneal nerve density and corneal sensitivity relative to healthy 

non-diabetic participants 8 . Interestingly, this reduction in 

corneal nerve density is associated with diabetic peripheral 

neuropathy, with suggestions being that observations of 

corneal nerves may be a surrogate measure of peripheral nerve 

changes 9,10 . Corneal nerves not only provide sensation but 

also provide trophic support in maintaining the structure and 

function of the cornea to regulate epithelial integrity, growth, 

proliferation and wound healing. Any impairment of corneal 

innervation can therefore disrupt epithelial integrity, leading 

to development of recurrent epithelial erosions. Significantly, 

this reduction in corneal nerve density disrupts the feedback 

mechanism that controls tear secretion 4,11 . 

References 

1. ID F. IDF Diabetes Atlas. 2015;7th Edition:http:// 

www.diabetesatlas.org/. 

2. Manaviat MR, Rashidi M, Afkhami-Ardekani M, 

Shoja MR. Prevalence of dry eye syndrome and 

diabetic retinopathy in type 2 diabetic patients. 

BMC Ophthalmology 2008; 8: 10. 

3. The definition and classification of dry 

eye disease: report of the Definition 

and Classification Subcommittee of the 

International Dry Eye WorkShop (2007). Ocul 

Surf 2007; 5(2): 75-92. 

4. Dogru M, Katakami C, Inoue M. Tear function 

and ocular surface changes in noninsulindependent 

diabetes mellitus. Ophthalmology 

2001; 108(3): 586-92. 

5. Sanchez-Thorin JC. The cornea in diabetes 

mellitus. International ophthalmology clinics 

1998; 38(2): 19-36. 

6. Said G. Diabetic neuropathy--a review. Nature 

clinical practice Neurology 2007; 3(6): 331-40. 

7. Charnogursky G, Lee H, Lopez N. Diabetic 

neuropathy. Handb Clin Neurol 2014; 120: 

773-85. 

8. Misra SL, Craig JP, Patel DV, et al. In Vivo 

Confocal Microscopy of Corneal Nerves: An 

Ocular Biomarker for Peripheral and Cardiac 

Autonomic Neuropathy in Type 1 Diabetes 

Mellitus. Invest Ophthalmol Vis Sci 2015; 56(9): 

5060-5. 

9. Ahmed A, Bril V, Orszag A, et al. Detection 

of diabetic sensorimotor polyneuropathy by 

BY SHYAM SUNDER TUMMANAPALLI AND DR MARIA MARKOULLI* 

corneal confocal microscopy in type 1 diabetes: 

a concurrent validity study. Diabetes care 2012; 

35(4): 821-8. 

10. Pritchard N, Edwards K, Dehghani C, et al. 

Longitudinal assessment of neuropathy in type 

1 diabetes using novel ophthalmic markers 

(LANDMark): study design and baseline 

characteristics. Diabetes research and clinical 

practice 2014; 104(2): 248-56. 

11. Ishida N, Rao GN, del Cerro M, Aquavella JV. 

Corneal nerve alterations in diabetes mellitus. 

Archives of ophthalmology (Chicago, Ill : 1960) 

1984; 102(9): 1380-4. 

12. Najafi L, Malek M, Valojerdi AE, et al. Dry eye 

and its correlation to diabetes microvascular 

complications in people with type 2 

diabetes mellitus. Journal of diabetes and its 

complications 2013; 27(5): 459-62. 

13. Goebbels M. Tear secretion and tear film 

function in insulin dependent diabetics. Br J 

Ophthalmol 2000; 84(1): 19-21. 

14. Ding J, Liu Y, Sullivan DA. Effects of Insulin and 

High Glucose on Human Meibomian Gland 

Epithelial Cells. Investigative Ophthalmology & 

Visual Science 2015; 56(13): 7814-20. 

15. Yeh S, Song XJ, Farley W, Li DQ, Stern ME, 

Pflugfelder SC. Apoptosis of ocular surface 

cells in experimentally induced dry eye. Invest 

Ophthalmol Vis Sci 2003; 44(1): 124-9. 

16. Cai D, Zhu M, Petroll WM, Koppaka V, 

Robertson DM. The Impact of Type 1 

Diabetes Mellitus on Corneal Epithelial Nerve 

• Damage to the microvasculature of the lacrimal gland may 

reduce tear secretion 

Another potential avenue for the reduction in tear production 

in diabetes is damage to microvasculature feeding the 

lacrimal gland or reduced lacrimal innervation from 

autonomic neuropathy, a mechanism supported by the 

observation of reduced Schirmer scores in diabetes 12 . 

• Damage to the trigeminal nerve and the direct effects of 

hyperglycaemia 

Patients with diabetes have also been shown to have reduced 

conjunctival goblet cell counts, resulting in a reduction in tear 

film stability and tear break-up time 13 . This reduction in goblet 

cell count may be due to the decrease in the trophic effects of 

trigeminal sensory nerves on the conjunctiva and cornea 4 . 

The hyperglycaemia that results from diabetes may also 

have a direct effect on the meibomian glands. One study has 

shown that insulin, the factor that controls glycaemic levels 

in the blood, is able to stimulate meibomian gland cells, 

resulting in cell proliferation and the accumulation of lipids 14 . 

A deficiency in insulin will therefore reduce the production 

of lipids, affecting the quality of the tear film. Conversely, the 

same study found that elevated glucose causes progressive 

cell loss and alterations to meibomian gland cell morphology, 

hence being toxic for the meibomian gland epithelial cells 

and placing individuals with diabetes at risk of meibomian 

gland dysfunction, the leading cause of dry eye disease 14 . 

Managing diabetes-related DED 

Given that dry eye disease in general predisposes the ocular 

surface to corneal staining 15 , the co-existence of diabetes 

and DED places individuals at increased risk of ocular 

surface damage 16 . The combination of poor corneal wound 

healing 17,18 as a result of diabetes, combined with a poor tear 

film increases the risk of epithelial damage, disrupting the 

normal barrier function of the epithelium 19 and increasing the 

likelihood of infection 20,21 . It is therefore important to assess 

all patients with diabetes for the signs and symptoms of dry 

eye disease as part of their diabetic work-up. The presence 

of DED needs to be managed according to clinical guidelines 

established by the Tear Film and Ocular Surface workshops 22 

and patients need to be educated about the need for rigorous 

management. By reviewing these patients on a regular basis, 

the more severe ocular surface sequelae of diabetes, such as 

neurotrophic keratopathy, can be minimised or avoided. 

Morphology and the Corneal Epithelium. The 

American Journal of Pathology 2014; 184(10): 

2662-70. 

17. Friend J, Thoft RA. The diabetic cornea. 

International ophthalmology clinics 1984; 

24(4): 111-23. 

18. Yoon KC, Im SK, Seo MS. Changes of tear film 

and ocular surface in diabetes mellitus. Korean 

journal of ophthalmology : KJO 2004; 18(2): 

168-74. 

19. Gekka M, Miyata K, Nagai Y, et al. Corneal 

epithelial barrier function in diabetic patients. 

Cornea 2004; 23(1): 35-7. 

20. Cho BJ, Lee GJ, Ha SY, Seo YH, Tchah H. 

Co-infection of the human cornea with 

Stenotrophomonas maltophilia and Aspergillus 

fumigatus. Cornea 2002; 21(6): 628-31. 

21. Holifield K, Lazzaro DR. Case report: 

spontaneous Stenotrophomonas maltophilia 

keratitis in a diabetic patient. Eye Contact Lens 

2011; 37(5): 326-7. 

22. Management and therapy of dry eye disease: 

report of the Management and Therapy 

Subcommittee of the International Dry Eye 

WorkShop (2007). Ocul Surf 2007; 5(2): 163-78. 

* Shyam Sunder Tummanapalli is a doctoral 

researcher and Dr Maria Markoulli is a lecturer 

with the School of Optometry and Vision Science at 

the University of New South Wales. Dr Markoulli’s 

research focus is on tear film biochemistry and the 

ocular surface. 

Sex hormones and dry 

eye disease 

Dry eye is a chronic inflammatory 

disease affecting millions 

of people worldwide¹. Dry 

eye has been shown to be more 

common in women than men 2 . The 

prevalence of dry eye increases post 

menopause 3 , which equates to almost 

half a woman’s life suffering with 

the disease. Dry eye has a substantial 

economic impact due to days off 

work, medication costs and doctors’ 

appointments 4 . 

Treatment for dry eye is ineffective, 

with a reliance on frequent instillation 

of lubricating eye drops. Treatment 

directed at the underlying cause has 

the potential to provide effective relief 

to the four million women in Australia 

(equivalent to approximately a third of 

a million women in New Zealand) who 

suffer from dry eye disease. 

The pathogenesis of dry eye is 

complex and as yet not completely 

understood. Its aetiology is 

multifactorial, including good evidence 

for a hormone-mediated contribution 5 . 

The role of sex hormones in dry 

eye 6 

• Androgens 

Androgen deficiency occurs in various 

physiological and disease states 

including general aging, menopause, 

autoimmune disease (including 

rheumatoid arthritis), the use of antiandrogen 

medication and complete 

androgen insufficiency syndrome 

(CAIS). Most studies support that 

androgen deficiency is associated with 

increased dry eye symptoms and signs 

• Oestrogens 

There is less known about the effect 

of oestrogens on dry eye, with 

published studies having contradictory 

conclusions. Many studies have 

examined the effects of hormone 

replacement therapy on dry eye; some 

found improvement of signs and/or 

symptoms, others found exacerbation 

of dry eye, whilst others found no 

effect. 

Current studies at UNSW looking at 

the effect of sex hormones on dry eye 

in: 

1. Post-menopausal women: novel 

ultra-sensitive methods are being 

developed to measure sex hormones 

in tears. Sex hormone levels in tears 

and blood will be measured and 

compared to signs and symptoms of 

dry eye to understand whether an 

imbalance of sex hormones causes 

BY EMMA GIBSON AND ARCHANA BOGA* 

dry eye and which hormones are the 

culprit 

2. Pre-menopausal women: 

continuous monitoring of ocular 

comfort symptoms across a complete 

menstrual cycle in women with a 

normal menstrual cycle, and those 

using combined oral contraceptive 

pills, to improve understanding of 

the impact of both physiological and 

induced hormone variations. The 

second stage of this study involves 

examining the effect of the oestrogen 

influx during IVF treatment on clinical 

signs and symptoms of dry eye 

The idea behind this research is to 

understand why women are more 

prone to dry eye (is it oestrogens 

or androgens?) and to contribute 

valuable information about the 

influence of sex hormones to enable 

development of effective treatment 

options for dry eye. 

References 

1. Schaumberg D, Sullivan D, Buring J, 

Dana M. Prevalence of dry eye syndrome 

among US women. AM J Ophthalmol. 

2003;136(03):318-326. 

2. Report of the Epidemiology Subcommittee 

of the International Dry Eye WorkShop. The 

epidemiology of dry eye disease. Ocul Surf. 

2007;5(2):93-107. 

3. Versura P, Campos EC. Menopause and 

dry eye. A possible relationship. Gynecol 

Endocrinol. 2005;20(February):289-298. 

4. Uchino M, Schaumberg D. Dry Eye Disease: 

Impact on Quality of Life and Vision. Curr 

ophthal reports. 2013;1(2):51-57. 

5. Gibson, E. J., Stapleton, F. J., Wolffsohn, J., 

& Golebiowski, B. (Under review). Local 

synthesis of sex hormones: are there 

consequences for the ocular surface and 

dry eye. The Ocular Surface. 

6. Truong S, Cole N, Stapleton F, Golebiowski 

B. Sex hormones and dry eye. Clin Exp 

Ophthalmol. 2014;97:324-336. 

* Emma Gibson and Archana Boga are PhD 

candidates undertaking these studies at the 

School of Optometry and Vision Science at The 

University of New South Wales (UNSW), with 

supervisors, Professor Fiona Stapleton (Head 

of School) and Dr Blanka Golebiowski. 

Feast your eyes update 

With the importance of diet 

playing an ever-increasing 

part in the treatment of dry 

eye, it’s timely that a second version 

of the popular Feast Your Eyes-The Eye 

Health Cookbook is due to be published 

later this year by the Look for Life 

Foundation (previously the Genetic Eye 

Foundation) in Australia. 

Lifestyle factors are a significant 

contributor to the severity of genetic 

eye conditions and in an effort to raise 

awareness, the Foundation says it’s long 

supported the Mediterranean diet, rich 

in Omega-3, as a leading method of 

genetic eye condition prevention. The 

Look for Life Foundation’s Feast your Eyes 

cook book features more than 40 recipes 

donated from some of Australia’s leading 

chefs in an effort to promote eye health 

through better nutrition. It was compiled 

by Professor Minas Coroneo, 

Foundation chairman and head of 

the Department of Ophthalmology 

at the University of New South 

Wales, and Foundation board 

member and Professor Coroneo’s 

wife, Hellene Coroneo. 

Roz Sturt from the Foundation 

says the new version of the 

book is not yet available for sale 

but should be offered later this 

year through the Foundation’s 

website. The new version will 

include recipes from chefs outside 

Australia as well as inside, she 

added. “We have some excellent 

American chefs, and their recipes 

are outstanding. They include Mario 

Batali and Jean-Georges Vongrichten to 

name a couple.” 

The cookbook also includes 

informative chapters on eye health 

penned by Professor Coroneo. It retails 

for just A$25 and all proceeds go to 

the Foundation to help it continue its 

research into eye health. 

Add data to your insights. 

There is quantitative data in every eye. Uncovering this information 

can help guide your diagnosis and management of the ocular surface. 

In fact, the point-of-care TearLab Diagnostic Test provides precise 

and predictive information regarding tear osmolarity, an important 

biomarker of ocular surface health. 

To learn more, 

visit Tearlab.com 

or call us at 

+61 437 648 746 

TearLab® 

© 2016 Tearlab Corp. I 920275ROW REV A 



19

Collaborative care 

and practical learnings 

The fifth Specsavers Clinical Conference (SCC5) from the 

10-11 September, held for the second year in Brisbane, 

attracted a record 550 delegates 

Our first conference in Melbourne in 2011 

saw 130 optometrists in attendance and we 

felt that was a huge success,” says Charles 

Horner, Specsavers’ director of communications. 

“This year we are pleased to have seen over 350 

delegates attend the education sessions on the 

Saturday (introduced last year), and over 550 come 

to the main clinical conference on the Sunday. 

“We were delighted to also have 60 students 

and over 80 optometrists from practices outside 

of Specsavers, attend as our guests,” says Horner, 

adding that while some were invited in person, 

many signed up after hearing positive reviews of 

previous Specsavers’ conferences. 

The extra clinical education sessions on 

Saturday were primarily optometry-led content, 

while Sunday was largely ophthalmology-led. 

This format is based on delegate feedback from 

previous conferences, says Horner. 

There was also a chance to earn CPD points 

with Australian attendees able to download a 

comprehensive conference app, which included 

the ability to answer questions at the end of each 

session in real time, with the anonymous results 

posted on screens around the conference room, and 

which automatically earned them their points. New 

Zealand delegates still needed to fill in a paper form, 

however. The conference also included many device 

charging points and excellent free Wi-Fi. 

The event’s platinum sponsors were Alcon and 

Johnson & Johnson, with the team from the latter 

displaying their new Acuvue Vita contact lenses, 

which will be available to Specsavers’ owners 

in New Zealand and Australia exclusively from 

November (see p6). 

“There’s huge consumer demand for contact 

lenses and we need to make sure Specsavers 

practices can capitalise on that,” says Horner. “In 

the last 12 months, Specsavers optometrists in 

New Zealand have prescribed over seven million 

lenses – a welcome surprise that has really driven 

business growth”. 

SSC5 gold sponsors included BOC, Zeiss, Hilco, 

CooperVision and health insurance funding 

company HICAPS. 

Horner believes that Specsavers investment 

in continued professional development for both 

optometrists and dispensing opticians is a huge 

draw card for franchise holders, as is the back office 

management model that frees up a clinician’s time 

to focus on their patients. He also noted the support 

Specsavers is giving to the Young Optometrists (YO) 

network, which supports optometrists during the 

first ten years of their career (a New Zealand chapter 

is currently in the process of being established – 

more on this in subsequent NZ Optics’ issues). 

Showing this support for YO, Specsavers ran an 

Instagram competition at SSC5, with several prizes 

including the chance for one optometrist to go to 

Everest with the Eyes for Everest charity. Jokingly 

Ben Ashby, Specsavers’ optometry development 

manager (ANZ) told delegates that if they weren’t 

able to use Instagram, then they were probably too 

old to be Young Optometrists! 

As for future Specsavers Clinical Conferences, 

no decision has been made on where to hold 

next year’s – the conference is held in a different 

city every two years – but Auckland hasn’t been 

ruled out as a potential location, says Hornor, 

adding he’s “thrilled” by the level of participation 

Specsavers has from its New Zealand professionals. 

Peter Larsen 

Collaboration and better patient care 

Hot off the heels of the announcement regarding 

the memorandum of understanding between 

Specsavers and RANZCO (see NZ Optics’ September 

issue), this year’s conference included a strong 

collaboration theme. Peter Larsen, optometrist and 

Specsavers’ professional services director, opened 

SSC5 on Sunday with a clear focus on the need 

for optometry and ophthalmology to work better 

together to achieve more measurable outcomes. 

“Opinions don’t count for anything,” said Larsen, 

noting there was still an old guard of clinical 

practitioners who felt the structures RANZCO and 

Specsavers are working toward are unnecessary. 

“Measurable clinical outcomes are essential to 

improve best practice and patient care.” 

With up to 30% false-positive referral rates for 

glaucoma, 15% of referrals failing to attend tertiary 

care and 50% of glaucoma sufferers still going 

undiagnosed, now was the time to put politics 

aside, and for optometry and ophthalmology to 

work better together, reducing risk, increasing 

education, streamlining services and ultimately 

improving patient care, he said. 

A key aspect to making the collaboration 

with RANZCO work, ensuring it received the 

feedback it needed on its new referral guides, was 

continuing education and working toward uniform 

standards and processes, said Larsen. To achieve 

this, optometrists needed data so Specsavers is 

investing in a number of platforms to provide that 

data, he said. 

Having rolled out the new, secure informationsharing 

portal Oculo to many of its Australian stores 

in June this year, Larsen said he was delighted to 

announce Specsavers would be subsidising Oculo 

for franchise holders for the next six months. 

“We are delighted to have Specsavers continued 

support as we expand our network with independent 

optometrists and ophthalmologists,” said Oculo’s 

Dr Kate Taylor. 

Dr Russel Bach 

RANZCO guidelines for DED 

RANZCO board member Dr Russell Bach, senior 

medical officer, ophthalmology at the Prince 

Alexandra Hospital in Brisbane, reinforced Fussey’s 

emphasis on collaboration during his session on 

RANZCO’s newly drafted clinical guidelines for 

diabetic eye disease (DED). The guidelines, which 

will be formally released later this year, aim to 

give all optometrists a clear clinical pathway from 

seeing a new patient through to when to refer 

and how to continue caring for low-risk patients. 

RANZCO released its first set of guidelines on 

glaucoma management in August, DED is next 

with AMD planned for late this year. 

“It’s exciting to be representing RANZCO and 

standing in front of a large group of eager 

Sunday speakers Drs Russell Bach, Jesse Gale, Andrew White and Christolyn Raj, Peter Larsen, Dr Nathan Walker and Professor Stuart Graham 

(missing Dr Sunil Warrier) 

Amy Winter and Megan Glover 

Leilei Zhou, Jingyi Xu, Daria Kozub and Sephy Cheng 

Debra So and Kiwi speaker Richard Johnson with Niall McCormack and ODOB board 

chair Damian Koppens 

participants. That gives me a very positive feeling,” 

said Dr Bach, noting how in this day and age we 

are inundated with data and it is beyond the ability 

of the human brain to cope with it all. 

While this data – big data – is useful, he said, 

clear structures and guidelines need to be put 

in place to make sure patients aren’t overlooked 

and don’t fall out of the system. “By following 

these guidelines, clinical practitioners can ensure 

the quality and standard of care that all patients 

receive, and can also begin to streamline practices 

and prevent duplication.” 

Dr Bach referred to a Michigan-based study from 

2005 which showed that by simply introducing 

guidelines for patient diagnosis and care, the 

survival rate of acute myocardial infarction (heart 

attack) patients improved. “Medicine based 

on memory is unreliable. Guidelines improve 

collaborative care for the benefit of the patients.” 

Dr Bach went on to preview the draft guidelines, 

which give optometrists a clear pathway from 

recognising an issue through to referral and 

ongoing patient care. 

Dr Nathan Walker 

Vitreoretinal surgery advances 

Dr Nathan Walker, an ophthalmologist and 

vitreoretinal surgeon based on the Gold Coast, 

followed with a look at advances in vitreoretinal 

surgery. Referring to a range of common retinal 

conditions seen by optometrists, such as macular 

hole, epiretinal membrane and retinal detachment, 

and how they are managed by specialists postreferral, 

he demonstrated the vital role optometry 

plays in identifying, referring and following up 

these patients. 

He also reviewed ocular trauma, emphasised 

the importance of urgent referral and discussed 

indications for surgery and the essential role 

optometrists must play in post-operative care. 

Dr Andrew White 

Glaucoma care 

Dr Andrew White, a senior lecturer at the University 

of Sydney and consultant ophthalmologist at 

Westmead Hospital, focussed on glaucoma care. 

With the increasing volume of glaucoma patients, 

neither optometry nor ophthalmology are able to 

review them all without working together, he said. 

Collaboration done well allows high-risk patients to 

see consultants sooner, while those of moderate risk 

Monica Lee, Bo Kim, Renee Song and Olivia Lee, Kiwis now working in Adelaide 

and Queensland 

Kiwi presenter Dr Jesse Gale discusses swollen optic discs 

Hector Chang and now Fiji-based Sashi and Namita Singh 

can be monitored, with a clear referral pathway, by 

optometrists where they may otherwise have fallen 

out of the system. Dr White referred to a study from 

Stanford University, which showed compliance with 

medicine and keeping appointments is higher when 

patients are seen regularly; if people are not seen 

regularly by a clinician, their condition deteriorates. 

He ran through scenarios where patients should 

be seen by an ophthalmologist and noted the 

standard of referrals from some optometrists 

can be quite poor, with no visual field or even 

refraction notes passed on. Referring to the recently 

released guidelines on referrals from the Asia- 

Pacific Glaucoma Society, he emphasised the need 

for the standardisation of referrals and discussed 

the benefits and pitfalls of different diagnostic 

tools, noting an OCT won’t always give an accurate 

reading because of the parameters of the preprogrammed 

data; and that a fundus – limited as it 

can be in this modern technological age – offers a 

comparable image with that of 20 years ago or 20 

years into the future, as the technology does not 

change. Ultimately, he emphasised the importance 

of a practitioner’s own clinical skills – machines are 

only as good as their operator! 

Professor Stuart Graham: 

Glaucoma case studies 

In the last session before lunch, Professor Stuart 

Graham, head of ophthalmology and visual science 

at the Faculty of Medicine and Health Science at 

Macquarie University, discussed the circumstances 

under which a glaucoma patient might find 

themselves in surgery, when to refer and what 

cases are suitable for monitoring by an optometrist. 

He ran through several interesting case histories, 

including an 84-year-old male with non-specific 

reduced vision. Despite having a normal optic 

nerve, open angle and normal IOP, his visual fields 

were really bad. Professor Graham noted glaucoma 

diagnosis rarely begins with poor visual field 

results and this was a referral alarm bell for other 

conditions. If this patient walked into your clinic, 

it is vital more questions are asked and a full case 

history taken, he said, as the result for this patient 

was melanoma and, caught early, melanoma 

patients have a good outcome. Another case of a 

46-year-old woman with exceptionally high IOP 

was highlighted. Although treatment progressed 

normally and her disease was halted, an initial 

post-treatment OCT revealed very unusual results 


Auckland’s Philip Walsh and Cleven Cui, now living in 

Camberwell, Victoria 

Oculo’s Dr Kate Taylor celebrating Specsavers’ decision to subsidise 

its portal for franchise holders with Specsavers’ director Peter Larsen 

Ian Russell and Specsavers NZ director Graeme Edmond 

that did not correlate with her previous tests. 

It turned out this was because the wrong 

patient’s OCT had been saved against her 

name, illustrating Prof. Graham’s key message 

that clinicians must think beyond the norm 

and, if something doesn’t fit, speak to other 

medical professionals and refer. 

Dr Jesse Gale 

Swollen optic discs 

Kiwi ophthalmologist Dr Jesse Gale kicked off 

the afternoon sessions with the key message 

that “all swollen optic discs are scary and all 

need to be referred.” 

He emphasised this point with a number of 

pictures with multiple choice answers as to the 

possible cause of the swollen optic discs. The 

answers were all “I don’t know”, demonstrating 

how “crazy” it is to make a diagnosis on the 

discs alone. It’s important ophthalmologists 

and optometrists “embrace uncertainty and 

our inability to make spot diagnosis” because 

some of the most critical emergencies in 

ophthalmology, including papilloedema, are 

diagnosed with disc swelling, whereas in 

another context this may just be a benign, 

incidental thing, but without a detailed patient 

history and other tests, we just don’t know, he 

said. Other key points were measuring visual 

function is more important than structure; 

there’s no conclusive way to differentiate 

pseudo-swelling from truly swollen discs with 

an OCT; and how important it was to recognise 

the key features of giant cell arteritis. 

Dr Christolyn Raj 

Clinical conundrums 

Paediatric and retinal ophthalmologist Dr 

Christolyn Raj, who swapped optometry for 

ophthalmology and now works at the Royal 

Children’s Hospital in Melbourne, delivered a 

fascinating, interactive lecture about common 

clinical scenarios that aren’t always all that 

they seem, and how to deal with that. “Be a bit 

Teflon, take the history again…develop a stepwise 

strategy to safely assess and manage a 

patient to avoid missing a possible diagnosis.” 

Using case studies to illustrate her point, she 

told optometrists to be careful not to have 

“tunnel vision and come to only one diagnosis” 

for example, jumping to the conclusion with 

Specsavers’ Charles Hornor with Optometry Australia National CEO 

Genevieve Quilty and NSW CEO Andrew McKinnon 

Saturday speakers (L to R) Dr Geoff Sampson, Prof Alex Gentle, Ben Ashby, A/Prof 

Darryl Guest, Dr Shelley Hopkins, Craig Muller, Michael Yapp and Richard Johson 

Alcon’s Leonie Sanders and Justine Challender (standing) with 

Deanne Graham and Thomas Wayne (seated) 

patients of a certain age that it’s AMD, when 

in her case study it wasn’t AMD it was myopic 

choroidal neovascularisation (CNV); and to 

recognise that visual loss may be multifactorial 

and thus you need to “look for the second 

pathology”. 

Dr Sunil Warrier: 

Ocular oncology 

The final session by Dr Sunil Warrier, a 

Queensland consultant ophthalmologist and 

RANZCO director of training, tackled one of 

the most serious concerns for all delegates and 

eye practitioners everywhere, the diagnosis 

and treatment of ocular cancers. “If as health 

professionals we can pick this up early, we can 

make a huge difference to people’s lives.” 

Breaking his presentation down into three 

areas: the good, the bad and the ugly, Dr 

Warrier said in general good lesions are found 

on the iris. They need to be watched, they can 

normally be treated, but it’s important any 

changes in IOP aren’t quickly dismissed as 

glaucoma and the patient put on a treatment 

regime for glaucoma as this could lead to very 

serious problems, he said. Choroidal lesions 

in general are bad, with 50% of all choroidal 

melanoma sufferers likely to die, far higher 

than the more common cutaneous melanoma, 

whereas conjunctival lesions (the ugly) 

which is particularly common in Queensland, 

behaves very similarly to cutaneous melanoma 

and with early detection and thorough 

treatment can be controlled. “I have a very low 

threshold for taking off brown things…because 

if it mestasises then that’s terrible.” 

Dr Warrier also noted and praised new 

technologies making a big difference to eye 

and vision care today, including microinvasive 

glaucoma surgery (MIGS) and Optos ultrawidefield 

retinal imaging devices. 

Closing 

Peter Larsen, optometrist and Specsavers’ 

professional services director, closed 

Specsavers Clinical Conference for 2016 

with a round of thank yous for those who 

attended, those who sponsored, and those 

who organised the event. Next year’s event 

will be held on 9-10 Sept at a location still to 

be confirmed. ▀ 

For the second year in a row the Specsavers 

Clinical Conference included two parallel, 

afternoon optometry-led education sessions on 

the Saturday afternoon, prior to the conference proper 

on the Sunday. The success of these sessions last year, 

and delegates’ desire to make more of a weekend of 

their conference, resulted in more than 350 of the 

550 plus total number of delegates registering for the 

Saturday programme and then dividing their time 

between three sessions on paediatrics and three on 

pathology management. 

Paediatrics Stream 

A/Prof Darryl Guest 

Anterior eye therapeutics 

Associate Professor Daryl Guest, clinical and executive 

director, optometry and vision sciences, at the 

University of Melbourne, opened the paediatrics 

sessions with his take on kids’ eye infections. He 

started with the case history of Aneata, age 9, to 

demonstrate one of the classic problems with working 

with children – honesty. Aneata’s examination showed 

a left corneal laceration with fibrin material in the 

stoma and anterior chamber, which could not have 

been caused by an insect, despite Aneata claiming it 

had been. After probing for more information, Aneata 

admitted she had been poked in the eye with a stick 

by her friend who she didn’t want to get into trouble. 

A/Prof Guest also emphasised the need to know not 

only when to refer, but when to insist on the urgency 

of a patient being seen. He said his favourite gambit 

was to ring a consultant and say, “I’ve got your patient 

sitting in my chair, when can you see them?” 

He ran through the categories of drugs that can be 

used in pregnancy and on children and reminded the 

audience, when treating a minor you are responsible 

for your actions for seven years after the child turns 

18. He also noted that just because a drug is readily 

available, that doesn’t make it safe, offering NSAIDs as 

a classic example, and said that controlled drugs can 

also be relatively benign. 

With pre-schoolers, the most likely cause of infection 

is bacteria, with virus’ and allergies becoming more 

common after the age of five. If you have a very young 

patient, under 28 days old, A/Prof Guest suggests 

you should assume the cause of their infection is 

gonorrhoea or chlamydia from the birth canal and 

treat them as such until proven otherwise, unless the 

child was delivered by C-section. 

HSV conjunctivitis, he noted, is also a relatively 

underdiagnosed condition optometrists should look 

out for in pre-schoolers. A/Prof Guest also provided 

a useful diagnostic tool for orbital cellulitis, which 

can be distinguished from its less dangerous cousin, 

preseptal cellulitis, by asking the patient a simple 

question, “did you sleep well last night?” If the answer 

is ‘no’, they need to be urgently referred, says A/Prof 

Guest, as children with orbital cellulitis are unwell, will 

not sleep and present with a fever. 

Dr Shelley Hopkins 

Assessing children 

Dr Shelley Hopkins, clinic coordinator, optometry at 

the QUT Health Clinics in Brisbane, discussed the 

Australian Government Initiative Smart Eye Start, 

which requires children under six to have seen an 

optometrist before they start school. The result, she 

said, was there would be more four and five year olds 

in Australian optometry practices requiring a careful, 

coordinated approach to ensure a successful outcome. 

First, optometrists should get a clear patient history, 

she said. Things like developmental delays, particularly 

in language skills, were not just important for 

planning your own assessment of that child but also 

for assessing them holistically and understanding the 

role their eye health might play in the bigger picture. 

If they’re taking medication, such as Ritalin, that’s 

important to know as a side effect could be blurred 

vision. 

It’s also important to document techniques when 

testing visual acuity, she said, so another practitioner 

can understand your methods and interpret results 

accordingly. Conventional subjective refraction is almost 

impossible in pre-schoolers, so use objective measures. 

Static dry retinoscopy should be the first approach, 

moving on to cycloplegic refraction if there are additional 

concerns from the school nurse or parents. 

Dr Geoff Sampson 

Understanding refractive errors 

Dr Geoff Sampson, senior lecturer at Deakin 

University, ended the paediatrics stream with 

a question of ethics: how can you improve the 

diagnostic tools and treatment for hyperopia, 

astigmatism and anisometropia in children when 

you cannot perform clinical tests and trials on 

these groups to gain further evidence? The answer 

paediatrics and 

pathology management 

is simulating low levels of these refractive errors, 

he says, running through his PhD student’s recent 

research. He also reminded delegates that reading 

ability has a huge impact on educational outcomes 

and these three refractive errors in particular, require 

more work and understanding in order to support 

children post-diagnosis. 

Pathology management stream 

Michael Yapp 

Assessing glaucoma suspects 

The pathology management stream was kicked off by 

Michael Yapp, chief staff optometrist at the Centre for 

Eye Health in Sydney. He tackled the tricky subject of 

assessing and diagnosing glaucoma in clinical practice, 

stressing there are now lots of guidelines to help and 

delegates should “learn to love” their gonioscopes. 

This lively interactive session used case studies to 

highlight methods of integrating all of the currently 

available clinical information (including imaging) in 

the glaucoma decision process. Tips included using 

a history checklist, looking at right and left discs and 

field data side-by-side, taking disc photos for change 

analysis and ensuring structural imaging correlates, 

analysing the raw data in ocular imaging and knowing 

Drance haemorrhages are a significant risk factor 

for progression. Yapp also stressed recalls were an 

optometrist’s responsibility: “If your patients don’t 

come back because they didn’t answer your recall, it 

is your problem”; and finally, optometrists need to go 

the extra mile when attempting to diagnose glaucoma 

in high myopes, he said. 

Prof. Alex Gentle 

Ocular allergy diagnosis 

Professor Alex Gentle, associate head of school at the 

School of Medicine at Deakin University, discussed the 

significance of allergy as a public health problem and 

the links between systemic and ocular manifestations 

and the diagnosis and interventions for ocular allergy. 

Studies show the signs and symptoms of allergic 

conjunctivitis are experienced by upwards of 20% 

of the general population and many may never seek 

treatment for their allergy. 

“If you can’t recognise the mechanism or cause of 

the allergy then it can be difficult to recommend an 

appropriate management process,” he said, referring 

to a useful Spanish study by Sánchez-Hernández et 

al, 2015, which came up with a consensus for grading 

allergies after an extensive literature review. 

When it comes to treatment, different authors have 

different suggestions, said Professor Gentle, stressing 

that many ocular therapies only offer symptom relief 

so patients still need to be referred for their systemic 

condition. Other points included: in managing simple 

allergic eye disease, the complex should be excluded 

first; and many patients’ symptoms will be best 

reduced with oral or intranasal therapy supplementing 

their topical management. 

Richard Johnson 

Uveitis 

The final speaker in the pathology section was New 

Zealander Richard Johnson, principal optometrist 

at Greenlane Clinical Centre. Johnson’s session on 

uveitis (or perhaps Johnson himself) was obviously a 

powerful drawcard as the vast majority of Specscavers’ 

Saturday afternoon delegates packed into his 

presentation, leaving no seat unfilled. 

Johnson reviewed the pathophysiology, clinical 

signs and symptoms of uveitis, shared evidence-based 

therapeutic management processes and highlighted 

red flags through a series of case studies. 

Uveitis is relatively common, especially anterior 

uveitis, affecting primarily those aged between 20 and 

50. It is rare in the very young and old, and it has many 

causes. Symptoms include brow ache, photophobia, 

redness and watering eyes developing over one to two 

days, and blurred vision. Undertreating uvetis can result 

in corneal oedema, synechiae, iris atrophy, cataracts, 

glaucoma, vitritis, cystoid macular oedema and ciliary 

body shut down. Red flags include systemic symptoms, 

atypical presentations, such as age, no fundal view 

or posterior involvement, declining visual acuity and 

hypopyon. 

An interesting complication and cause of uveitis, 

highlighted by Johnson, was syphilis, with an 

increasing number of cases in New Zealand, stemming 

from (primarily) British-born workers involved in the 

Christchurch rebuild, who contracted the disease in 

Britain after Europe’s extension into the Eastern Bloc 

caused a flood of Polish and Eastern European sex 

workers. 

Johnson ended on an amusing note, referring to his 

tourist status in Australia, saying if you can figure out 

how to use Brisbane’s public bike hire system, you can 

treat uveitis. ▀ 



21

with 

Prof Charles McGhee 

& A/Prof Dipika Patel 

Series Editors 

Lamellar corneal 

surgery in 2016 

MOHAMMED ZIAEI*, DIPIKA PATEL, CHARLES MCGHEE 

Introduction 

Full-thickness corneal transplantation is an 

operation that deals with a wide variety of corneal 

pathologies, but the procedure has not changed 

significantly since Eduard Zirm successfully 

performed the first penetrating keratoplasty (PK) 

over a century ago. Lamellar keratoplasty revolves 

around the concept of targeted replacement 

of diseased corneal tissue and techniques have 

evolved at an astonishing speed over the past 15 

years. This article reviews some of the most recent 

developments in this field. 

Overview of lamellar surgery 

Lamellar surgery includes anterior lamellar 

keratoplasty (ALK) in which stromal tissue is 

selectively replaced, and endothelial keratoplasty 

(EK) which aims to replace damaged endothelial 

tissue (Fig 1.). 

Anterior lamellar keratoplasty 

ALK has undergone a renaissance with the 

dissemination of several new techniques since 

Arthur von Hippel performed the first successful 

anterior lamellar graft in 1886. This operation is 

the procedure of choice for a variety of corneal 

stromal disorders where the endothelium is 

healthy such as ectasia, stromal dystrophies and 

anterior stromal opacities. The modern version of 

this surgery, deep anterior lamellar keratoplasty 

(DALK), involves complete or near complete 

removal of diseased stromal tissue and perhaps 

the two most widely adopted techniques are 

Anwar’s “Big Bubble” technique (Descemetic 

DALK), and Melles’s “Closed manual dissection” 

technique (pre-Descemetic DALK). 

The major advantage of DALK surgery results 

from the retention of healthy native endothelium 

thereby eliminating endothelial allograft rejection, 

although epithelial and stromal rejection are still 

possible. Other advantages include a reduced 

need for topical steroids (15% vs 75% still on 

topical steroids after 12 months) and potential 

for earlier suture removal. Several studies have 

also shown that the visual quality with this form 

of keratoplasty is comparable to that of PK. The 

DALK procedure is also thought to be more cost 

effective when compared to full thickness corneal 

transplantation and reported to result in lower 

endothelial cell loss 1-3 . 

In a recent meta-analysis whilst the proportion 

of patients achieving best corrected visual acuity 

≥ 6/12 did not differ statistically between DALK 

and PK, the uncorrected and best corrected visual 

acuity levels were significantly better for PK. The 

Fig 1. Different types of keratoplasties (9). 

(A) Penetrating keratoplasty. (B) Anterior lamellar keratoplasty. (C) Endothelial keratoplasty 

DALK group however had a significantly lower 

frequency of graft rejection than the PK group 3 . 

It is worthwhile noting that refractive error is a 

significant barrier to functional vision with one 

long term study reporting a mean refractive error of 

-6.5 ± 1.7 D after pre-Descemetic DALK and -6.1 ± 1.8 

D after Descemetic DALK 4 . 

DALK does however have a steep learning curve 

and is technically more challenging to perform 

than PK. It is associated with unique potential 

complications such as Descemet’s membrane 

perforation, double anterior chamber (separation of 

the donor stroma tissue from the host Descemet’s 

membrane) and interface related issues. There are 

also some challenges associated with performing 

lamellar surgery in patients with a history of acute 

corneal hydrops, in individuals with a pre-existing 

split in Descemet’s membrane and patients with 

advanced ectasia. 

DALK makes up only 7% of corneal transplants 

performed in New Zealand in 2015 (unpublished 

data). This may reflect local population factors 

such as advanced ectasia or late presentation of 

patients. The low uptake of DALK could also be 

due to the fact that whilst DALK has a number of 

theoretical advantages over PK, long-term survival 

of DALK performed for keratoconus has been 

shown to be inferior to that of penetrating grafts in 

the recent Australian graft registry study. 

There have been some recent innovations in the 

field of anterior lamellar keratoplasty. One novel 

technique is that of femtosecond laser-assisted 

anterior lamellar keratoplasty (FALK) in which 

the depth of the recipient corneal pathology is 

measured using anterior segment OCT (AS-OCT). 

Subsequently the femtosecond laser is used to 

create the lamellar cut in the recipient and donor 

corneas and this depth can be adjusted based on 

the extent of the corneal pathology. The recipient’s 

scarred corneal tissue is then removed and replaced 

with the healthy donor lenticule. The lenticule 

can then be sutured into place or even retained by 

applying a contact lens in a “sutureless” procedure. 

Endothelial keratoplasty (EK) 

Charles Tillet performed the first known successful 

EK case in 1956 to treat corneal oedema. EK has since 

transformed beyond recognition and is now the 

procedure of choice for a variety of corneal endothelial 

disorders such as Fuchs’ endothelial corneal dystrophy 

and pseudophakic bullous keratopathy. 

The two most widely adopted techniques are 

Descemet stripping automated endothelial 

keratoplasty (DSAEK) in which the Descemet’s 

membrane endothelial complex is transplanted 

Fig 2. Anterior segment Optical Coherence Tomography (OCT) images of two patients who have undergone DSAEK. 

Note that the graft is fully attached in the top image and partially detached (arrow) in the bottom image. 

Fig 3. Anterior segment Optical Coherence Tomography (OCT) image of a patient following DMEK. 

Note the focal area of donor detachment nasally (arrow). 

with a sheet of stroma and Descemet’s membrane 

(Fig 2.), and Descemet’s membrane endothelial 

keratoplasty (DMEK) in which the Descemet’s 

membrane endothelial complex is transplanted 

in isolation and attached in a sutureless method 

through air tamponade (Fig 3.). 

Endothelial keratoplasty has replaced penetrating 

keratoplasty as the preferred technique for treating 

endothelial disease in the developed world, as 

it offers numerous advantages compared to PK. 

The most striking advantages of EK include the 

predictability and rapidity of visual rehabilitation 

associated with lower surgically-induced 

astigmatism. These advantages have driven the 

uptake of this technique. EK has also been shown 

to be more cost effective than PK as it is associated 

with fewer rejection episodes and requires less 

intensive patient follow-up. Other advantages of EK 

include the reduced need for topical corticosteroids 

and a tectonically stronger eye. 

In one large single centre study 50% of patients 

reached a best corrected visual acuity of Snellen 

6/12 or better, by four months following DMEK, 

18 months following DSAEK, and more than 24 

months following PK. A best-corrected visual 

acuity of Snellen 6/7.5 or better at 24 months 

postoperatively was reached in 53% after DMEK, 

15% after DSAEK, and 10% after PK 6 . However, in 

another large study, 6/12 was achieved in 60.7% of 

patients following DSAEK at three months, 71.0% 

at six months, and 85.4% at 12 months 7 . 

Disadvantages of EK include the technically 

challenging nature of surgery, the need for special 

instrumentation and its association with unique 

potential complications such as graft dislocations 

requiring re-bubbling (re-injection of air into the 

anterior chamber), and interface related issues. 

There are also some challenges with performing 

EK in patients with a history of prolonged 

endothelial dysfunction in which the stroma has 

become scarred and in the presence of other ocular 

co-pathology such as iris defects, aphakia and in 

patients with a glaucoma drainage device. 

EK is now the gold standard procedure for 

endothelial disease comprising 31% of corneal 

transplants performed in New Zealand in 2015 

(unpublished data). However, whilst there are 

a number of theoretical advantages over PK, 

long term survival of EK performed for Fuchs’ 

endothelial dystrophy has been shown to be 

inferior to that of penetrating grafts in the recent 

Australian graft registry study 5 . 

This has fuelled the interest in minimally 

invasive procedures such as cultured human 

corneal endothelial cell transplantation either 

as a monolayer or by injection of cells into the 

anterior chamber. Indeed we may soon see the 

widespread use of medical therapy in patients 

where topical treatment with Rho-associated 

kinase (ROCK) inhibitors, a molecule that enhances 

corneal endothelial survival, promotes cellular 

proliferation, and has the potential to inhibit and 

even reverse endothelial cell dysfunction 8 . 

Conclusion 

Penetrating keratoplasty has long been the standard 

of care for treating eyes with corneal disease with 

up to 95% long term success in keratoconus but 

nonetheless, significant shortcomings. Noteworthy 

barriers towards functional success include 

prolonged refractive instability and high irregular 

astigmatism. Advances in surgical instrumentation 

and technique are improving keratoplasty outcomes 

and it is widely believed that selective lamellar 

keratoplasty is the future of corneal transplantation. 

Advantages of lamellar surgery include a safer 

surgical procedure, quicker visual recovery, less need 

for topical steroids and a tectonically stronger eye. 

However, there needs to be further innovation and 

refining of current surgical techniques to improve 

survival rates and long-term outcomes of lamellar 

grafts. Until such time there will likely remain a 

place for penetrating keratoplasty. ▀ 

References 

1. Koo TS, Finkelstein E, Tan D, Mehta JS. Incremental costutility 

analysis of deep anterior lamellar keratoplasty 

compared with penetrating keratoplasty for the treatment 

of keratoconus. Am J Ophthalmol. 2011;152(1):40-7 e2. 

2. Keane M, Coster D, Ziaei M, Williams K. Deep anterior 

lamellar keratoplasty versus penetrating keratoplasty 

for treating keratoconus. Cochrane Database Syst Rev. 

2014;7:CD009700. 

3. Chen G, Tzekov R, Li W, Jiang F, Mao S, Tong Y. Deep 

Anterior Lamellar Keratoplasty Versus Penetrating 

Keratoplasty: A Meta-Analysis of Randomized Controlled 

Trials. Cornea. 2016;35(2):169-74. 

4. Huang T, Hu Y, Gui M, Hou C, Zhang H. Comparison of 

refractive outcomes in three corneal transplantation 

techniques for keratoconus. Graefes Arch Clin Exp 

Ophthalmol. 2015;253(11):1947-53. 

5. Coster DJ, Lowe MT, Keane MC, Williams KA, Australian 

Corneal Graft Registry C. A comparison of lamellar and 

penetrating keratoplasty outcomes: a registry study. 

Ophthalmology. 2014;121(5):979-87. 

6. Heinzelmann S, Bohringer D, Eberwein P, Reinhard T, 

Maier P. Outcomes of Descemet membrane endothelial 

keratoplasty, Descemet stripping automated endothelial 

keratoplasty and penetrating keratoplasty from a 

single centre study. Graefes Arch Clin Exp Ophthalmol. 

2016;254(3):515-22. 

7. Khor WB, Han SB, Mehta JS, Tan DT. Descemet stripping 

automated endothelial keratoplasty with a donor 

insertion device: clinical results and complications in 100 

eyes. Am J Ophthalmol. 2013;156(4):773-9. 

8. Nakagawa H, Koizumi N, Okumura N, Suganami H, 

Kinoshita S. Morphological Changes of Human Corneal 

Endothelial Cells after Rho-Associated Kinase Inhibitor Eye 

Drop (Ripasudil) Administration: A Prospective Open-Label 

Clinical Study. PLoS One. 2015;10(9):e0136802. 

9. Tan DT, Dart JK, Holland EJ, Kinoshita S. Corneal 

transplantation. Lancet. 2012;379(9827):1749-61. 

About the author 

* Dr Mohammed Ziaei 

completed his ophthalmic 

training at Moorfields 

Eye Hospital in London 

and is currently in his 

second year as a cornea 

& anterior segment 

fellow at the University of 

Auckland. 


An educating evening 

Eye Institutes’ second educational evening 

of the year, and last before its conference in 

November, was an upbeat affair fuelled with 

a healthy dose of nibbles, liquid refreshments and a 

good turnout of optometrists from across the region. 

Dr Adam Watson opened the evening, promising 

attendees “a rich smorgasbord of education” and 

thanking Alcon for sponsoring the event. 

The subjects covered were eclectic ranging 

from shingles and the latest technology to be 

employed at Eye Institute to current thinking on 

endothelial and choroid diseases to an interesting 

and personal account from Dr Peter Ring on 

ophthalmology in China. 

The following is a summary of the evening and 

some of the highlights: 

Herpes zoster ophthalmicus 

Dr Watson kicked off proceedings with a look at 

shingles and how it can have a devastating effect 

on the eye. Describing the virus, Herpes zoster, 

as “quite a beast of a thing,” he outlined the 

aetiology, epidemiology and manifestations of 

herpes zoster ophthalmicus (HZO) and suggested 

how best to treat what can frequently become a 

severe and sight-threatening disease. 

Studies show there is a 34% to 76% chance of 

ocular complications when a patient develops 

shingles on their face. Complications include, 

most commonly, keratitis, anterior uveitis and 

corneal endotheliitis. Less common afflictions 

include neurotrophic keratopathy, corneal oedema 

and cranial nerve palsies. Chronic and recurrent 

inflammation is common, treatment is less reliant on 

antiviral medication than in HSV disease and, given 

the potential severity and effect on the eye, older 

patients, especially those over 60, should consider 

vaccination with the varicella vaccine as studies 

show those vaccinated have 50% less HZO and, if 

they do develop it, tend to have much milder effects. 

OCT angiography 

Fresh from running workshops at the popular, 

biennial Snowvision event in Queenstown, Dr 

Shanu Subbiah shared his thoughts about optical 

coherence tomography angiography (OCTA). 

OCTA is a new, non-invasive imaging technique 

that generates retinal and choroidal angiography 

images in a matter of seconds, allows close-up 

imaging of the retinal vasculature and has the 

potential to significantly change the routine 

assessment and characterisation of certain retinal 

and choroidal diseases. “Fluroscein angiography 

(FA) used to be the gold standard for studying the 

retina, now it’s OCT, but they complement each 

other,” said Dr Subbiah, adding OCTA takes this 

one step further allowing you to view a 3D image 

of the retinal vasculature in a non-invasive, more 

cost-effective manner. One limitation, however, 

is there’s no way of spotting fluid leakages or 

ascertaining how severe they may be as no dye 

is used. Thus OCTA is a very useful adjunct to 

OCT and FA, though is unlikely to replace them. 

However, with swept-source technology, hopefully, 

becoming more affordable, OCTA will become 

more useful for deeper scans and better choroidal 

visibility, he concluded. 

Dr Peter Ring and Roger Apperley 

John McLennan, Chris Earnshaw and Alastair Kyle 

For more about OCTA, see the review by 

Drs Shanu Subbiah and Peter Hadden in 

April’s NZ Optics. 

Neuro-ophthalmic emergencies 

Professor Helen Danesh-Meyer presented 

three cases which highlighted neuroophthalmic 

emergencies to show when 

diplopia is a sign of danger. Monocular 

diplopia is not dangerous as it’s an ocular 

not a neurological symptom. Whereas with 

binocular diplopia, if there’s more than one 

cranial nerve involvement then it’s always 

potentially dangerous, she said. Other 

warning signs include otherneurological 

symptoms associated with the diplopia, 

such as vomiting, headache or weakness 

on one side of body. Trickier, are isolated 

cranial nerve palsies. These should be 

considered dangerous, especially when the 

patient is young; if the diplopia progresses 

or doesn’t resolve; and if the patient is 

over 55 and has any signs or symptoms 

of giant cell arteritis, such as headaches, 

scalp tenderness or pain with chewing. 

Other factors to consider include a history 

of cancer and third, or partial-third, nerve 

palsy (ptosis with big pupil). In summary, 

said Professor Danesh-Meyer, “When it 

comes to diplopia, things are not always 

what they seem.” 

Anterior uveitis 

Dr Trevor Gray ended the first half of the 

evening discussing uveitis. All uveitis is potentially 

sight threatening and sometimes life threatening, 

so you need to keep your minds open and stay 

watchful, he said. KPs (keratic precipitates) can 

tell us a lot about the potential for vision loss and 

other complications; check distribution, colour and 

size. Anterior chamber cells are the key measure 

for uveitis activity and all patients with chronic 

uveitis will have chronic problems with leaky blood 

vessels in their iris, allowing albumin from the 

blood stream to flow into the anterior chamber and 

cause flare, he explained. There are many causes of 

uveitis and a number of treatments. Key treatment 

points include: topical steroids are only effective for 

anterior chamber treatment, with the exception of 

cystoid macular oedema; Pred Forte gets into the 

eye the best; Maxidex ointment is “pretty useless” 

because penetration of dexamethasone is much 

poorer in ointment than in drops form; the risks with 

treatments directly relate to drug concentration 

used; preserved drops have better penetration than 

non-preserved; frequency counts; don’t withdraw 

treatment too fast; and always document the 

absence and presence of complications. 

The choroid: source of all that’s bad? 

After a short break and an opportunity to refill 

glasses and plates, Dr Peter Hadden tackled the 

diagnosis and management of sight and lifethreatening 

diseases of the choroid, including 

how best to view the choroid with OCT. Given the 

advances with OCT, we now have a much better 

appreciation of the role of pathologic choroidal 

Dr Trevor Gray, Gary Filer, Sonia Swan and Kristine Jensen 

Dennis Oliver and Anne Durrant 

Alex Petty and Nick Mathew 

Cliff Harrison and Raj Maiti 

changes in a variety of retinal disease, he said. 

Choroid thickness can change in all mammals 

throughout the day (especially chickens), 

however, a “pachychoroid” (pachy-[prefix]= thick) 

is considered abnormal and can be a sign of 

disease such as central serous chorioretinopathy; 

choroidal osteoma (a benign tumour that 

can cause vision loss); choroidal metastasis; 

choroidal haemangioma; and chorioretinitis from 

toxoplasmosis. Choroidal thickness in relation 

to age-related macular degeneration (AMD) 

remains controversial, however, with some leading 

researchers refuting the link between thin choroids 

and AMD, though pathological myopia is definitely 

associated with thinning. 

Endothelial disease 

Professor Charles McGhee tackled endothelial 

disease, including presenting the endothelial 

life cycle in a single slide. There has been a 

greater understanding of the form, function and 

reparative capacity of the endothelium in the 

last decade leading to better understanding of 

the endothelial structure and function and the 

repair and replacement of the endothelium. This 

includes topical agents such as Rho-kinase (ROCK) 

inhibitors, injection of cultivated endothelial 

cells and the surgical replacement of layers, 

better known as Descemet’s stripping automated 

endothelial keratoplasty (DSAEK) and Descemet’s 

membrane endothelial keratoplasty (DMEK) – 

or partial thickness corneal transplants. These 

innovations may provide a tiered, possibly earlier, 

approach and more rapid recovery in common 

endothelial diseases encountered 

by optometrists, particularly 

Fuchs’ endothelial corneal 

dystrophy, explained Professor 

McGhee. In conclusion, he said, 

ROCK inhibitors promise much, 

but are yet to deliver; there’s been 

a revolution in transplantation in 

the last 15 years; more than 50% 

of surgery is now lamellar, with 

DALK, DSEK and DSAEK all wellestablished, 

and DMEK variations 

under study, but looking 

promising; and other cell-based 

treatments on the horizon. For 

more on this subject, see p22. 

Ophthalmology in China 

Dr Peter Ring shared an interesting 

account of his personal experience 

of joining the team on the Lifeline 

Express, a rainbow-coloured 

hospital eye-train that provides 

free cataract operations to 

patients in rural and semi-rural 

China, and The First People’s 

Hospital of Luoyang, which is 

well-known for ophthalmology. In 

conclusion, he said it was, “a very 

enlightening experience” and he’ll 

be back to help again next year. 

Cystoid Macular Oedema 

Dr Nick Mantell brought the 

evening to a close with a look at 

Hannah Kersten, Chelsey Wood and Samantha Simkin 

Emilie Langley and Jason Dhana 

Professors Helen Danesh-Meyer and Charles 

McGhee 

cystoid macula oedema (CMO). CMO is when fluid 

and protein deposits collect within the macula, 

leading to thickening and swelling which distorts 

central vision. It’s a common, non-specific response 

to a number of different ocular diseases, including 

diabetic retinopathy, vascular occlusions, postsurgical 

conditions (post-cataract is the most 

common cause) and uveitic diseases. Diagnosis is 

relatively easy with OCT, but without, the patient’s 

history and changes to visual acuity are critical, as 

is a thorough retinal exam. Monitoring is best done 

with OCT, measuring visual acuity changes and, 

as a lot of these patients are being treated with 

steroids, monitoring changes in intraocular pressure 

over time. For the most part treatment of CMO is 

relatively easy and effective. Optometrists should 

retain a high level of suspicion when it comes to 

CMO, especially post-surgery, so it can be diagnosed 

quickly and treated, he said. ▀ 

Eye Institute’s next educational event will be their 

annual scientific conference 5-6 November 2016, 

now incorporating workshops for optometrists 

and special educational opportunities for optical 

dispensers and optometry staff on Saturday 5 

November. 

Product recall 

– diabetic 

patients 

Novo Nordisk is recalling two batches of 

GlucaGen HypoKit in New Zealand. The 

GlucaGen HypoKit is indicated for the 

“treatment of severe hypoglycaemic reactions 

(low blood sugar), which may occur in the 

management of diabetic patients receiving 

insulin or oral hypoglycaemic agents”. Novo 

Nordisk found a small number (0.006%) of 

needles were detached from the pre-filled 

syringe supplied in certain batches of the 

HypoKit, so it’s recalling affected batches from 

wholesalers, pharmacies and patients in New 

Zealand. The recalled GlucaGen HypoKit batch 

numbers and expiry dates are: batch-FS6X537, 

expiry-31 August 2017; and batch-FS6X873, 

expiry-31 August 2017. The company has 

asked health professionals to ask their diabetic 

patients and their carers to check the batch 

number of any GlucaGen HypoKit in their 

possession to see if it’s affected. The product 

can be returned to their pharmacy where it will 

be replaced. ▀ 



23

Virtual reality in everyday practice 

Jai Breitnauer finds out what virtual reality (VR) can offer 

practices and gives the new Nautilus a whirl 

The “Year of VR” is the 

name many tech experts 

dubbed 2016. With the 

long-awaited launch of the 

virtual reality headset, Oculus 

Rift, plus other offerings to the 

market, like Google cardboard 

and the new Samsung Gear 

headset, 2016 is living up 

to its geek moniker. But 

if you thought VR was all 

about gaming, you’re sorely 

mistaken. 

“In medicine as a whole, VR 

systems have been used for 

some time as a surgical training 

tool. This trend will likely 

continue as the resolution of 

the displays, as well as methods 

to portray tactile sensation, 

improve over time,” says Dr 

Philip Turnbull, an optometrist 

and research fellow from 

the School of Optometry & Vision Science at The 

University of Auckland, noting the multitude 

potential uses of the technology. “There are already 

amblyopia treatment VR ‘games’ on the market, 

and it is not inconceivable that an eye-tracking VR 

system will be able to measure a range of clinically 

useful visual function in the near-future.” 

Dr Turnbull cites increased consumer computing 

power and cost reductions, from sharing 

technology elements with the cell phone industry, 

as driving forces behind the accessibility of VR. 

VR and AR (augmented reality, where digital 

devices add computer-generated images to 

real situations – think Pokémon Go) have many 

applications within optometry and ophthalmology, 

and headsets are now beginning to find their 

way into high street practices. Hoya are currently 

working on a VR Vision Simulator system, which is in 

a beta stage of development. “It’s a great dispensing 

tool that simulates the multifocal experience for 

patients,” said Hoya’s national customer services 

manager Sara Leonard at this year’s O-Show. While 

Essilor released its own VR headset called Nautilus 

in July, with 20 headsets being snapped up within 

the first week they were available. 

“We are pleased with the positive response; 

it’s been very well received,” says Kumuda Setty, 

marketing manager for Essilor New Zealand. 

Virtual reality in reality 

Paterson Burn have jumped on board the Nautilus 

ship, investing in headsets for all seven of their 

practices. 

“We’ve had it since early July and we’ve had a 

good response so far,” said dispensing optician 

Alisha Walker when I popped into her practice in 

Newmarket. “At first, we used it on everybody, but 

we’re now starting to learn what types of patients 

benefit from it the most. We’ve found myopes 

respond better to it than those with hyperopia, 

who can be quite sensitive. It’s also great for 

displaying the different sun care products we have, 

such as Transitions lenses.” 

The Nautilus itself is a light weight plastic unit, 

sealed on all but one side. A flap at the front opens 

to enable an iPhone to be placed in the front. An 

Alisha Walker demonstrates Nautilus’ capabilities to a client 

app on the iPhone demonstrates the different 

types of lenses to the user, who can look through 

the open side, and it is controlled by a linked iPad. 

“Most people are quite excited when we bring 

it out,” Walker explains as she sets the unit to my 

prescription. “It’s quite good fun to use.” 

The first set of lenses Walker demonstrates are 

Transitions. I’m able to look at two different scenes, 

a village square and a colourful marketplace, 

while the lenses scroll through the different tints 

available. An area around my peripheral vision, 

where my lenses wouldn’t reach in real life, allows 

me to compare the Transitions lenses to the view 

with a clear lens or naked eye. 

“The XtraActive lens is for driving; it’s a lighter 

tint,” explains Walker, changing my view so I’m 

looking at a street over a dashboard and through a 

windscreen. “In this one, you can see a reflection of 

a man in the rear view mirror that shows you what 

the lens colour looks like to other people.” 

We’ve moved away from static images now, and 

into video. I’m being shown the Xperio polarising 

lens and at first I’m driving a car along a highway, 

then I’m hiking in the mountains and finally I’m 

skiing down an alpine slope. With each lens change 

I am able to clearly the see the benefits and pitfalls 

of the lens, which allow me to make an informed 

choice before purchase. 

“Everyday annoyances can be quite intangible,” 

says Walker, as she demonstrates the Optifog and 

Crizal lens settings. “Things like steamed up lenses 

or moisture on your lenses are hard to imagine. This 

is where the Nautilus is really helpful.” 

I only have a single prescription lens need, but 

Walker is keen to talk me through the progressive 

lens showcase on the Nautilus. 

“People can be quite worried about going into 

progressives, they may have heard bad things,” 

says Walker, as she demonstrates an entry level 

lens that makes me feel like I’ve just got off a 

rollercoaster. “By showing them these products in 

different settings, and also walking up and down 

stairs – which can be a problem with progressives 

– clients can see how far the lenses have come and 

make a choice that is right for them.” 

Understanding the benefits of coatings, different 

standards of lenses and even different shade of 

tints can be hard without the ability to experience 

the lens, says Walker, and with the Nautilus fixed 

to my face, I can’t help but agree. 

“Nautilus really aides that conversation,” she says. 

“A big issue for the optics industry is that the only 

tangible part is the frame. Previously we worked off 

a chart to demonstrate lens differences. It’s easier 

with VR, and we can take into account a patient’s 

lifestyle before we make a recommendation.” 

VR certainly seems like it has a role to play in 

today’s practices, particularly in helping to convey 

the benefits of progressive lenses or the multitude 

of different lenses out there. Walker hopes that in 

VOSO TONGA 2016 

Mãlõ e lelei from the 

Kingdom of Tonga! 

The 2016 Voluntary 

Ophthalmic Services Overseas 

(VOSO) trip to Nuku ‘Alofa, Tonga 

this August included a Kiwi team 

of two ophthalmologists (Dr 

Andrew Riley from Auckland and 

Dr Jean-Paul Blanc now based 

in Hervey Bay, Queensland) 

and two optometrists (Richard 

Johnson and myself, both from 

Auckland). Although I had 

previously visited the Pacific 

Islands, this was my first trip 

to Tonga. I was reminded of 

the relaxed and stress-free 

lifestyle within my first hour 

when my taxi driver, en-route 

to my hotel, stopped to buy 

taro and thereafter went to 

a supermarket for his weekly 

shopping! 

Our working week was spent at Vaiola Hospital, 

in the Japanese government-built eye clinic. 

This involved a walk-in clinic service for patients 

requiring an eye exam or glasses, recalls for 

diabetic screening and lists of mostly pre-booked 

cataract surgeries. In total we saw 225 patients 

who were refracted and screened for diabetes 

and general ocular health. 

Most days we had finished with patients around 

4pm, so I spent some of my spare time in theatre 

watching Dr Riley complete a series of complex 

cataract extractions – the majority of which were 

SICS (Small-Incision Cataract Surgery). Interesting 

cases we came across included a child with a 

possible rhabdomyosarcoma, a sebaceous cell 

carcinoma, a dislocated crystalline lens in the 

vitreous and, as expected, keratoconus, diabetic 

retinopathy and dense cataracts. In particular, 

though there were many diabetes patients, there 

wasn’t much evidence of diabetic retinopathy, 

something VOSO has also noted from previous 

visits. Perhaps they’re all great at controlling their 

blood glucose levels! 

The local nurses are well-trained and are now 

experienced, so VOSO is moving into more of 

a supportive role where we supplement their 

training and assist in cases where needed. 

Initially the weather was not in our favour; 

very wet yet a comfortable 24 degrees with 

low humidity. Through the week the weather 

BY JASON DHANA* 

Jason Dhana refracting a patient in Tonga 

the future it could help with diagnostics as well. 

“It is likely that the ‘virtual’ reality headsets in 

the market today (which close off the real world, 

and can be isolating) will be replaced with ‘mixed’ 

reality (eg. Google Glass, Microsoft Hololens), 

where virtual images are overlaid on the real 

world,” says Dr Turnbull, stressing VR is far from 

a fad and will continue to rise in popularity. 

“Combined with other emerging technologies 

such as real-time eye tracking and machine 

object-recognition, VR will provide a mechanism to 

enhance the world around us, to simulate/correct 

vision loss or, for mixed reality headsets, to be a 

tool for the vision impaired.” ▀ 

improved, however, and the combination of fresh 

papaya and coconuts, fresh fish, and after-work 

wharf-jumping and snorkelling left us with a 

sense that we were actually on holiday. I’ve also 

learnt that diving masks and beards do not go 

well together, so I guess that means I won’t be 

snorkelling again! The coastline of the main 

island of Tongatapu is stunning, and is one of the 

few places in the world where Humpback whales 

migrate to breed in the warm Tongan waters. 

To top off the holiday feeling, toward the end 

of our visit, the clinic staff treated us to a night 

of entertainment, including traditional Tongan 

dancing and a local feast. 

The assistance from foreign governments is 

evident, however, and basic healthcare in Tonga 

still has a long way to go. Thankfully, there are 

numerous medical teams from Australasia 

helping our neighbours in need. This was my 

first VOSO trip and I couldn’t have asked for a 

better team to go with. It was truly a rewarding 

experience and the locals with their grateful 

smiles made it even better – I look forward to 

returning! 

For more information, visit VOSO’s Facebook page 

or website at www.voso.org.nz ▀ 

* Jason Dhana splits his week between emergency and 

glaucoma clinics at Greenlane Hospital and as a Professional 

Teaching Fellow within the School of Optometry and Vision 

Science, University of Auckland. 

For more personalised eye care 

talk to Dr Hussain Patel 

Consultant Ophthalmologist 

MBChB, MD, FRANZCO 

SERVICES INCLUDE: 

Glaucoma Specialist / Refractive Cataract Surgery 

General Ophthalmology / Acute & Emergency Eye Care 

Available throughout Auckland 

and also in Hamilton 

Phone 0800 750 750 or Fax 09 282 4148 

info@eyesurgeryassociates.co.nz or 

Dr Patel at: patel@glaucoma.co.nz 

www.eyesurgeryassociates.co.nz 

Eye Surgery Associates are a Southern Cross Health Society Affiliated Provider 

Support VOSO and have a good night out at Merediths in Auckland, which has chosen VOSO as its Charity of the Month for October 


Obituary: Johan Steeman 10/11/1929 – 10/08/2016 

BY KATHRYN STEEMAN 

Johan (John) Steeman was born at the 

beginning of the Depression on 10 November 

1929 in Den Helder, northern Netherlands. He 

was the younger and weaker of twins born to his 

Polish mother and Dutch father. Johan was born a 

‘blue’ baby and his parents did not think he would 

survive, but little Johan was stubborn, determined 

and possessed a strong will to live and he made it 

through. These were traits that would stay with 

him for life. 

Johan’s early years were dramatically changed 

in May 1940 when the Germans invaded and 

occupied the Netherlands. Life was hard during 

the war with little food, and Johan’s family hid 

three Jewish people, so needed to feed extra 

mouths. One evening, German troops burst in 

and demanded to know why there were three 

dark haired people amongst all the blond ones. 

Johan’s mother was quick thinking and took the 

photo of her older son from her first marriage, 

whom had been unwillingly conscripted into the 

German army. She said the soldier in this photo 

was that woman’s husband, and that was their 

little boy and the older woman was his mother-inlaw. 

This satisfied the officer and they left. Johan 

said he had never been so scared as the Germans 

would have had no qualms about taking everyone 

outside and shooting them. He learnt from his 

mother to be quick thinking and always find a 

way around a problem. 

At the end of the war, the Jewish residents 

left only to find most of the people they had 

known were no longer alive. They were so 

grateful to Johan’s parents that they gave them 

enough money to pay for their children’s further 

Johan Steeman’s ‘Alien’ passport, which he was required to carry until the late 1970s as a noncommonwealth 

passport holder 

education. Johan went to technical college in 

1946 to obtain his engineering certificate. After 

graduating, Johan was called up for National 

Service, but as the youngest of five sons, he had 

the option not to go. He stayed in Den Helder 

where he worked as a civilian engineer at the 

navel harbour workshop. 

This job only lasted for a short while as returned 

servicemen were being employed. Johan then 

went to work as a plumber’s mate but was eager 

to see something of the world. His twin had 

finished his National service in Indonesia and had 

gone on to Australia to work in the Queensland 

sugar cane fields. Johan said he would meet him 

there, but Australian migrant recruiters said he 

would need to show five years’ work experience 

and Johan only had two and a half years. Luckily 

the NZ migrant recruiters only required two years’ 

work experience. 

Johan was on one of the first four boats of 

Dutch immigrants to arrive in New Zealand in 

1952. He could not speak much English and found 

the first 18 months very hard. Luckily his twin 

– who had now moved to New Zealand – could 

speak better English and he got Johan his first job 

in Christchurch at engineering company Andrews 

& Bevan where he worked until 1954, when he 

went to work for another equally well known 

engineering company, CWF Hamilton. Johan met 

his English wife Evelyn in 1954 and they married 

in December 1955. 

Johan worked for CWF Hamilton on night shift 

until 1966 and it was during this time he had his 

first contact with the optical side of things. During 

the day his own small engineering business was 

doing machine repair work for Standard Optical. 

Johan’s good friend Eddie Turner was working for 

them and had recommended 

Johan for his quality of 

workmanship. 

In the early 1970s Johan 

found himself without a job 

after the camping equipment 

manufacturer he worked for 

since 1968 was unexpectedly 

dissolved. Whilst deciding 

which direction to go next, his 

friend Eddie Turner mentioned 

a new company were starting 

up in Christchurch and needed 

someone with engineering 

knowledge. 

The company turned out to be 

the contact lens manufacturing 

business Corneal Lens 

Corporation. Johan got the job 

of laboratory manager and was 

sent to Australia for training. He 

became a pioneer in the contact lens field and very 

forward thinking. In the early 1970’s importing 

goods was not easy and very expensive. So Johan, 

after much trial and error, made up most of the 

polishing ‘pitch’ compounds and polish mixtures 

required for the different PMMA and early soft lens 

materials in use. He was instrumental in making 

some of CLC’s first polishing machines, and other 

equipment, that was easy to service and replace 

and more financially viable. 

CLC’s ‘Generator’ machine, which was the 

equipment used at the time to cut the Conoid 

lens design, was a temperamental and tricky 

piece of equipment that required a talented 

engineer like Johan to keep it under control. It 

was the bane of many a Steeman family weekend 

outing as Johan was forever having to go in to 

reset the machine ready for Monday. Knowing 

how to produce a good final product from a 

machine like this required a talent few had but 

Johan possessed. Johan worked at CLC until 1977. 

After this he went back to engineering and 

worked as a tool and die maker, but his dream 

was to open his own contact lens laboratory. He 

decided that if he could make equipment for his 

previous employer then why not for himself. So 

over the next three years, in his weekends and after 

work, Johan, with the permission and generous 

use of his current employers milling machine and 

lathes, made his own polishing and engraving 

machines and two contact lens lathes. In June 

1980 he finally fulfilled his dream, and Precision 

Contact Lenses Ltd began manufacturing. I joined 

my father at the end of 1981 and my brother Neil 

joined in 1986 – a true family affair. 

Johan wanted to help young newly graduated 

optometrists and so he provided his trial sets 

free of charge and encouraged them to try fitting 

customised contact lenses to their patients by 

making all parameters available no matter what 

they wanted. He did not make stock lenses as 

he felt this restricted the fit for the patient. 

Johan also re-introduced a design from the late 

1960’s at the request of a practitioner friend in 

Dunedin. The practitioner wanted to keep the 

BCOR spherical but needed some toricity only 

in the secondary/peripheral curves. So Johan 

developed what was to be known as the TSP 

Curve lens design and another generation of 

practitioners had the experience of giving their 

patients a better-fitting lens if needed. Johan was 

encouraged by the feedback he received from 

practitioners who said patients often asked if the 

lens was still in their eye, or said that they could 

see like a hawk. Johan also used his engineering 

skills to make a range of his own plastic products, 

Tweezer, Contact Lens Catcher and various 

packages and cases. He had his own milling 

Johan Steeman in recent times 

machine and lathe and enjoyed creating injection 

moulds for these products. 

Johan’s personal health had moments of 

upheaval; in 1984 he was diagnosed with diabetes, 

in 1994 he had a heart attack at Hamner hot pools 

and in 1995 he battled prostate cancer. He had 

further problems with his heart and circulation 

and in 1999 he had a triple bypass. This gave him 

a new lease of life, but his diabetes was getting 

harder to control with just tablets so in 2005 he 

was put on insulin. Too high sugar levels due to 

an under dose of insulin shortly after left him in 

a coma. Doctors didn’t think he would make it, 

but that stubborn, determined, strong will to live 

kicked in and he pulled through. Afterwards Johan 

took things slower and left the day-to-day running 

of the business to myself and Neil. 

The earthquake of February 2011 nearly 

shattered Johan’s dream of owning his own 

laboratory. It was a tense three months before it 

was known whether or not the laboratory would 

survive. Luckily PCL managed to salvage all their 

equipment and after much TLC and overhauling 

managed to keep going and the company is still 

trading today. 

Johan’s final ‘occupation’ was that of funloving 

and generous Grandad, one that he 

enjoyed very much. He had many dreams in 

life and on reflection fulfilled most of them. He 

battled through the last six weeks of illness but 

unfortunately did not win and it was his time to 

finally rest. 

Johan is survived by his children Kathryn, Neil 

and Martin and his three grandchildren. ▀ 

Retina NZ workshop 

BY SALLY ROSENBERG* 

Introduced by Mike Smith and hosted by the 

Blind Foundation, Hamilton, a workshop 

hosted by Retina NZ in August was attended 

by participants from around New Zealand. The 

two presenters and facilitators, Dieu Nguyen and 

Vildana Praljak from Vision Australia showed their 

style from the outset of the meeting. 

The team in the room varyingly knew or didn’t 

know each other so the process of introductions 

took on a special flavour. We did the usual ‘roll 

call’ but with a twist – each person had to add an 

alliterative adjective to their name. So we had the 

pleasure of meeting Reliable Ricky, Peaceful Peter, 

Adaptable Amy and Sincere Sue, amongst others. 

I’ve been to many events, endured many ‘ice 

breaker’ moments and I have to say that this was 

one of the most effective I’ve experienced, bridging 

the gap between professional and personal 

through the reflective choice of descriptor. 

The purpose of the workshop was to explore 

services that are available to the low vision 

people of New Zealand, those where the criteria 

for support through agencies and the Blind 

Foundation have not quite met yet. The approach 

taken by Dieu and Vildana was a mixture of 

group discussion, ‘around the house’ individual 

statements, small group work to explore 

solutions for problems outlined in scenarios, and 

a bit of role playing to offer differing viewpoints 

of a pertinent challenge. 

Key messages and challenges from the day 

include the perceived gap between a clinician’s 

view of risk in the landscape of low vision 

conditions and that of the person being affected 

by low vision. In the ideal world there would be a 

person-centred approach to support for low vision 

patients and collaboration between clinicians, 

providers, organisations, patients and their family. 

The anecdotal barriers in New Zealand to this 

being successful and available ubiquitously are 

time and money. 

However, these are not insurmountable – 

improvement in the processes and approaches 

to low vision support can improve the personcentred 

outcome. Provision of guiding questions 

for clinicians to ensure that assumptions about 

accessible services don’t derail a holistic approach 

could help. 

Even within the room of interested individuals 

there was a mismatch of knowledge – the option 

of using occupational therapists and social workers 

as part of the whole equation was discussed, for 

example. The Waikato DHB’s Disability Support 

Services carries out in-home assessments of need 

and can offer support in novel ways. Prevention of 

falls is a strong driver for the provision of support 

and if adding resources and aids to the home of a 

person with low vision reduces the likelihood of 

falls then this support can be accessed. 

Another area of support not commonly offered, 

and this was backed up by several participants with 

low vision themselves, is counselling to assist a 

person manage the emotional and psychological 

impact of a diagnosis of low vision and a prognosis 

of gradual (or rapid) blindness as a result of their 

condition. This is an area of improvement that 

could be added to the suite of tools in a clinician’s 

treatment and management regime. 

The topic that took us to the role play was the 

return to work of a person with low vision after an 

absence from the workforce of some ten years. Dieu 

stated that employment is the greatest symbol of 

social inclusion in modern urban life. People are 

judged on output and employment status and this 

links strongly to our sense of self-worth. A survey of 

Australian employers conducted by Vision Australia 

found that only 17% would employ a vision-impaired 

person. 

Five teams role-played the differing influencers 

in a ‘return to work’ situation – the person herself, 

friends and family, the employer and support 

agencies. The consensus was that “Rachael” would 

confirm her place in the workforce, that she would 

be supported and assisted to return to meaningful 

work with additional help from technology that 

wasn’t available ten years prior. As a group we 

clearly had a bias towards a positive outcome (and 

I quietly left the meeting with a slight smugness 

that if we surveyed New Zealand employers we’d 

achieve better than 17%!) 

After lunch, the focus of the workshop shifted 

specifically to innovative ways for agencies to work 

together. As practice manager of Hamilton Eye 

Clinic duty called so the bridge was built without 

a view from private ophthalmology, however 

mine is just one view. Others in the meeting 

included optometrists, a post graduate student 

of low vision, executive members of Retina NZ, 

Blind Foundation representatives, occupational 

therapists and nurses, so the innovation pathways 

were well seeded with diverse inputs. 

Key messages from the day included: 

• Strength-based conversations with people 

facing low vision challenges which don’t (yet) 

meet the Blind Foundation criteria are a necessary 

part of a management plan for each person 

• Blind Foundation, Disability Support Link and 

allied health services are all accessible, at least 

for enquiry, in the holistic support of a low vision 

person 

• Making time or taking time for a ‘joined up’ 

approach to low vision care is the most personcentric 

mode for treatment and management – 

the challenge of insufficient time can be mitigated 

somewhat if we understand what the available 

options are and can access information easily ie. 

sharing our knowledge and knowledge of each 

other as providers. 

And Mike Smith – I’ll pick you to order the lunch 

any day!!!!! ▀ 


* Sally Rosenberg is practice 

manager at the Hamilton Eye 

Clinic which she manages 

alongside other consulting 

work. Prior to this she worked 

in senior roles predominantly 

in the dairy and agriculture 

sectors. Personal interests 

include choral singing, 

rudimentary fitness (no 

marathons) and sailing, which 

is a challenge in the land-locked 

Waikato! 


25

Style-Eyes 

BY JO EATON* 

On reflection 

Some years ago, during my first work experience at a spectacle shop, I had 

an interaction with a customer that brought me to tears. A woman came 

in looking for new glasses. She’d left it too long and she really needed a 

new pair in her updated prescription. We picked out a few pairs for her to 

try on. When it came to putting them on and looking in the mirror, it was 

obvious she didn’t want to look at herself. She screwed up her face at the 

first sight of her reflection, looked away quickly, mumbled, “Not these ones” 

and reached for the next pair, only to have the same reaction. The thing is, 

she looked great. All of the frames complemented her face shape and the 

colours we’d chosen made her eyes pop. I told her this, but because I was 

trying to sell her something, she told me, “You have to say that.” 

I was so surprised that I didn’t know how to respond. I was thinking, “Well, 

I’m new to this job and I really don’t have to say those things. I don’t earn 

commission. I’m not going to sell you something that I don’t think looks 

right on you or works for your prescription.” But I didn’t know how to say 

that without sounding rude. So we moved on. She chose some frames, but 

I could tell she didn’t love them. She left and I went into the back room to 

tell the optometrist and I felt my eyes prick with tears. I wanted to know 

why she couldn’t see what is beautiful about her. Why couldn’t she see her 

beautiful eyes, brightened by the frames we’d picked? 

There’s something beautiful about everyone 

I soon discovered that this is not unusual. The optometrist told me she had 

seen similar situations quite often over the years. I wanted to know how 

I could make people feel comfortable looking at themselves. I wanted to 

know how I could help them see the beauty that I see in them. 

Lights, cameras… 

There are some practical things you can do to help when words fail 

you. Lighting should be considered. No one looks their best under harsh 

fluorescent tubes. If your store has these, then perhaps consider upgrading 

to more flattering lighting options. A low-cost alternative is to take out 

or turn off some of the tubes and get some decent free-standing lamps 

(without fluorescent bulbs) near your mirrors and angle them correctly. 

The last store I worked in had very flattering lighting, but I often like to 

encourage customers to go out onto the street with a hand mirror to look at 

themselves in natural sunlight if they’re expressing concerns. Of course, this 

is also great for trying on sunglasses. 

People who dislike looking in the mirror often equally dislike having their 

photo taken. Even so, if you can encourage them to get out their phone to 

take some selfies (or take photos of them yourself) trying on frames, these 

photos can be sent to family or friends who can help them make decisions 

and send some positive reinforcement that they look great. This comes 

with a warning though – often family and friends will disagree with the 

customer and dispenser’s choice! 

Ask the professionals 

Geraldine Booth from Geraldine Booth Optical in Wellington says that it’s 

important to get to know a patient before you offer opinions on how a 

frame looks on them, “If I don’t know a patient at all, then I will [initially] 

hold back on a cosmetic opinion. I know that can be hard but hold off on it! 

Fit is of prime concern, but as you see how people react to frames it starts 

to reveal their personality. I often tell them that any feedback is good – 

negative and positive. Again it reveals more of their personality... So much 

comes down to the individual and you have to find your way of ‘unpeeling 

the layers’ to establish the best plan of attack.” 

When they’re having trouble looking in the mirror, she says, “I think 

it’s all part of coaxing them along until they have confidence in you and 

know you’re not there to sell. Optical practices do not fit a retail model. 

Remember we ‘sell’/dispense what’s termed ‘optical appliances’ in formal 

speak. We are governed by strict government-enforced professional 

standards. We’re not just selling a commodity, so exercising your 

professional role is paramount.” 

Great advice! 

Dealing with this situation is something that I’m still learning. When my 

greatest pleasure in this role is helping someone look fantastic, it’s hard if a 

customer can’t recognise the beauty you see in them. 

How do you deal with this? I’d love to hear! Email me: jo@eyeheartglasses. 

com 

* Jo Eaton is an optical dispensing student at RMIT. Originally from Wellington, Jo became 

interested in eyewear after discovering she was myopic at the age of 14. In 2008, many years 

after deciding to make unusual glasses her ‘thing’, she founded eyewear fashion blog ‘Eye Heart 

Glasses’. When she’s not immersed in the world of spectacles, she works in digital marketing, 

DJs, volunteers for community radio and is a director of feminist music organisation LISTEN. 

Visique Oamaru’s new look 

Oamaru Visique’s team Dave Roberts, Barb Bain and Nicky Hay 

They say a change is as good as a holiday, and Visique 

Oamaru Eyecare have certainly embraced this 

philosophy, revamping their interior to reinvigorate the 

practice. 

Last fitted out in the 1990s, while under the name Peter 

Dick Optometrists, current owners Dave and Debbie Roberts, 

who took over the practice in 

2007, felt the time was right for 

a change. 

“We needed to use our 

space better,” says Dave. “It 

was originally set up as a one 

optometrist, part-time practice. 

We are now full-time and had 

outgrown the previous layout. 

We needed another testing 

room to accommodate another 

part-time optometrist.” 

Working with a local builder 

and interior designer, Dave and 

Debbie had a ‘Steampunk light’ 

vision for the interior, to reflect 

Oamaru’s local heritage and 

embrace the Steampunk trend. 

“Steampunk is described as 

a mixture of Victoriana and 

science fiction,” says Dave. 

“Oamaru is the self-proclaimed 

‘capital of steampunk’ and we 

wanted to incorporate the light 

industrial side of it.” 

The practice was completely 

Statuesque, intelligent and fiercely independent, it’s hard to 

image Dame Maggie Smith even having a cold, let alone a more 

serious condition. The truth is that formidable actress Maggie 

Smith was diagnosed with Graves’ Disease in 1988, which required 

optical surgery for Graves ophthalmology – the characteristic 

raised lids, bulging eyes and redness that affect sufferers of the 

autoimmune disorder. 

Understanding more about eye conditions than others, Dame 

Maggie became a patron of the International Glaucoma Association 

in 2012, and more recently it has emerged that she has glaucoma 

herself. “Forgive me for looking at you like this. It’s because I’m blind 

in one eye, not being furtive”, she said to a reporter for the Daily 

Telegraph during a recent interview. The award-winning star of 

stage and screen is now 80 and still ploughing through a selection 

of wonderful roles, such as the beloved Professor McGonagall in the 

Harry Potter franchise and Mary Shepherd in Alan Bennett’s The Lady 

in the Van. The fact she is able do this with a visual impairment (and 

the need for a hip replacement) can surely only win this formidable 

star more adoration. ▀ 

gutted and remodelled more efficiently, to incorporate two 

testing rooms and a room for the Medmont, which used 

to be in the hallway. They now also have a kitchenette and 

a sink, with hot running water – which has caused much 

excitement! 

“We used to have to boil the kettle and fill a bucket to do the 

dishes,” says Debbie. 

They’ve also doubled their 

retail space and upgraded their 

operating systems, moving to 

a cloud-based server and VOIP 

phone system. 

“(The new fit out is) great for the 

customers. It’s warmer, we have a 

wider range of frames, the lighting 

is better, and it gives more privacy,” 

says Dave “It has allowed us to 

grow our business and see our 

patients more quickly.” 

Local patients have given 

the new-look practice an 

overwhelmingly positive response, 

says Debbie. 

“We’ve had people just pop in to 

have a look because someone told 

them about the refurbishment. 

Someone even said they felt 

they had popped into a shop in 

Parnell. It was absolutely worth 

the investment and the inevitable 

stress that goes along with a 

renovation.” ▀ 

Stars and their eyes: Dame Maggie Smith 

William Morris’ 

new campaign 

William Morris has 

launched its European 

autumn/winter 

fashion campaign, with stylish 

images shot in some of London’s 

trendiest spots. 

Using locations around Notting 

Hill, and featuring a canine 

companion named Quincy, the 

iconic British eyewear brand 

aims to showcase their sense 

of humour and patriotic eye as 

well as their new designs, the 

company said in a press release. 

Alongside the parent collection 

is the all-new Wills collection, 

aimed at stylish teens. Subtle 

re-workings of popular classics 

for younger, more petite face 

shapes, open up a range of 

on-trend styles to a more 

junior, but no less demanding 

audience. The company is also 

using lighter yet more durable 

materials, it said. 

William Morris is distributed 

in New Zealand by Phoenix 

Eyewear. ▀ 


Alcon launches 

DT1 multifocal 

The Alcon roadshow for the launch of its new Dailies Total1 

Multifocal contact lenses arrived in Auckland in August, 

with special guest speakers Tim Grant, Alcon ANZ’s regional 

professional affairs manager, and Mark Koszek, a therapeuticallyqualified 

Australian optometrist with a special interest in contact 

lenses, orthokeratology and dry eye. 

Chairing proceedings at the Crowne Plaza Hotel in Auckland, 

Karen Fowler, Alcon Vision Care ANZ country head, said New 

Zealand is second only to Australia to launch Alcon’s new multifocal 

version of its popular, premium Dailies Total1 contact lens (CL) 

range. While Grant added that New Zealand was the first country in 

the world to actually sell the product to a patient. 

Described by Alcon as the “first and only multifocal water gradient 

contact lens,” Grant provided an in-depth look at the science and 

technology behind Dailies Total1 and the new multifocal lens. 

According to Alcon, “The Dailies Total1 water gradient 

technology reduces end-of-day dryness, as the water content 

approaches nearly 100% at the outermost surface of the lens. The 

hydrophilic (water-loving) surface of the lens is almost as soft as 

the surface of the cornea to enhance comfort, while the innovative 

optical design of this new multifocal lens offers a smooth 

progression of power designed to provide a seamless experience 

between distant, intermediate and near vision.” 

In Alcon studies, compared with similar lenses, 8/10 people 

reported better end-of-day comfort with the new Dailies Total1 

lenses and 9/10 said upon trying it that it was not like wearing a 

contact lens at all. Research supported by clinical studies conducted 

on Dailies Total1, in comparison with other silicone hydrogel daily 

disposable contact lenses, by the Optometry and Vision Science 

Department at the University of Waterloo in Ontario, Canada, which 

looked at both the comfort response and the clinical performance, 

Richard Chinn, Jeremy Wong and Darryl Eastabrook 

including lens surface deposits, wettability, pre-lens non-invasive tear 

breakup time, lens movement and centration. 

Bringing the proceedings back to multifocals, Grant explained 

how monovision lenses are on the decline, while multifocals are 

on the up, as new technology comes into play. “In practices every 

day we are talking to patients about adaptation…adaptation is 

another term for ‘it takes time’, it takes time to have that delight our 

patients wish for.” 

Alcon’s “Precision Profile Design” technology features smooth 

progression of power gradients, with the ability to push-plus 

without adversely affecting distance vision, he said. 

The lens is particularly aimed at people with presbyopia, as an 

alternative to reading glasses or bifocals, though it suits progressive 

Renata Watene and Jared Neame from Occhiali with Alcon’s Karen Fowler (centre) 

lens wearers equally well too, said Koszek. 

It also makes economic sense to encourage more CL patients, he 

added, referring to a study he conducted in his own practice. His study 

found that his average CL wearing-patient spent A$1,340 over four 

years, compared with an average non-CL patient who spent A$656 over 

the same period. Plus, on average, his CL patients remained patients for 

11.4 years, while non-CL patients stayed for just nine years. 

In conclusion Koszek, who referred extensively to the Waterloo 

University studies, said he’d actively recommend the new multifocal 

from Dailies Total1, that optometrists should introduce it to 

potential patients (myopic and presbyopic) early, they should “push 

the plus in hyperopes”, closely monitor patients and sell the science 

to get buy-in and trial. ▀ 

PORSCHE DESIGN 

EYEWEAR 

Hirdesh Nair and guest speaker Mark Koszek 

Bhavna Patel, Rochelle Yukich and Roger Apperley 

CASUAL ELEGANCE IN TITANIUM 

www.porsche-design.com 

For more information, please contact BTP 

or visit BTP stand at Visionz Conference. 

T: 64 7 307 2410 | E: info@btpid.co.nz 

BTP | 58 McAlister St, Whakatane 3158 | PO Box 604, Whakatane 3158 |www.btpid.co.nz 

Paula Farrar, Robert Ng, Kristine Jensen and Tony Cradwick 



27

DISPENSING OPTICIAN 

HAVELOCK NORTH 

Grant & Douglas Optometry & Eyewear are seeking a qualified 

Dispensing Optician (or someone who is currently training to be 

a Dispensing Optician). We are a busy independent Optometry 

practice providing excellent eye care and eye wear solutions 

tailored to our customer’s individual needs. 

This role will be based mainly in our Havelock North practice 

however you may occasionally be required to work in our 

Hastings practice. 

This is a great opportunity for a confident, versatile individual 

who has the following attributes: 

• Experience in customer service with a proven track record for 

a high level of customer satisfaction. 

• Excellent communication and sales skills. 

• Shows initiative, is reliable and honest. 

• Strong computer literacy. 

• Good standard of personal presentation. 

• Able to work cohesively and productively within a team. 

Monday to Friday, approx 30 - 40 hours per week (Negotiable) 

Please email your CV and cover letter outlining your skills and 

experience to Anna Byers abyers@grantanddouglas.co.nz 

OPTOM PLATE FOR SALE 

The personalised plate OPTOM is for sale after 18 years. Asking 

price is $3000+GST or make an offer. Additional fees apply to 

change or remove message and have the plate made. 

Contact stuart.warren@nsoptom.co.nz 

AUCKLAND PRACTICE FOR SALE 

Finally, a bustling, central Auckland practice for sale! 

The current owner is looking to retire and would like to find 

someone to take over this profitable, independent practice and 

their loyal customers. There’s tremendous scope for growth for the 

right owner who has the skills and the energy, drive and marketing 

know-how to make this practice stand out. 

This practice is ideally suited to an optometrist who yearns to be 

truly independent and is ready to run their own business, make 

their own decisions and reap the rewards from the hard work they 

put in. Or perhaps you’re overseas and looking to move or return to 

New Zealand? 

Situated in a very sought after suburb with good schools and 

amenities close by, with many high-value customers and a great 

team, this practice has it all, and you’ll receive the full support of 

the current owner in a comprehensive handover process. 

If this sounds like you, please email, in strictest confidence, 

info@nzoptics.co.nz, quoting code PFSB20 

RETAIL/OPTICAL ASSISTANT 

PART-TIME 

Optik Eyecare Pukekohe Ltd are looking for a part time retail/ 

optical assistant. The position would include reception and 

general optical duties. Starting immediately. 

All enquires please email admin@optik.co.nz 

MANUAL VERT NEEDED 

Do you have an old manual lens meter lying around gathering 

dust? Why not sell, or rent it to a training DO? If you can help, 

please email mgr.pukekohe.nz@specsavers.com 

PART-TIME DO/OPTICAL ASSISTANT 

Nicholls Optometrists in Browns Bay are looking for a part-time 

Dispensing Optician or Optical Assistant to provide maternity 

cover for 12 months from November 2016. Days required are 

Mon & Fri 8.30-5.30 and Sat 8.30-1.30. You will become part of an 

experienced team in a well resourced independent practice. Please 

contact Bruce Nicholls in confidence at nicholls4@gmail.com 

D/O TO COVER MATERNITY LEAVE 

We require a dispensing optician for a one year fixed-term 

contract to cover maternity leave in sunny Gisborne. Hours and 

days worked flexible, either part-time or full-time. Contact either 

Steve Stenersen or Sue Kain (06) 867 5465, 027 486 7540 or 

steve@sko.co.nz 

Whether you are looking for new staff, to sell your practice or buy 

some equipment, NZ Optics classified page connects you. 

For all your advertising needs email 

Lesley@nzoptics.co.nz or 

(for classifieds only) do it online at 

www.nzoptics.co.nz 

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Thinking of selling your practice - we have buyers 

Considering buying - we’ll give you all the options 

OpticsNZ specialises in optometry practice sales, 

we've helped dozens of Optometrists buy and sell their practices 

For more information contact Stuart Allan on: 03 546 6996 

027 436 9091 stu@opticsnz.co.nz www.opticsnz.co.nz 

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Oct 2016

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