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NEW ZEALAND<br />
Pregnancy<br />
and the eye<br />
AUSCRS<br />
castaways<br />
OCTOBER <strong>2024</strong><br />
DOs’<br />
remake role<br />
Page 16<br />
Page 30<br />
Page 48<br />
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as required. Blink Intensive Tears, Blink Intensive Tears PF, Blink Intensive Tears PLUS: Place 1 or 2 drops in affected eye as required, then blink several times. Use as often as required. References: 1. Wasmanski A et al. Cross- Over Evaluation PEG-400 0.4% & 0.25% artificial tears<br />
in mild dry eye patients. Poster ARVO, 2010. 2. Montani G. lntrasubject tear osmolarity changes with two different types of eye drops. OVS. 2013; 90(4): 372-377. ©<strong>2024</strong> Bausch & Lomb Incorporated. ®/TM denote trademarks of Bausch & Lomb Incorporated and<br />
its affiliates. Other product names are trademarks of their respective owners. Bausch & Lomb (New Zealand) Ltd c/- Bell Gully Auckland, Vero Centre, 48 Shortland Street, Auckland 1140, New Zealand. Marketed by Radiant Health. 0508 RADIANT. BNF.0002.NZ.24.
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revision. 3. DOF2023CT4043 - Clinical investigation of the TECNIS IOL C1V000 and C2V000. Patient Satisfaction Outcomes 18 July 2023. 4. Black D. et al.<br />
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REF2023CT4129. 5. DOF2023CT4041 – Clinical investigation of the TECNIS IOL, C1V000 and C2V000 Tolerance to Refractive Error. 17 July 2023.<br />
6. DOF2023CT4036 – Clinical Investigation of the TECNIS IOL, Models C1V000 and C2V000. Contrast Sensitivity Outcomes. 17 July 2023. 7. Vilupuru S, et al.<br />
Clinical evaluation of a new Extended Depth of Focus intraocular lens based on a refractive technology. Abstract ISOP 2023. REF2023CT4178.
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Inside<br />
14<br />
6 EDITORIAL<br />
NEWS<br />
8 Taking the sting out of cataract surgery<br />
10 ODOB tackles CPD woes<br />
14 Shingles and the over-50s<br />
22 Foureyes Foundation seeks partners<br />
24 Diabetes care by ethnicity<br />
34 Predicting glaucoma treatment response<br />
52 Eyeball <strong>2024</strong>: Starry night<br />
30<br />
FEATURES<br />
16 What to expect when patients are expecting<br />
40 MIGS – in the surgeon’s seat!<br />
48 The DO’s role in spectacle remakes<br />
34<br />
EDUCATION<br />
28 AI: an exciting frontier<br />
30 AUSCRS’ desert I-land castaways<br />
36 Glaucoma: stents, trabs and tubes<br />
44 Inaugural emergency eyecare seminar<br />
46 Retina Specialists’ genes and gems<br />
RESEARCH<br />
26 Shingles, uveitic glaucoma and more<br />
BUSINESS<br />
42 Your business’s BFFs<br />
52<br />
12<br />
54 CHALKEYES PRESENTS:<br />
The nothing that is not there<br />
53 CLASSIFIEDS<br />
51<br />
19<br />
www.nzoptics.co.nz | PO Box 32185, Devonport 0744 | New Zealand | ISSN 0110-8697 (Print) | ISSN 2703-660X (Online) | facebook.com/NZOptics<br />
For general enquiries or classifieds please email info@nzoptics.co.nz<br />
For editorial, please contact Susie Hill at susie@nzoptics.co.nz or +64 21 815 504 or Drew Jones at drew@nzoptics.co.nz<br />
For all advertising/marketing enquiries, please contact Susanne Bradley at susanne@nzoptics.co.nz or +64 27 545 4357<br />
To submit artwork or to query a graphic, please email susanne@nzoptics.co.nz<br />
NZ Optics is the industry publication for New Zealand’s ophthalmic community. It is published monthly, 11 times a year, by New Zealand Optics 2015 Ltd. Copyright is held by NZ Optics<br />
2015 Ltd. As well as the magazine and the website, NZ Optics 2015 Ltd publishes the New Zealand Optical Information Guide (OIG), a comprehensive online listing guide that profiles the<br />
products and services of the industry. NZ Optics is an independent publication and has no affiliation with any organisations. The views expressed in this publication are not necessarily<br />
those of NZ Optics 2015 Ltd or the editorial team.
Seeing things… differently<br />
SPRING HAS WELL and truly<br />
sprung and I’m loving the longer<br />
evenings, as I’m sure you are too.<br />
While our globetrotting<br />
publisher/editor Lesley is soaking<br />
up the latest trends at Silmo in<br />
Paris, Drew, Sara, our ‘editorto-the-rescue’<br />
Susie and I have<br />
been busy holding the fort. This<br />
month, we are pleased to present<br />
a fascinating feature on the<br />
impact of pregnancy on the eye<br />
by our wonderful optometrist<br />
contributor Layal Naji (p16), a<br />
CPD update from the ODOB<br />
(p10), musings from our ‘whitecaner’<br />
columnist Trevor Plumbly (p54), plus Dr Ben LaHood’s take on the<br />
latest AUSCRS conference, held on sunny Hamilton Island (p30) – never a<br />
dull moment there!<br />
And remember, World Sight Day is just around the corner on Thursday<br />
10 <strong>Oct</strong>ober. How will your practice mark it? Why not consider joining<br />
the final stretch of the Eye Health<br />
Aotearoa campaign spotlighting kids’<br />
eye health? For resources, see www.<br />
eyehealthaotearoa.org.nz/childrens_<br />
eye_health_campaign. Or, if you have<br />
a manual lensmeter collecting dust,<br />
Fred Hollows Foundation is seeking<br />
equipment support (see classifieds p53).<br />
Enjoy!<br />
Susanne Bradley,<br />
NZ Optics<br />
CONTRIBUTORS<br />
Vicky Wang<br />
Therapeutically qualified optometrist<br />
Vicky Wang grew up in a family with<br />
two generations of doctors and nurses,<br />
so curiosity about the human body<br />
was practically in her DNA, she says.<br />
“I remember the thrill of peeking at<br />
specimens and glass jars of organs<br />
whenever I visited my grandfather’s<br />
hospital.” But, as a high myope herself,<br />
it was the eye that really caught her<br />
attention and ultimately sparked her<br />
passion for optometry.<br />
Vicky says she vividly remembers fitting spectacles on a child with<br />
a significant refractive error for the first time. “The smile on his face<br />
was absolutely priceless. That was when I knew I had found something<br />
truly special. Even now, every time I place aphakic contact lenses on a<br />
baby and watch their eyes start to focus and connect, my heart pounds<br />
with excitement.”<br />
What gets Vicky fired up about the future of optometry is the human<br />
element, she says. She’s involved in a school screening project with<br />
Auckland University’s School of Optometry and Vision Science, which she<br />
says will be a highlight for the next couple of years. “We’ll be traveling across<br />
various parts of New Zealand to provide a much-needed service to kids.”<br />
After-hours, Vicky says her two children keep her on her toes, attending<br />
their music concerts and sports events. She also has an enduring love for<br />
music and baking. “At one point, I even dreamed of owning a cosy coffee<br />
shop where I could bake treats and host live music nights. Who knows,<br />
maybe one day I’ll combine all my passions into one!”<br />
Vicky reports on Greenlane’s inaugural emergency eyecare seminar on p44.<br />
Lynden Mason<br />
At 18 years of age, when Lynden Mason<br />
had been accepted into Otago medical<br />
school, his future was seemingly<br />
mapped out. “But my entrepreneurial<br />
ventures had given me a taste for<br />
making money without as much effort<br />
as I’d have to put into being a doctor,”<br />
he admits. The grumblings of a career<br />
counsellor, rather than his advice, was<br />
what eventually steered Lynden into<br />
optometry. “He complained he’d just<br />
spent 30 minutes getting his eyes<br />
tested and it had cost him $800 for new glasses. My interest was piqued!”<br />
Fiscal benefits aside, within his first year as an optom, Lynden says<br />
he’d realised how eyecare could make huge tangible improvements to<br />
patients’ lives. “To this day, this is still what I get such a buzz out of: either<br />
providing reassurance to someone who’s nervous about losing their vision<br />
or showing them how much improvement we can give them.”<br />
Lynden suggests any optom at the start of their career should learn to<br />
be a good communicator and a great listener and remember people are<br />
at optometry’s heart. He also encourages them to be open to exploring<br />
the many avenues the profession offers. “I went straight into focusing<br />
on business, which meant I didn’t take advantage of being young. I wish<br />
someone had told me not to take it all so seriously in my youth!”<br />
Lynden’s business partner, Teréze Taber, is also his wife. He says<br />
they’re fortunate to really enjoy working together. “Our skill sets are<br />
very complementary and we give each other space to thrive in the areas<br />
that we each excel. It’s always refreshing to be able to bounce ideas off<br />
someone who knows you well and sees your vision.”<br />
Lynden and Teréze offer practice owners some bottom-line fundamentals<br />
on p42.<br />
6 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
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NEWS<br />
Taking the sting out of cataract surgery<br />
By Drew Jones<br />
WHAT IS EXPECTED to be permanent Pharmac funding of Ilevro, a<br />
non-steroidal anti-inflammatory drop for post-cataract surgery patients,<br />
has been welcomed by New Zealand eyecare professionals.<br />
Ilevro (nepafenac 0.3% ophthalmic suspension) is a “dream come<br />
true” for cataract patients who would have previously been prescribed<br />
Voltaren drops, which really sting, said Jagrut Lallu, co-owner and<br />
senior optometrist at Rose Optometry in Hamilton. “I only know<br />
about it because I recently had surgery myself and had to sort out my<br />
medication. It’s on the (Pharmac funding) schedule now and it’s light<br />
years ahead of Voltaren.”<br />
The Voltaren data sheets say approximately 15% of patients have<br />
‘transient stinging and burning’, said Nick Mathew, optometrist and<br />
clinic director at Re:Vision Laser & Cataract. “But I would say the<br />
stinging is almost universal; it’s just that some patients are affected by it<br />
more than others.”<br />
Ilevro has actually been available off and on for the last three years,<br />
he explained. “When Voltaren supplies were low in January 2021, Ilevro<br />
was brought in as a funded alternative. We hoped it would continue<br />
to be funded, but once Voltaren supply resumed in July 2021, Ilevro<br />
was de-funded and it was back to Voltaren.” However, with Voltaren<br />
production ceasing, it will be delisted from the schedule in December<br />
<strong>2024</strong>, meaning this time it should be a permanent change to Ilevro,<br />
said Mathew.<br />
Ilevro’s thickness means it blurs the vision a little, so it’s<br />
recommended patients use it at bedtime for an overnight antiinflammatory<br />
effect, he said. “They use their dexamethasone drops in<br />
the daytime, so I believe we<br />
have better anti-inflammatory<br />
cover this way. Clinically,<br />
there seems to be little<br />
difference to Voltaren, but<br />
patient comfort and oncedaily<br />
dosing (compared to<br />
four times daily with Voltaren)<br />
are major advantages.”<br />
Mathew said he expects<br />
this will lead to better<br />
patient compliance and,<br />
therefore, post-surgery<br />
outcomes. “Voltaren really<br />
stings. Patients prefer Ilevro, for<br />
sure. Hands down, it’s better.”<br />
The drops have other roles<br />
beyond cataract surgery recovery, he added. “Post-surgical is the main<br />
reason it is prescribed by me, in place of Voltaren or Acular (ketorolac). I<br />
have prescribed it twice daily for episcleritis with good effect.”<br />
Although the preservative benzalkonium chloride (BAK), whose<br />
cornea-damaging effects have been highlighted in a recent Glaucoma<br />
New Zealand campaign, is used in Ilevro, Mathew said this shouldn’t be<br />
a major concern for post-surgery use. “While it is helpful to avoid BAK<br />
in long-term medications, it can assist the penetration of the drop and<br />
improve clinical effectivity.”<br />
Eye Surgeons expands team<br />
Drs Verona Botha and Ammar Binsaqiq and A/Prof James McKelvie<br />
DRS VERONA BOTHA and Ammar Binsadiq have joined Associate<br />
Professor James McKelvie at his Waikato-based clinic Eye Surgeons,<br />
to accommodate growing demand from population growth and<br />
shifting demographics.<br />
Welcoming the new doctors, A/Prof McKelvie said the addition<br />
of Drs Botha and Binsadiq represents a significant step for Eye<br />
Surgeons. “We are constantly striving to enhance the level of care<br />
we provide. By welcoming these new specialists with expertise in<br />
oculoplastic and retinal surgery, respectively, we’re able to offer a<br />
more comprehensive range of treatments and stay at the forefront<br />
of advancements in eyecare.”<br />
A shared commitment to providing patient-centered care,<br />
leveraging advanced technology and fostering a collaborative<br />
approach appealed to Dr Botha. “By joining forces, we can offer a<br />
comprehensive range of services to patients in the Waikato. As one<br />
of the only fellowship-trained oculoplastic surgeons in this region,<br />
I’m personally committed to providing exceptional specialised care<br />
to our patients,” she said.<br />
To improve accessibility, especially for those living in the southern<br />
Waikato region, Eye Surgeons now offers clinics in both Hamilton<br />
and Cambridge, said A/Prof McKelvie.<br />
8 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
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References: 1. Alcon data on file, 2021. CLY935-C013, p.4; [REF-11403]. 2. Alcon data on file, 2021. CLV201-C001, p.4; [REF-15339].<br />
3. Alcon data on file, 2021. CLV201-M102, p.8,9; [REF-15340].<br />
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NZOPTICS.CO.NZ | 9
NEWS<br />
ODOB tackles<br />
CPD woes<br />
By Susanne Bradley<br />
RESPONDING TO FRUSTRATIONS from practitioners<br />
and education providers, the Optometrists and<br />
Dispensing Opticians Board (ODOB) has reviewed<br />
its CPD accreditation process and made changes to<br />
improve user experience and help facilitate compliance.<br />
The certification programme is not designed to be punitive or<br />
restrictive, said Suzanne Halpin, ODOB registrar and chief executive.<br />
“Its sole purpose is to facilitate practitioners maintaining their<br />
competence to practise and there’s no need for it to be overly complex<br />
or convoluted.”<br />
St George’s Eye Care<br />
Dr Paul Baddeley and Dr Oliver Comyn<br />
Cataract Surgery<br />
Glaucoma<br />
Medical Retina<br />
Retinal Surgery<br />
Oculoplastics<br />
Uveitis<br />
E: Eyecare.Reception@stgeorges.org.nz<br />
P: 03 375 633 W: stgeorges.org.nz<br />
Check ODOB’s events calendar to see which events have been accredited<br />
Following the review, there is no<br />
longer a requirement to reference the<br />
Board’s standards when applying for<br />
accreditation of a CPD event/activity;<br />
CPD providers will no longer need to<br />
provide multiple-choice questions for<br />
online events; if practitioners write<br />
and present (15 minutes or longer) at a<br />
CPD event or activity accredited by the<br />
ODOB, they may claim one CPD credit<br />
in addition to any CPD credits that<br />
apply for attendance at the event; and<br />
practitioners undertaking peer-to-peer<br />
Suzanne Halpin<br />
reviews or case discussions (which are<br />
not independent glaucoma-prescriber general peer reviews) may<br />
now apply for accreditation of these events using a standard CPD<br />
accreditation application form.<br />
Also, practitioners wishing to obtain CPD credits for conferences where<br />
the organiser has not obtained accreditation from the ODOB, now only<br />
need to make one application to cover accreditation of all conference<br />
sessions they attend, rather than one per session. For any CPD event or<br />
activity, Halpin encourages practitioners to check ODOB’s events calendar<br />
to see if the event has been accredited. If it hasn’t already, apply for<br />
accreditation well in advance (or as soon as possible afterwards), because<br />
CPD events aren’t accredited indefinitely, she said.<br />
Next, the ODOB is attempting to devise a better process for the<br />
accreditation of glaucoma peer reviews Halpin said. “The current system<br />
involves the event organiser having to chase up information from event<br />
attendees and then upload it to our system so it can be accredited, which<br />
is less than ideal. The practitioner should be solely responsible for that.”<br />
A change already initiated is that optometrists who aren’t independent<br />
glaucoma prescribers (IGPs), or IGPs who aren’t attending an IGP event<br />
for fulfilment of their IGP research vocational requirements, can now<br />
apply for general CPD credits, she added.<br />
Halpin reiterated the ODOB has a 20-working-day turnaround on<br />
each CPD accreditation application. However, she said it is typically<br />
done in a much shorter timeframe, especially when an application is<br />
complete or near complete from the start and requires fewer requests for<br />
additional information.<br />
If practitioners experience difficulties, they are strongly encouraged<br />
to contact the ODOB education officer, Penny Davenport, with their<br />
concerns as soon as they arise, said Halpin. “Penny is fantastic at getting<br />
people across the line and goes above and beyond to help practitioners<br />
and providers out. If it turns out there’s a potential systemic issue,<br />
she is also very good at advocating for change, taking a commonsense<br />
approach.”<br />
Finally, Halpin stressed that while the ODOB’s primary role is as<br />
a regulator of health professionals to protect the health and safety<br />
of patients and the public, it also prioritises agility, transparency,<br />
accountability and fairness. “When we receive complete applications<br />
for accreditation of CPD events and activities, all the changes we have<br />
implemented so far should make for a more streamlined process, which<br />
practitioners should perceive as less onerous and time consuming.”<br />
10 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
EDUCATION<br />
One patient’s arduous journey to<br />
cataract surgery<br />
By Naomi Meltzer<br />
A 74-YEAR-OLD insulin-dependent diabetic went for his<br />
diabetic retinal screening (DRS) last year but was told his retina<br />
could not be seen due to cataracts. They advised him to go to<br />
the eye clinic to arrange surgery.<br />
The patient is the caregiver for his wife, who’s had Parkinson’s<br />
disease for 50 years, along with other health issues. While<br />
waiting for his wife to have her DRS, and armed with a letter<br />
from his optometrist, he headed off to make an appointment,<br />
as advised. Shortly after taking a seat at the eye clinic, he was<br />
approached by a staff member who ranted at him about the<br />
incompetency of his optometrist for sending a letter that was<br />
not adequate for a referral, implying the patient was trying to<br />
dodge the system to get cataract surgery!<br />
Angry and confused, the man went home and decided his<br />
eyes were not a priority.<br />
As his 75th birthday approached, he plucked up the<br />
courage to deal with the renewal of his driver’s licence –<br />
essential to being able to attend the couple’s various medical<br />
appointments and going to the supermarket. As his last vestige<br />
of independence, financially and psychologically, the loss of his<br />
driver’s licence would be devastating.<br />
Having been assured by his optometrist he was right on the<br />
legal limit for driving, he high-tailed it out of there without<br />
admitting the extent to which his vision was troubling him,<br />
particularly his inability to read.<br />
A month later, he attended an appointment at the hospital<br />
eye clinic for his cataracts, only to be told that since he was<br />
just on the legal limit for driving, he did not qualify for publicly funded<br />
cataract surgery. There was no mention of diabetes, nor the fact he had<br />
been sent there after failing the DRS! In fact, his diabetes seemed to have<br />
completely slipped off the page. To this day, he has not been called back<br />
to the screening programme.<br />
He was, however, relieved that no eye surgery was imminent, as he<br />
was about to restart chemotherapy for colorectal cancer. He had been in<br />
remission for about a year, but it was now raising its head again. Sadly,<br />
though, he was no longer able to read books or newspapers to take<br />
his mind off the side effects of chemo or the intense sciatic pain, which<br />
eventually radiated down both legs. He was angry and frustrated, and<br />
his wife and family were not able to broach the subject of his worsening<br />
vision with him, as he had made up his mind that cataract surgery was<br />
not available to him.<br />
A turning point<br />
Eventually the gentleman in question was persuaded that, even though<br />
he could not afford new glasses and he had too many other things to<br />
deal with, a visit to his optometrist was needed to check out what might<br />
be going wrong with his eyes, besides cataracts. It was pointed out that,<br />
after 30 years of diabetes, macula damage was a strong possibility and<br />
potentially more urgent than cataract surgery.<br />
His optometrist confirmed advanced cataracts needing urgent<br />
attention and referred him to the Aotearoa Charity Hospital Trust (ARCH),<br />
which was established to provide free elective surgery and medical<br />
outpatient clinics to those in immediate need but unable to afford<br />
private treatment. To receive pro bono surgery at ARCH the patient must<br />
be referred by a health professional who signs a declaration confirming<br />
the patient meets all the criteria, such as being a New Zealand citizen<br />
who is unable to afford private treatment, not having medical insurance<br />
or ACC cover, and who has been declined access to treatment in the<br />
public system within the last six months.<br />
Difficulties in a patient journey can cause anger and frustration. Credit: Andy Urdaneta<br />
Auckland practices Re:Vision, Auckland Eye and Milford Eye Clinic<br />
regularly provide free cataract surgery under the ARCH umbrella. The<br />
patient then underwent a thorough examination at Re:Vision to rule out<br />
any other pathology. Fortunately, with no sign of diabetic maculopathy,<br />
cataracts were confirmed as the source of the problem.<br />
His latest spectacle prescription was: RE +4.25 -2.50 x 112, add +2.50;<br />
LE +2.75 -1.00 x 40, add +2.50. His right eye was slightly amblyopic, with<br />
best corrected acuity prior to cataract being 6/9. He had always been<br />
very dependent on his left eye, the acuity of which had now slipped<br />
to a poor 6/18. It was decided that immediately sequential, bilateralcataract<br />
surgery (ISBCS) would be the safest solution, given his high<br />
anisometropia, increasing the risk of a fall or a driving accident, were<br />
the surgeries separated by any length of time. His walking had become<br />
a little wobbly anyway, because his spine had collapsed in the last few<br />
months, causing immense pain and leading to an increased intake of<br />
painkillers just to enable him to stand upright.<br />
A couple of weeks later, his ISBCS went smoothly; his uncorrected<br />
vision at the first check-up the next day had returned to 6/12+. One<br />
month later, his uncorrected vision was 6/9 binocularly, and best<br />
corrected acuity 6/6+.<br />
He went from being reluctant to admit he had yet another problem<br />
to trumpeting how life-changing his cataract surgery had been and how<br />
thankful he was to ARCH for making this pro bono surgery possible, and<br />
to the Re:Vision team for their amazing philanthropic care.<br />
Fortunately, this patient is not one of my low-vision patients, he is<br />
my brother.<br />
Naomi Meltzer is an optometrist who runs an independent<br />
practice specialising in low-vision consultancy. She is a regular<br />
contributor to NZ Optics.<br />
12 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
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NEWS<br />
Shingles: a crucial<br />
conversation for the over-50s<br />
By Susie Hill<br />
SINCE HERPES zoster (HZ) infections<br />
can cause permanent vision loss, eyecare<br />
professionals should make it a priority to<br />
talk to patients aged over 50 years about the<br />
importance of preventing shingles through<br />
vaccination, said Dr Rachael Niederer,<br />
an ophthalmologist and senior lecturer at<br />
Auckland University.<br />
Dr Niederer emphasised the importance<br />
of the Shingrix vaccine, administered in two<br />
doses, two to six weeks apart. This vaccine has<br />
shown remarkable efficacy, she said, with an<br />
overall effectiveness of 97.2% in individuals<br />
aged 50 and older, and 91.3% in those aged<br />
70 and older. “About 1 in 10 people who get<br />
shingles will lose their vision. I frequently see<br />
people who lose their vision due to shingles,”<br />
she said.<br />
When the varicella-zoster virus reactivates<br />
in the ophthalmic division V1 of the<br />
trigeminal nerve, it can lead to herpes zoster<br />
ophthalmicus (HZO), which often manifests<br />
as conjunctivitis, uveitis and keratitis, she said.<br />
Approximately one in three New Zealanders<br />
Distribution of shingles associated with the ophthalmic nerve<br />
will experience shingles in<br />
their lifetime, with 10–15% of<br />
these cases showing V1 distribution and half of<br />
these involving the eye. The risk of moderate<br />
(6/15) permanent vision loss is 1 in 10, while<br />
severe (6/60 or worse) vision loss is 1 in 30 for<br />
those with this distribution.<br />
Further HZO complications include<br />
corneal scar, neurotrophic keratopathy, band<br />
keratopathy, corneal melt, corneal perforation<br />
and acute retinal necrosis or panuveitis, all<br />
contributing to vision loss, she added.<br />
Patients with shingles can suffer<br />
from permanent nerve pain, chronic dry eye,<br />
and even dementia, said Dr Niederer, with<br />
cranial nerve palsy leading to stroke and<br />
double vision in rare cases.<br />
Recent evidence suggests shingles can<br />
have profound neurological effects. “Strokes<br />
typically occur two to four months after<br />
infection. The risk of dementia persists for<br />
several years after a shingles episode.”<br />
Dr Niederer said she is excited by the<br />
research in this area, citing a large metaanalysis<br />
in Neurology which concluded the<br />
herpes zoster vaccination was associated with a<br />
reduction of the risk of dementia.<br />
A study in Nature Medicine also found<br />
subjects receiving Shingrix had a 17% lower<br />
risk of being diagnosed with dementia in<br />
the six years after inoculation, compared to<br />
people who got the Zostavax vaccine. Further,<br />
a GSK study of 600,000 patients showed<br />
those who got the Shingrix vaccine were<br />
about 23% less likely after five years to have a<br />
diagnosis of dementia, compared with people<br />
receiving Zostavax.<br />
In New Zealand, only those aged 65 years<br />
or who are immunosuppressed are eligible for<br />
the free vaccine; for others, immunisation costs<br />
between $600 to $800. “If you are 66, you don’t<br />
get it funded, which is crazy!” said Dr Niederer.<br />
Dr Niederer advised that patients must<br />
wait at least 12 months after their shingles<br />
episode (off treatment and no flare-ups) before<br />
receiving the vaccine.<br />
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Health checks for older doctors?<br />
FOLLOWING DATA REVEALING patient complaints jump significantly<br />
with increasing age of their doctor, the Medical Board of Australia (MBA)<br />
is considering regular health checks for medical practitioners over 70<br />
years old.<br />
The rate of notifications related to health impairments is more than<br />
three times higher for those over 70 compared with younger colleagues,<br />
according to an MBA statement. “The Australian Health Practitioner<br />
Regulation Agency’s complaints data show that doctors aged over 70<br />
are 81% more likely to be the subject of a notification for any reason (not<br />
just impairment) than those under 70. Proposals for keeping late-career<br />
doctors in safe practice are now open for public comment.”<br />
Doctors in the 70–74-year-old bracket “jumped disturbingly” rising<br />
more than 130% from 2015 to 2023. For medical practitioners aged 80<br />
and over, notifications climbed by more than 180% per 1,000 doctors<br />
between 2015 and 2023, the statement revealed.<br />
While late-career doctors make up a relatively small proportion of the<br />
medical workforce, health ministers<br />
and the community expect the<br />
MBA to prevent avoidable harm to<br />
patients, said the MBA. “To protect<br />
patients while also extending the<br />
careers of medical practitioners in<br />
a safe way, the Board is consulting<br />
on a range of proposals to<br />
safeguard the health, privacy<br />
and independence of late-career<br />
doctors by managing preventable<br />
risks to patient safety.”<br />
The Board’s preferred proposal<br />
would require late-career doctors<br />
to undergo general health checks<br />
with their GP or another doctor<br />
every three years and yearly from<br />
80 years of age.<br />
Such a measure could prevent<br />
future patient harm and provide<br />
opportunities for practitioners<br />
to extend their careers, said MBA<br />
chair Dr Anne Tonkin AO. “It’s in line<br />
with all public health screening<br />
measures. Early detection means<br />
early management, which can<br />
mean preventing avoidable<br />
risks,” she said. “Doctors are often<br />
reluctant patients and we are<br />
concerned they don’t always seek<br />
the care they need. We’re looking<br />
for a way to keep late-career<br />
doctors in charge of their career.”<br />
Under the proposal, results of<br />
such checks would be confidential<br />
between the late-career doctor<br />
and their treating practitioner.<br />
The MBA would only be informed<br />
if a treating practitioner made a<br />
mandatory report about a latecareer<br />
doctor who refused to<br />
manage the risk to patients caused<br />
by ill health.<br />
Public consultation is open until<br />
4 <strong>Oct</strong>ober <strong>2024</strong>. For more, see<br />
www.medicalboard.gov.au/News/<br />
Current-Consultations.aspx.<br />
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NZOPTICS.CO.NZ | 15
What to expect when your patient is expecting<br />
By Layal Naji<br />
ANYONE WHO HAS been pregnant or lived with someone who<br />
was pregnant knows that being expectant comes with its fair share of<br />
surprises – good and bad. Changes in the release of hormones such<br />
as oestrogen, progesterone, relaxin and others incite a chain reaction<br />
with subsequent changes in vascularity, fluid retention and tissue<br />
remodelling. These changes may also have effects on how the eyes look<br />
and function, too. Let’s take a look at some of the eye-related clinical<br />
considerations and possible pathologies during pregnancy.<br />
Pigmentation<br />
An increase in the release of oestrogen, progesterone and melanocytestimulating<br />
hormones during pregnancy can lead to an increase in<br />
pigmentation in the body, including periorbitally 1 . As clinicians, we need<br />
to be able to differentiate iatrogenic causes of hyperpigmentation (for<br />
example, use of prostaglandin analogues) from those related to pregnancy.<br />
Vision<br />
Hormonal modulations also lead to swelling in the lens and cornea,<br />
most often creating a myopic shift (although sometimes it may be<br />
hyperopic or astigmatic). This is why procedures addressing refractive<br />
correction (such as LASIK) are contraindicated during pregnancy.<br />
When screening women of child-bearing age for laser eye surgery, we<br />
must enquire about pregnancy or breastfeeding, says Dr Lana Del Porto,<br />
a Melbourne-based ophthalmologist specialising in cataract, refractive<br />
and strabismus surgery. “It’s important we have a very accurate<br />
understanding of the patient’s refractive error and that the prescription<br />
is not changing when planning laser eye surgery. For this reason, we<br />
do not offer it when the patient is pregnant or breastfeeding. Instead,<br />
we invite them to return for an assessment, generally six weeks after<br />
cessation of breastfeeding.”<br />
The ocular surface<br />
Increasing gestational age is associated with changes to tear-film<br />
physiology and increased incidence of dry eye in pregnant women.<br />
Pregnancy leads to several ocular surface changes, which are further<br />
exacerbated by existing pathology, says Dr Stuti Misra, an optometristscientist<br />
and senior lecturer at the University of Auckland’s Department<br />
of Ophthalmology. “Dry eye disease is known to occur throughout<br />
pregnancy but increases with gestational age 2 . Common assessments<br />
including tear breakup time and Schirmer test are reported to worsen in<br />
the third trimester of pregnancy 3 .”<br />
There is conflicting evidence on the cause of this association.<br />
Hormonal modulations to oestrogen/prolactin/testosterone levels<br />
and immunoarchitectural changes to the lacrimal gland have been<br />
postulated to play a role 4 . Similarly, there is no consensus on whether<br />
pregnancy is related to evaporative, aqueous deficient, or mixed dry<br />
eye 5,2 . Following the DEWS II dry eye sub-group diagnostic tests,<br />
including a dry eye questionnaire, non-invasive tear breakup time,<br />
Schirmer test and identification of meibomian gland disorder (eg,<br />
through meibography/meibomian gland assessment) can help us<br />
adequately assess and manage the presentation of dry eye in our<br />
pregnant patients 5,6 .<br />
Keratoconus<br />
Pregnancy can also be considered a risk factor for keratoconus<br />
progression, affecting not only corneal topography, thickness<br />
measurements and curvature, but also biomechanical properties<br />
such as corneal hysteresis and corneal resistance factor 7 . Again, the<br />
mechanisms behind these changes are unclear; they could be related to<br />
lower thyroxine levels, changing oestrogen levels, or increasing relaxin<br />
levels (changing synthesis of MMPs and TIMPs) 8 . Interestingly, there<br />
is some evidence there may be some partial recovery after cessation of<br />
breastfeeding 9 , indicating that clinicians should wait for stabilisation of<br />
corneal parameters before determining a management approach. “I had<br />
a patient last year who had recently moved to Australia from Canada,”<br />
says Dr Del Porto. “She had keratoconus. Her corneal tomography<br />
showed significant worsening of her keratoconus compared to three<br />
years prior. During that time, she had been pregnant twice.”<br />
Keratectasia<br />
Dr Misra points out that a scoping review noted the tendency of<br />
pregnant patients to develop iatrogenic keratectasia several years<br />
after receiving LASIK, with or without preoperative risk factors.<br />
“Importantly, the ectasia may re-occur in second or third pregnancies.<br />
However, most of the related ocular symptoms are likely to persist<br />
postpartum 10 . A few studies have also shown steepening of topography,<br />
a decline in spherical equivalent refraction and an increase in<br />
astigmatism 11 .” So, in addition to standard refraction for pregnant<br />
patients, it may be of benefit for optometrists to conduct a complete dry<br />
eye disease work-up, along with corneal topography, Dr Misra suggests.<br />
Continued on p18<br />
16 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
Eye Institute Annual<br />
Optometry Conference<br />
A FREE<br />
half day<br />
educational<br />
conference at<br />
Aotea Centre<br />
Please join us for an exciting and informative<br />
half day of valuable CPD points and engaging<br />
rapid fire presentations. Accompany your peers<br />
in listening to our world class surgeons speak<br />
on the latest in ophthalmic topics.<br />
This conference includes a stand-up breakfast, morning<br />
tea, lunch with beverages and a barista onsite!<br />
We recognise how the economic slow-down has<br />
impacted New Zealand, including throughout the health<br />
sector. Eye Institute has decided to make this a free event<br />
to thank and recognise the support that our optometrist<br />
colleagues have provided for almost 30 years.<br />
Venue: Aotea Centre,<br />
50 Mayoral Drive, Auckland<br />
Date: Sunday 10th November <strong>2024</strong><br />
Time: 8.30am – 1.30pm<br />
(including breakfast and lunch)<br />
Parking: Free parking is available at The Civic<br />
undercover carpark if your ticket is validated<br />
by the event manager on the day.<br />
Tickets: To thank our optometry colleagues,<br />
we have made this a FREE event. Any<br />
purchased tickets will be automatically<br />
refunded.<br />
THANK YOU TO OUR SPONSORS<br />
Book now for your CPD credits (including therapeutics).<br />
Visit eyeinstitute.co.nz and go to our event page to REGISTER.<br />
NZOPTICS.CO.NZ | 17
FEATURE<br />
Continued from p16<br />
Intraocular pressure and<br />
glaucoma<br />
Studies have shown intraocular<br />
pressure (IOP) can decrease by up to<br />
20% during pregnancy 12 . There are<br />
not enough randomised controlled<br />
trials to understand the physiology<br />
behind this change, but it has been<br />
hypothesised it could be multifactorial<br />
– attributable to increased aqueous<br />
outflow, decreased episcleral venous<br />
pressure (from an overall decrease<br />
in systemic vascular resistance)<br />
and decreased scleral rigidity due<br />
to increase in tissue elasticity (from<br />
oestrogen and progesterone release) 13 .<br />
This is a genuine decrease in IOP<br />
and not artefactual, so normal IOP<br />
cut-offs for our pregnant patients with<br />
glaucoma and ocular hypertension<br />
should be applied.<br />
Conversely, there is some evidence<br />
that a history of pregnancy that<br />
results in delivery (especially three or more) can be associated with<br />
an increased incidence of open-angle glaucoma 14 . This has been<br />
suggested to be related to high oestrogen levels during pregnancy;<br />
transient events during labour (including systemic hypotension and<br />
decreased ocular perfusion because of bleeding) inducing glaucomalike<br />
changes in the optic nerve; oxytocin levels during labour inducing<br />
capillary constriction and decreasing aqueous outflow; stress during<br />
labour causing the release of adrenaline and noradrenaline that lead<br />
to an increase in IOP; and the valsalva reflex during labour producing<br />
intermittent increases in IOP.<br />
Uveitis<br />
It is hard to generalise about pregnant<br />
women who have uveitis associated<br />
with autoimmune conditions (Behçet<br />
disease, idiopathic, sarcoidosis,<br />
Vogt-Koyanagi-Harada-associated,<br />
juvenile idiopathic arthritis etc.) as<br />
there are issues with sample size and<br />
limited studies when it comes to the<br />
literature. From what is available,<br />
though, uveitis appears to worsen in<br />
the first trimester, be less active later<br />
on, and increases postpartum, with an<br />
increased risk of uveitis flare within six<br />
months of delivery 15,16 . More than 50%<br />
of patients in a case series experienced a uveitis episode in the first six<br />
months postpartum 16 .<br />
Neuro-ophthalmic presentations<br />
Multiple sclerosis is another autoimmune inflammatory condition that<br />
presents a similar situation: most cases improve during pregnancy, but<br />
attacks (including episodes of optic neuritis) can increase in the first few<br />
months postpartum 17 .<br />
Idiopathic intracranial hypertension can be exacerbated during<br />
pregnancy, especially as maternal weight gain increases with increasing<br />
gestational age 18 . Pituitary adenomas are another pathology that can<br />
progress during pregnancy, with the classic bitemporal visual-field<br />
defect becoming more prominent or deepening/expanding 19 . For each<br />
of these presentations we should follow our pregnant patients a little<br />
more frequently, with appropriate visual field and optical coherence<br />
tomography performed as indicated.<br />
There is some evidence that a<br />
history of pregnancy that results<br />
in delivery … can be associated<br />
with an increased incidence of<br />
open-angle glaucoma<br />
During the postpartum period, pituitary<br />
apoplexy/Sheehan syndrome is a neuroophthalmic<br />
presentation to watch out for.<br />
With the significant blood loss associated<br />
with labour and the postpartum period, a<br />
large haemorrhage can decrease perfusion<br />
of the pituitary gland. This infarct leads to<br />
swelling of the pituitary gland, which leads<br />
to compression of the visual pathway and<br />
symptoms such as sudden headache, diplopia,<br />
or vision loss 20 .<br />
Posterior eye and visual pathway<br />
Pregnancy can be considered an immune<br />
condition (since there are genetic<br />
differences between the mother and foetus).<br />
This can alter immune functionality<br />
and in some instances be related to<br />
toxoplasmosis reactivation 21 .<br />
Preeclampsia is a condition that may<br />
develop in women who are more than 20<br />
weeks pregnant. Blood pressure rises above<br />
140/90 (this does not need to be sustained)<br />
and there is proteinuria. Preeclampsia<br />
exists on a spectrum, with a variant<br />
being HELLP (haemolysis, elevated liver enzymes and low platelets)<br />
syndrome, and more end-stage presentations including eclampsia<br />
and posterior reversible encephalopathy syndrome (PRES). Each of<br />
these presentations can cause visual changes such as blurred vision,<br />
photopsias, scotomas, diplopia and, in the case of PRES, even cortical<br />
infarcts that lead to visual field defects and cortical blindness 22 . The<br />
treatment for these presentations targets the eclampsia; if your patient’s<br />
vision is affected and they have a positive history for one of these<br />
presentations, then you must take a multidisciplinary approach and<br />
contact their obstetrics team. This spectrum of presentations can also<br />
lead to ocular signs such as bilateral serous retinal detachments, or<br />
retrograde retinal nerve fibre layer/<br />
ganglion cell damage. Since first<br />
observation could even be in the<br />
postpartum period, it is important to<br />
get a thorough history of the patient’s<br />
pregnancy, where relevant. If there<br />
is a positive history, once again, a<br />
multidisciplinary approach with<br />
involvement from general practice<br />
(including vascular workup), obstetrics<br />
and endocrinology could be indicated.<br />
The exact pathophysiology of the<br />
serous detachments is unknown,<br />
but current knowledge points to a<br />
link to the higher choriocapillaris<br />
vascular density in pregnant women. When there is a comorbidity of<br />
hypertension, there can be formation of microthrombi in the choroidal<br />
vasculature, and this ischaemic environment causes a breakdown of<br />
the blood-retina barrier and reduced resorption of subretinal fluid,<br />
ultimately leading to a serous retinal detachment 23 .<br />
Vascular changes<br />
During pregnancy cardiac output and systemic volume increases by<br />
30–50%, blood vessels swell and become more friable and there is a<br />
decrease in fibrinolytic activity, creating a hypercoagulable state. This<br />
can lead to retinal arterial and venous occlusion during pregnancy.<br />
This is especially relevant for patients with pre-existing thrombophilic<br />
conditions or other underlying disease (such as preeclampsia/<br />
thrombotic thrombocytopenic purpura). The resulting increase<br />
in venostasis means relevant patients are often prescribed<br />
prophylactic anticoagulants 24 .<br />
18 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
Diabetes<br />
Worldwide, there is an increased incidence of diabetes, obesity and<br />
increased maternal age at first pregnancy. This has created an increasing<br />
likelihood of comorbidity of pregnancy and diabetes. It is important<br />
to note that a patient with gestational diabetes is less likely to develop<br />
diabetic retinopathy (DR); rather, it is the patients with existing DR<br />
who we should watch more closely as their retinopathy is more likely to<br />
progress. This is because the haemodilution associated with pregnancy<br />
leads to a more hypoxic/ischaemic retinal environment, which<br />
can exacerbate the DR. The risk factors for progressing DR during<br />
pregnancy are poor glycaemic control, comorbid hypertension, and<br />
degree of retinopathy pre-pregnancy 25 . Interestingly, during pregnancy<br />
HbA1c is no longer the gold standard method to gauge glycaemic<br />
control, since the increased renal clearance during pregnancy makes<br />
HbA1c artificially low. Instead, clinicians may ask to review blood<br />
glucose log sheets, and obstetricians will make decisions based on the<br />
glucose tolerance test 26 .<br />
Patients with non-proliferative DR (NPDR) can experience up to<br />
50% progression, with some regressions being observed postpartum.<br />
Severe NPDR transitions to proliferative diabetes in 5–20% of cases and<br />
there is progression of up to 45% in those with existing proliferative DR<br />
(PDR) 27 . So, depending on the severity of your pregnant patient’s prepregnancy<br />
level of DR, comorbidities and glycaemic control, they may<br />
need to be reviewed every trimester, or even monthly.<br />
next year. If they are, it is better<br />
to pursue treatment of the<br />
DR and get it under control<br />
before they are pregnant,<br />
since we know it is<br />
likely to progress. For<br />
example, it would be<br />
clinically justified to treat<br />
a patient with severe<br />
NPDR who is planning<br />
to become pregnant in<br />
the next 12 months. It<br />
could also be a motivation<br />
to better define the full extent<br />
of DR (since some peripheral<br />
neovascularisation is undetected<br />
at times). As optometrists, we can<br />
refer our patients for fluorescein<br />
Delay changes in lens refraction until<br />
after pregnancy or breastfeeding<br />
angiography once it is established that the patient is definitely not<br />
pregnant at the time of testing.<br />
Clinical pearls from Professor Stephanie Watson<br />
Professor Stephanie Watson, chair of the Ophthalmic Research<br />
Institute of Australia, has some clinical pearls to share when it comes to<br />
managing our pregnant and breastfeeding patients:<br />
• Due to changes in refractive error, it is best to delay changes<br />
in spectacle or contact lens refraction until after pregnancy<br />
or breastfeeding<br />
• In cases of accommodative loss or insufficiency, reading glasses could<br />
be provided as a temporary measure<br />
Continued on p20<br />
Pregnant women with existing DR should be watched more closely<br />
Guidelines for treating DR<br />
Guidelines based on the available evidence on DR and pregnancy<br />
recommend treatment in pregnant patients only when their DR has<br />
progressed to PDR. This is because the treatment paradigms for<br />
pregnant women with DR are different. Since anti-VEGF therapy<br />
can alter placental growth factor it must be avoided in pregnancy,<br />
especially during the first trimester. Beyond that, it will be a riskbenefit<br />
conversation between the ophthalmologist and the patient 24 .<br />
Additionally, bevacizumab (Avastin) has a prolonged systemic effects<br />
profile. There are limited data on this matter, but it is interesting to<br />
note that in a study with three patients who received intravitreal<br />
bevacizumab therapy during pregnancy, all of the resulting toddlers<br />
reached developmental milestones appropriately during infancy 28 .<br />
Another notable finding in this review is that more than 50% of the<br />
women receiving intravitreal anti-VEGF were only discovered to be<br />
pregnant after receiving the injection 28 . This raises the question of<br />
whether pregnancy tests should be a routine consideration in relevant<br />
patients before administering intravitreal anti-VEGF.<br />
Intravitreal steroid injection also risks systemic absorption,<br />
so typically the treatment of choice during pregnancy is<br />
retinal laser therapy 27 .<br />
One way this knowledge can improve our practice is by asking<br />
relevant patients with DR if they are planning to be pregnant in the<br />
GRAND ROUNDS <strong>2024</strong><br />
Join us for our next Grand Rounds event at the Remuera Golf Club.<br />
We welcome you and your team to this information CPD points evening.<br />
Wednesday 16 <strong>Oct</strong>ober <strong>2024</strong>, 5.30pm<br />
Remuera Golf Club, 120 Abbotts Way, Remuera<br />
• Dr Mark Donaldson - Lens Replacement & Cataract Surgery<br />
• Dr Penny McAllum - Corneal Epithelial Basement Membrane Dystrophy<br />
• Dr Andrew Riley - Blepharoplasty for Dermatochalasis<br />
• Dr Julia Escardo-Paton - Abusive Head Trauma in Children<br />
• Dr Arvind Gupta - Obstructive Sleep Apnea and Eyes<br />
Dinner from 5.30pm; Presentations begin 6pm<br />
Please register your attendance via eyedoctors.co.nz<br />
NZOPTICS.CO.NZ | 19
NEWS<br />
J&J boosts non-invasive<br />
refractive tech<br />
JOHNSON &<br />
JOHNSON (J&J)<br />
has invested in<br />
TECLens, a startup<br />
developing a nonincisional<br />
procedure<br />
leveraging<br />
crosslinking (CXL)<br />
technology to<br />
address keratoconus<br />
and correct<br />
refractive errors. Rendering of TECLens treatment with CXLens device<br />
According to<br />
TECLens, while most current treatments to reshape the cornea<br />
require laser ablation or invasive surgery, the company’s noninvasive<br />
treatment incorporates quantitative CXL technology and<br />
a CXLens device bathing the eye in UV light from a fibre-opticconnected<br />
scleral contact lens. The computationally optimised UV<br />
pattern is accompanied by a dose of riboflavin customised for each<br />
eye, stiffening and reshaping the cornea to a specific prescription.<br />
The correction effect is monitored in real time with ultrasound,<br />
said TECLens.<br />
TECLens has conducted a successful pilot study in keratoconus<br />
patients and is currently planning the first refractive-correction<br />
clinical studies.<br />
LD atropine use deemed safe<br />
with exotropia<br />
THE RESULTS OF a Chinese study of myopic children with basic-type<br />
intermittent exotropia support the use of 0.01% atropine eye drops<br />
for slowing myopia progression without interfering with exotropia or<br />
binocular vision, said authors.<br />
Led by Dr Zijin Wang, Nanjing Medical University, researchers<br />
recruited 300 children aged six to 12 years old with myopia of −0.50<br />
to −6.00 diopters. Of these, 200 received 0.01% atropine drops nightly<br />
in both eyes for 12 months, while 100 received placebo. The mean<br />
accommodative amplitude<br />
(AA) change was −3.06D<br />
vs 0.12D in the atropine<br />
and placebo groups,<br />
respectively. The 0.01%<br />
atropine group also<br />
had a decrease in near<br />
magnitude of exodeviation,<br />
whereas the placebo group<br />
had an increase (−1.25<br />
prism diopters (PD) vs<br />
0.74PD, respectively).<br />
Although their findings<br />
support the use of lowdose<br />
(LD) atropine in<br />
these children, AA was<br />
compromised to some<br />
extent, noted authors. Exotropia. Credit: Community Eye Health<br />
Continued from p19<br />
• Corneal crosslinking for keratoconus is contraindicated in pregnancy<br />
but can be considered postpartum if there has been progression<br />
• If vision is reduced during pregnancy or breastfeeding, don’t assume<br />
it is due to refractive error – check for exacerbation of underlying<br />
systemic disease.<br />
Keeping these considerations in mind can prevent unwelcome surprises<br />
for our patients’ ocular and systemic health and help them make the<br />
most of this special time in their life.<br />
References<br />
1. Handel A, Miot L, Miot H. (2014) Melasma: a clinical and epidemiological review. An Bras Dermatol.<br />
Sep-<strong>Oct</strong>;89(5):771-82.<br />
2. Asiedu K, Kyei S, Adanusa M, Ephraim R, Animful S, et al. (2021) Dry eye, its clinical subtypes and<br />
associated factors in healthy pregnancy: A cross-sectional study. PLOS ONE 16(10): e0258233.<br />
3. Stella O, Uden N. (2019). Dry eye disease: a longitudinal study among pregnant women in Enugu, south<br />
east Nigeria. Ocul Surf, 17(3), 458-463.<br />
4. Schechter J, Pidgeon M, Chang D, Fong Y, Trousdale M, Chang N. (2002). Potential role of disrupted<br />
lacrimal acinar cells in dry eye during pregnancy. Adv Exp Med Biol, vol 506.<br />
5. Kunduracı M, Koçkar A, Helvacıoğlu Ç, et al. (2023) Evaluation of dry eye and meibomian gland function<br />
in pregnancy. Int Ophthalmol 43, 4263–4269<br />
6. Craig J, Nichols K, Akpek E, Caffery B, Dua H, Joo C, Liu Z, Nelson J, Nichols J, Tsubota K, Stapleton F.<br />
(2017). TFOS DEWS II definition and classification report. Ocul Surf. 15(3):276-283.<br />
7. Naderan, M. and Jahanrad, A. (2017), Topographic, tomographic and biomechanical corneal changes<br />
during pregnancy in patients with keratoconus: a cohort study. Acta Ophthalmol, 95: e291-e296.<br />
8. Bilgihan K, Hondur A, Sul S, Ozturk S.(2011) Pregnancy-induced progression of keratoconus. Cornea.<br />
Sep;30(9):991-4.<br />
9. Toprak I. To what extent is pregnancy-induced keratoconus progression reversible? A case-report and<br />
literature review. (2023) Eur J Ophthalmol. 33(1):NP37-NP41.<br />
10. Jani D, McKelvie J, Misra S. (2021). Progressive corneal ectatic disease in pregnancy. Clin Exp Optom,<br />
104(8), 815-825.<br />
11. Ataş M, Duru N, Ulusoy D, et al. Evaluation of anterior segment parameters during and after pregnancy.<br />
Cont Lens Anterior Eye. 2014;37:447–450.<br />
12. Pilas-Pomykalska M, Luczak M, Czajkowski J, Woźniak P. (2004) Changes in intraocular pressure during<br />
pregnancy. Klin Oczna. 106(Suppl 1-2):238–9.<br />
13. Yenerel N, Küçümen . (2015) Pregnancy and the eye. Turk J Ophthalmol. 45(5):213-219.<br />
14. Lee J, Kim J, Kim S, Kim I, Kim H, Chung P, Bae J, Won Y, Lee M, Park K. (2019) Epidemiologic Survey<br />
Committee of the Korean Ophthalmological Society. Associations among pregnancy, parturition, and<br />
open-angle glaucoma: Korea National Health and Nutrition Examination Survey 2010 to 2011. J Glaucoma<br />
28(1):14-19.<br />
15. Chiam N, Hall A, Stawell R, Busija L, Lim L. (2013) The course of uveitis in pregnancy and postpartum. Br<br />
J Ophthalmol. 97:1284-1288.<br />
16. Rabiah P, Vitale A. (2003) Noninfectious uveitis and pregnancy. Am J Ophthalmol.136:91-98.<br />
17. Varytė G, Zakarevičienė J, Ramašauskaitė D, Laužikienė D, Arlauskienė A. (2020) Pregnancy and multiple<br />
sclerosis: an update on the disease modifying treatment strategy and a review of pregnancy’s impact on<br />
disease activity. Medicina (Kaunas). 21;56(2):49.<br />
18. Thaller M, Wakerley BR, Abbott S, et al. (2022). Managing idiopathic intracranial hypertension in<br />
pregnancy: practical advice. Practical Neurology 22:295-300.<br />
19. Sirilert S, Traisrisilp K, Pantasri T, Tongsong T. (2019) Pregnancy-induced progressive change of prolactinsecreting<br />
macroadenoma with the development of bitemporal hemianopia and severe headache. Clin Case<br />
Rep. 3;7(7):1365-1369.<br />
20. Woodmansee W. Pituitary disorders in pregnancy. (2019) Neurol Clin. ;37(1):63-83.<br />
21. Elbez-Rubinstein A, Ajzenberg D, Dardé M-L, Cohen R, Dumètre A, Year H, Gondon E, Janaud J-C,<br />
Thulliez P. (2009) Congenital toxoplasmosis and reinfection during pregnancy: case report, strain<br />
characterization, experimental model of reinfection, and review, J Infect Dis, 199(2): 280–285<br />
22. Hindjua A. (2020). Posterior reversible encephalopathy syndrome: clinical features and outcome. Front.<br />
Neurol., Vol 11<br />
23. Kovács E, Molvarec A, Rigó J Jr, et al. (2011) Bilateral serous retinal detachment as a complication of<br />
acquired peripartum thrombotic thrombocytopenic purpura bout. J Obstet Gynaecol Res. 37(10):1506-9.<br />
24. Soma-Pillay P, Nelson-Piercy C, Tolppanen H, Mebazaa A. (2016). Physiological changes in pregnancy.<br />
Cardiovasc J Afr. 27(2):89-94.<br />
25. Blumer I, Hadar E, Hadden D, Jovanovič L, Mestman J, Murad M, Yogev Y. (2013) Diabetes and<br />
pregnancy: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 98(11):4227-49.<br />
Update in: J Clin Endocrinol Metab. 2018 Nov 1;103(11):4042<br />
26. Radin M. (2014) Pitfalls in hemoglobin A1c measurement: when results may be misleading. J Gen Intern<br />
Med. 29(2):388-94<br />
27. Chandrasekaran P, Madanagopalan V, Narayanan R. (2021) Diabetic retinopathy in pregnancy - a review.<br />
Indian J Ophthalmol. 69(11):3015-3025.<br />
28. Polizzi S, Mahajan VB. (2015) Intravitreal anti-VEGF injections in pregnancy: case series and review of<br />
literature. J Ocul Pharmacol Ther. 31(10):605-10.<br />
Layal Naji is an Australia-based optometrist, a lecturer of<br />
optometry at the University of Canberra, a co-founder of the<br />
outreach optometry clinic at the Asylum Seekers Centre in<br />
Newtown, Sydney, and a regular contributor to NZ Optics.<br />
20 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
Plastic<br />
neutral †
NEWS<br />
Kids’ vision champion appeals for partners<br />
By Susanne Bradley<br />
WELLINGTON OPTOMETRIST<br />
RAVI Dass, founder of the Foureyes<br />
Foundation, is seeking optical<br />
partnerships to sustain a long-term<br />
expansion of vision services for primaryschool-aged<br />
kids in Aotearoa.<br />
On a mission to help remove<br />
barriers to eyecare for children in need,<br />
the foundation provides free vision<br />
screening, eye exams and glasses through<br />
a network of three clinics in Wellington,<br />
Porirua and Masterton. Partnering with<br />
the Eye Institute in 2020, the charity ran a<br />
successful pilot programme in Dargaville,<br />
which Dass said he is now keen to give a<br />
sustainable, long-term future.<br />
One potential avenue to fund a<br />
Dargaville clinic, besides industry<br />
partnerships, is through research,<br />
said Dass. “As the clinic is based out<br />
of a medical centre, someone with a<br />
research project could capitalise on the<br />
infrastructure and the partnerships<br />
within the systems that I’ve created for the Foureyes Foundation to setup<br />
and fund research.”<br />
Launched in 2016, the foundation’s vision-screening programme<br />
followed Dass’ encounter with a 19-year-old who needed glasses but<br />
had somehow slipped through the system and his vision error had never<br />
been picked up, Dass said. “He had dropped out of school at a young<br />
age and eventually ended up on benefits. I couldn’t help thinking ‘if<br />
his vision problem had been identified earlier, could his life have been<br />
different?’ That encounter became a catalyst for me.”<br />
One in five kids fall through the cracks<br />
Ravi Dass is ‘Mr Foureyes’ to the students he screens<br />
Looking at the B4 School and Well Child programmes to avoid<br />
duplicating existing services, Dass partnered with local schools and<br />
started screening five-to-10-year-olds<br />
for whom there appeared to be a gap<br />
in services and no straightforward<br />
pathway for teachers picking up<br />
suspected vision issues with a child,<br />
he said. Equipped with a Plusoptix<br />
vision screener provided by OptiMed<br />
New Zealand, Dass said he was<br />
averaging about 20% referrals during<br />
screenings, indicating a significant<br />
shortfall in vision problems being<br />
detected through existing channels.<br />
To manage the referral load<br />
and programme expansion, the<br />
screening part of the programme<br />
was successfully transferred to the<br />
participating schools’ learning<br />
support coordinators, Dass said.<br />
This freed up his time to manage the<br />
referrals at the three small, low-cost<br />
clinics he had set up in partnership<br />
with iwi-led medical centres in the<br />
region. “This opened a path for the<br />
kids being referred from the school to get a proper examination and be<br />
equipped with glasses, should they need them,” he said.<br />
What is really needed now is someone who can help fund the service<br />
to make it sustainable long term and to expand the programme to<br />
include areas in the North and South Islands, Dass said. “I know that<br />
there are a lot of optometrists and ophthalmologists out there who<br />
would like to be involved in this process; I welcome them to get in<br />
touch. I can’t replicate myself, so partnering is the key thing for us to<br />
continue to grow our services sustainably.”<br />
Since 2016, the Foureyes Foundation has screened nearly 8,000 kids<br />
and donated around 700 pairs of glasses. The glasses are manufactured<br />
in Dass’ Wellington lab and are paid for through fundraising. For more,<br />
email hello@foureyesfoundation.org.nz<br />
Robotic guide-dog substitute<br />
RESEARCHERS FROM SHANGHAI Jiao Tong University reported a<br />
robot ‘guide dog’ is in development to improve independence for the<br />
visually impaired and shore up demand for traditional guide dogs.<br />
The researchers report the six-legged robo-dog (three legs are<br />
always on the ground) is about the size of an English bulldog and<br />
navigates the physical environment using cameras and sensors. It also<br />
has route-planning capabilities and can communicate with its visually<br />
impaired operator using AI technology and, unlike traditional guide<br />
dogs, it can recognise traffic light signals.<br />
A prototype is being field tested by Shanghai married couple, Li<br />
Fei, who is completely blind, and Zhu Sibin, who is partially blind,<br />
reported researchers. Zhu, who uses a cane to assist him in getting<br />
around, told Reuters that if the robot guide dog came onto the<br />
market, it could solve some of his problems in travelling alone. “If I<br />
want to go to work, the hospital or the supermarket (now) I cannot go<br />
out alone and must be accompanied by my family or volunteers.”<br />
Lead researcher Professor Gao Feng said robot guide dogs are under<br />
development in other countries, including Australia and the UK, but<br />
China has a greater shortage of traditional guide dogs, with just over<br />
Shanghai Jiao Tong University's robot guide. Credit: TrimFeed<br />
400 animals for almost 20 million blind people. “I think this could<br />
be a very large market, because there might be tens of millions of<br />
people in the world who need guide dogs,” he said.<br />
__<br />
22 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
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NEWS<br />
Diabetes care by ethnicity at<br />
Greenlane Clinical Centre<br />
By Jahnvee Solanki and Drs Rachael Niederer and Sarah Welch<br />
MĀORI PATIENTS ARE disproportionately<br />
affected by diabetes in New Zealand 1 . The<br />
prevalence of diabetes among Māori is twice<br />
that of Pakeha 1 , and Māori have higher<br />
rates of diabetic complications, including<br />
hospitalisation due to end-stage renal disease,<br />
lower-limb amputations, reduced time to<br />
first major cardiovascular event, and sightthreatening<br />
diabetic retinopathy (DR) 2-4 .<br />
Inequities in healthcare provision to Māori<br />
patients have also been documented across a<br />
range of specialty services 5,6 .<br />
Although DR prevalence is increasing,<br />
and disproportionately affects Māori and<br />
Pasifika, the extent of inequity in the standards<br />
of DR care provided by ethnicity is largely<br />
unknown 7-9 . Our study aimed to evaluate<br />
the comprehensiveness of history taking,<br />
examination and treatment decisions in first<br />
specialist DR appointments by ethnicity at<br />
Greenlane Clinical Centre, Auckland.<br />
Clinical records of all 388 patients seen in<br />
the DR clinic, referred between January 2021<br />
to August 2022, were analysed. We found no<br />
difference in the quality of history taking,<br />
examination, investigations and treatment<br />
offered to patients by ethnicity. These are<br />
unique and promising findings – studies of<br />
general practice and cardiac revascularisation<br />
have found less time on history taking and<br />
fewer investigations and treatments offered to<br />
Māori patients, despite the same eligibility for<br />
treatment as Europeans 5,6 .<br />
Māori patients were under-represented in<br />
referrals to ophthalmology for their disease<br />
burden in the Auckland population and had a<br />
significantly higher number of treatments they<br />
were eligible for (see Fig 1). This represents<br />
more severe disease, delayed presentation and<br />
increased barriers to accessing DR screening<br />
and referral to tertiary care. Known barriers<br />
from previous literature include physical<br />
distance, cost, fewer GP referrals, poor<br />
diabetes education and previous experiences<br />
Fig 1. Māori patients had a significantly higher number<br />
of treatments they were eligible for at presentation<br />
(p=0.003)<br />
of culturally insensitive<br />
comments 10-12 . Marae-based<br />
diabetes education and cervical<br />
screening clinics in Auckland<br />
have improved participation in<br />
exercise and health screening<br />
among Māori 13,14 . Promoting<br />
such educational and DR screening clinics in<br />
marae may improve the uptake of screening<br />
and referral to ophthalmology.<br />
Although referral numbers for Māori<br />
patients were low, the overall rates of<br />
attendance to initial and rescheduled<br />
ophthalmology appointments were<br />
comparable between Māori and other<br />
ethnicities in this study. Previous research<br />
has shown the non-attendance rate to<br />
ophthalmology specialist appointments<br />
among Māori is initially high but improves<br />
for follow-up appointments 15 . Common<br />
reasons for missing appointments include<br />
previous negative staff interactions and<br />
inability to contact clinic schedulers 15 . Our<br />
study highlights that, with significant effort by<br />
clinic schedulers and with culturally sensitive<br />
care, we are able to achieve equivalent<br />
eventual clinic attendance for Māori patients.<br />
Greenlane Clinical Centre staff must be<br />
commended for these efforts and this work<br />
should be continued.<br />
The overall documentation of a complete<br />
assessment and treatment plan was suboptimal<br />
across all ethnicities. Common treatments<br />
missed were performing CPAC scores for<br />
significant cataract, referral to diabetic<br />
nurse clinic for an HbA1c of >100 mmol/<br />
mol, and commencing intravitreal Avastin<br />
(bevacizumab) for macula oedema with a<br />
visual acuity of 6/9 or worse. A proforma<br />
for DR consultations could improve quality<br />
of assessment and hence treatment for<br />
all patients.<br />
References<br />
1. Te Whatu Ora Health New Zealand. Virtual Diabetes Register and<br />
web tool. 2021 [updated 2023 Mar 27; cited 2023 Apr 2]. www.<br />
tewhatuora.govt.nz/our-health-system/data-and-statistics/virtualdiabetes-tool<br />
2. Ministry of Health. Tatau Kahukura: Māori Health Chart Book<br />
2015 (3rd Edition). [updated 2018 Aug 2; cited 2023 Apr 2]. www.<br />
health.govt.nz/our-work/populations/maori-health/tatau-kahukuramaori-health-statistics/nga-mana-hauora-tutohu-health-statusindicators/diabetes<br />
3. Kenealy T, Elley CR, Robinson E, et al. An association between<br />
ethnicity and cardiovascular outcomes for people with Type 2<br />
diabetes in New Zealand. Diabet Med. 2008 Nov;25(11):1302-8<br />
4. Yu D, Zhao Z, Osuagwu UL, et al. Ethnic differences in mortality<br />
and hospital admission rates between Māori, Pacific, and European<br />
New Zealanders with type 2 diabetes between 1994 and 2018: a<br />
retrospective, population-based, longitudinal cohort study. Lancet<br />
Glob Health. 2021 Feb;9(2):e209-217<br />
5. Sandiford P, Bramley DM, El-Jack SS, Scott AG. Ethnic differences in<br />
coronary artery revascularisation in New Zealand: does the inverse<br />
care law still apply? Heart Lung Circ. 2015 <strong>Oct</strong>;24(10):969-74<br />
Diabetic retinopathy disproportionately affects Māori and Pasifika<br />
6. Crengle S, Lay-Yee R, Davis P, Pearson J. A Comparison of Māori<br />
and Non-Māori Patient Visits to Doctors: The National Primary<br />
Medical Care Survey (NatMedCa). Wellington (NZ): Ministry of<br />
Health; 2005<br />
7. Yau JW, Rogers SL, Kawasaki R, et al. Global prevalence and<br />
major risk factors of diabetic retinopathy. Diabetes Care. 2012<br />
Mar;35(3):556-64<br />
8. Rogers JT, Black J, Harwood M, Wilkinson B, Gordon I, Ramke J.<br />
Vision impairment and differential access to eye health services in<br />
Aotearoa New Zealand: protocol for a scoping review. BMJ Open.<br />
2021 Sep 13;11(9):e048215<br />
9. PwC New Zealand. The Economic and Social Cost of Type 2<br />
Diabetes. 2021 Mar [cited 2023 Apr 3] https://healthierlives.co.nz/<br />
wp-content/uploads/Economic-and-Social-Cost-of-Type-2-Diabetes-<br />
FINAL-REPORT.pdf<br />
10. Simmons D, Weblemoe T, Voyle J, et al. Personal barriers to diabetes<br />
care: lessons from a multi-ethnic community in New Zealand.<br />
Diabet Med. 1998 Nov;15(11):958-64<br />
11. Harbers A, Davidson S, Eggleton K. Understanding barriers to<br />
diabetes eye screening in a large rural general practice: an audit of<br />
patients not reached by screening services. J Prim Health Care. 2022<br />
Sep;14(3):273-79<br />
12. Low J, Cunningham WJ, Niederer RL, Danesh-Meyer HV. Patient<br />
factors associated with appointment non-attendance at an<br />
ophthalmology department in Aotearoa New Zealand. N Z Med J.<br />
2023 Apr 14;136(1573):77-87<br />
13. Ormandy J, Phillips S, Campbell M, et al. ‘I was able to make a<br />
better decision about my health.’ Wāhine experiences of colposcopy<br />
at a marae-based health clinic: A qualitative study. Aust N Z J<br />
Obstet Gynaecol. <strong>2024</strong> Feb 29. Epub ahead of print<br />
14. Simmons D, Voyle JA. Reaching hard-to-reach, high-risk<br />
populations: piloting a health promotion and diabetes disease<br />
prevention programme on an urban marae in New Zealand. Health<br />
Promot Int. 2003 Mar;18(1):41-50<br />
15. Low J, Cunningham WJ, Niederer RL, Danesh-Meyer HV. Patient<br />
factors associated with appointment non-attendance at an<br />
ophthalmology department in Aotearoa New Zealand. N Z Med J.<br />
2023 Apr 14;136(1573):77-87<br />
Jahnvee Solanki is a non-vocational<br />
ophthalmology registrar at<br />
Greenlane Clinical Centre. She<br />
completed her bachelor of<br />
medicine and bachelor of surgery at<br />
Auckland University in 2020 and a<br />
postgraduate diploma in ophthalmic<br />
basic sciences with the University of<br />
Sydney in <strong>2024</strong>.<br />
Dr Rachael Niederer is a RANCZO<br />
ophthalmologist and researcher.<br />
She is a member of the RANZCO<br />
Māori and Pasifika Committee<br />
and has been involved in previous<br />
research exploring health disparities<br />
in eye health in New Zealand.<br />
Dr Sarah Welch is a consultant<br />
ophthalmologist and the clinical<br />
director of the Ophthalmology<br />
Department at Greenlane<br />
Clinical Centre.<br />
24 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
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NEWS<br />
Dr Mo Ziaei,<br />
series editor<br />
Herpes zoster ophthalmicus, uveitic<br />
glaucoma, and more<br />
By Drs Lucy Lu and Joseph Kam<br />
Herpes zoster ophthalmicus recurrence: risk factors and long-term<br />
clinical outcomes<br />
DAR Scott, et al<br />
Am J Ophthalmol. <strong>2024</strong> Jun 22;268:1-9<br />
Review: This paper is the largest study looking at herpes zoster<br />
ophthalmicus (HZO) recurrence. The authors reviewed 869 patients with<br />
HZO treated at Auckland’s Greenlane Eye Clinic between 2006 and 2016<br />
and found at least one recurrence of ocular inflammation in 200 subjects<br />
(23%) during a median follow up of 6.3 years. The median time from HZO<br />
onset to first recurrence was 3.5 months. Uveitis was the most common<br />
form of recurrence, followed by keratouveitis and keratitis. In subjects<br />
who required topical steroid treatment, the median time to recurrence<br />
was 1.4 months following steroid cessation.<br />
Significant risk factors for recurrence include immunosuppression,<br />
higher presenting IOP, corneal involvement, and uveitis. Moderate vision<br />
loss (6/15 or worse) at final follow-up occurred in 19.6% of patients. There<br />
was a significant association between a greater number of recurrences<br />
and poorer final vision.<br />
Comment: HZO is one of the most common acute eye conditions treated<br />
in eye emergency clinics. Recurrent ocular inflammation can lead to<br />
vision threatening complications such as neurotrophic keratopathy,<br />
glaucoma and optic neuropathy. This study highlights those patients at<br />
greater risk of recurrence so that measures can be taken to prevent poor<br />
visual outcomes. A longer taper of steroid may be required for higherrisk<br />
patients, such as immunosuppressed individuals and those with<br />
hypertensive kerato-uveitis. The general practice pattern at Greenlane<br />
Eye Clinic is a three-month gradual taper of topical steroids, along with<br />
monitoring for recurrence on steroid cessation.<br />
Malignancy risk associated with the use of systemic<br />
immunomodulatory therapy in the management of<br />
noninfectious uveitis<br />
GN Papaliodis et al<br />
Am J Ophthalmol. <strong>2024</strong> Apr 26;265:241-247<br />
Review: This US nationwide retrospective cohort study from<br />
Massachusetts evaluated the risk of developing malignancy in<br />
patients treated with systemic immunomodulatory therapy (IMT)<br />
for noninfectious uveitis (NIU). The incidence rate of malignancy was<br />
compared between NIU patients who were treated with IMT and those<br />
who were not. All cancer types were included, except non-melanoma<br />
skin cancer. In the 15-year enrolment period, 492 of the 318,498 (0.15%)<br />
NIU patients on IMT developed malignancies. The NIU patients who did<br />
develop malignancy were treated with either systemic corticosteroids,<br />
antimetabolites, T-cell inhibitors, TNA-alpha inhibitors, IL-6 inhibitors, or<br />
CD-20 antibodies. No patient on alkylating agents developed secondary<br />
malignancy. In addition, multi-variable Cox regression analysis did not<br />
identify any association with the incidence of malignancy with any of the<br />
drug classes.<br />
Comment: This is the largest study to date to evaluate the incidence<br />
of malignancy in patients on a variety of IMT drug classes for noninfectious<br />
uveitis. While previous studies with smaller sample sizes did<br />
show a similar finding, the lack of power made it difficult to draw strong<br />
conclusions. The results reassure both the treating clinician and the<br />
patient starting on IMT for uveitis that the therapy does not significantly<br />
increase the risk of secondary malignancy development.<br />
Herpes zoster virus keratitis<br />
Preserflo Microshunt implant for the treatment of refractory uveitic<br />
glaucoma: 36-month outcomes<br />
G Triolo et al<br />
Eye (Lond). 2023 Aug;37(12):2535-2541<br />
Review: This paper from Moorfields is the first to report 36-month<br />
outcomes of Preserflo Microshunt in uveitic glaucoma. Twenty-one eyes<br />
with refractory uveitic glaucoma on maximal tolerated medical therapy<br />
were included. The overall cumulative success rate was 47% over three<br />
years. The overall mean IOP decreased by 30% (from 26.0±9.0mmHg<br />
at baseline to 15.2±5.4mmHg at final follow-up), and the number of<br />
IOP-lowering medications dropped by an average of 3.8 medications<br />
(from 4.1±0.9 at baseline to 0.9±1.2 at three years). Twelve of the 21 eyes<br />
(57.1%) required revision of the Preserflo or additional glaucoma surgery.<br />
There were no cases of sight-threatening complications, such as loss of<br />
vision, hypotony with sequelae or bleb-related ocular infections. Non-<br />
White ethnicity was a significant risk factor for failure.<br />
Comment: Preserflo Microshunt is a bleb-forming glaucoma filtering<br />
device that is gaining popularity in New Zealand. It is less invasive,<br />
provides faster visual recovery and requires less intensive follow-up<br />
compared to traditional trabeculectomy. This is a promising treatment<br />
in uveitic patients in whom post-op hypotony and inflammation are<br />
major risks, and very low IOPs are usually not required. This case series<br />
demonstrates the device’s success and safety in this patient group,<br />
but also highlights the lower success rate in non-White ethnicities and<br />
the frequent need for revision due to subconjunctival fibrosis or shunt<br />
blockage. More experience and data of its use in uveitic glaucoma will be<br />
useful to inform glaucoma surgeons managing these difficult cases.<br />
Dr Jospeh Kam is a senior uveitis fellow at Greenlane Eye<br />
Clinic, supervised by Drs Jo Sims and Rachael Niederer. He is<br />
from McGill University, Montreal, Canada.<br />
Dr Lucy Lu is currently a senior uveitis fellow at Greenlane Eye<br />
Clinic, supervised by Drs Jo Sims and Rachael Niederer. She is<br />
an Auckland-based RANZCO trainee in her final year.<br />
26 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
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glaucoma (POAG) currently treated with ocular hypotensive medication. The device can be implanted with or without cataract surgery. CONTRAINDICATIONS: The device is contraindicated for use in eyes<br />
with primary angle closure glaucoma, or secondary angle-closure glaucoma, including neovascular glaucoma, because the device would not be expected to work in such situations, and in patients with<br />
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should monitor the patient postoperatively for proper maintenance of intraocular pressure. iStent inject is MR-Conditional, meaning that the device is safe for use in a specified MRI environment under<br />
specified conditions; please see labelling for details. Physician training is required prior to use. Do not re-use the stent(s) or injector. ADVERSE EVENTS: Postoperative adverse events include but are not<br />
limited to: corneal complications including edema, opacification and decompensation, cataract formation (in phakic patients), posterior capsule opacification, stent obstruction, intraocular inflammation<br />
(non-pre existing), BCVA loss and IOP increase requiring management with oral or intravenous medications or surgical intervention. Please refer to Directions for Use for additional adverse event information.<br />
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NEWS<br />
Transforming clinical practice and outcomes with AI<br />
By Rishi Kattar<br />
AT A RECENT CPD event held at Southern<br />
Cross Hospital in Hamilton, optometrists<br />
from the Waikato region gathered to<br />
discuss one of the most exciting topics in<br />
eyecare today: artificial intelligence (AI).<br />
The event was a resounding success, with<br />
attendees excited about AI’s potential<br />
to revolutionise clinical practice and<br />
patient outcomes. The speakers provided<br />
a deep dive into AI’s transformative<br />
capacity, highlighting tools already in<br />
use and those on the horizon that could<br />
revolutionise eyecare.<br />
Associate Professor James McKelvie,<br />
consultant ophthalmologist and CEO of<br />
CatTrax, discussed exciting updates to<br />
his cutting-edge clinical management<br />
platform that is already being used in<br />
many regions within the country. CatTrax<br />
is expanding to manage everything from<br />
referrals and prescriptions to clinical diaries,<br />
with secure cloud-based storage for ocular<br />
data easily accessible to both optometrists<br />
and ophthalmologists. This feature promises<br />
to improve collaboration and streamline<br />
patient care.<br />
Another innovation A/Prof McKelvie<br />
highlighted was an AI scribe which<br />
automatically generates clinical notes and<br />
referrals during consultations, reducing<br />
administrative workload and allowing more<br />
focus on patient care. He also introduced an AI<br />
voice agent used to assess post-cataract surgery<br />
patient satisfaction, providing efficient, realtime<br />
feedback during follow-ups.<br />
Enhancing image analysis<br />
Consultant ophthalmologist Dr Ammar Binsadiq<br />
presented promising AI tools he is testing for<br />
ocular image analysis. These tools can enhance<br />
the accuracy and speed of detecting conditions<br />
such as diabetic retinopathy, glaucoma and<br />
macular degeneration. With AI’s help, early<br />
Daphene Rong and Rishi Khattar with<br />
A/Prof James McKelvie<br />
detection could become<br />
more precise, allowing<br />
for timely interventions<br />
and potentially better<br />
patient outcomes.<br />
Next, Dr Finley Breeze, a<br />
Bay of Plenty house officer,<br />
introduced an innovative AIdriven<br />
solution to predict nonattendance<br />
at ophthalmic clinics.<br />
By analysing patient data, his<br />
machine-learning model identifies patterns<br />
that predict missed appointments. This could<br />
significantly improve clinic efficiency by<br />
reducing non-attendance, helping clinics better<br />
allocate resources and enhance continuity of<br />
patient care.<br />
AI-assisted cataract surgery feedback<br />
CatTrax software engineer Jesse Whitten<br />
demonstrated a periscope device used in<br />
cataract surgeries, currently deployed in A/<br />
Prof McKelvie’s clinic. Attached to a surgical<br />
microscope, this device provides automated,<br />
real-time statistical feedback and records video<br />
Nigel Thrush and<br />
Dr Ammar Binsadiq<br />
for later review. This tool is poised to<br />
play a crucial role in training future<br />
ophthalmologists by offering immediate<br />
insights into surgical performance.<br />
Concluding the evening, Dr Henry<br />
Wallace, an ophthalmology registrar,<br />
made a presentation on semantic<br />
analysis. He proposed creating AI<br />
models that allow practitioners to<br />
evaluate their own clinical performance<br />
helping them identify strengths and<br />
areas for improvement. This data-driven<br />
approach empowers clinicians to<br />
continuously enhance their techniques<br />
and deliver better patient outcomes.<br />
Better clinical efficiency<br />
The overarching theme of<br />
the event was clear: AI is not<br />
here to replace clinicians, but<br />
to act as a powerful tool for<br />
enhancing clinical efficiency<br />
and patient outcomes.<br />
Whether through automated<br />
notetaking, predictive analytics or<br />
real-time surgical feedback, AI offers<br />
a multitude of opportunities to make<br />
eyecare practices more efficient and<br />
personalised. The evening illustrated<br />
how AI’s integration into clinical practice<br />
can free up valuable time for practitioners,<br />
allowing them to focus on delivering better<br />
care to their patients.<br />
AI in eyecare is undoubtedly an exciting<br />
frontier and we look forward to seeing these<br />
advancements rolled out in practices across<br />
the country.<br />
Rishi Khattar and Daphene Rong are optometrists at<br />
Specsavers in Hamilton who share a keen interest in AI<br />
in eyecare. As part of their Specsavers year 2 project,<br />
they organised this CPD event to promote innovation<br />
in clinical practice and empower fellow practitioners to<br />
embrace new and upcoming technology.<br />
Novel cataract drop’s promising results<br />
A NOVEL EYE drop of 2.6% EDTA ophthalmic<br />
solution (C-KAD, Livionex) showed<br />
significant and consistent improvement<br />
in visual quality and function in patients<br />
with early-stage cataract, according to<br />
US researchers.<br />
Writing in the American Journal of<br />
Ophthalmology, researchers at the<br />
University of Utah conducted the phase<br />
1/2 clinical trial of 41 subjects, who were<br />
given C-KAD (n=21) or placebo (n=20).<br />
The primary endpoint of the proportion of<br />
eyes with mesopic contrast sensitivity (CS)<br />
improvements ≥ 0.30 logCS (equivalent<br />
to 100% CS improvement) in at least<br />
two of the five spatial frequencies was<br />
significantly greater for C-KAD (66.7%<br />
vs. 35.0% for placebo, p=0.043) at day<br />
120, they said. “The proportion of eyes<br />
achieving ≥ 0.30 logCS improvement<br />
(mesopic) was also significantly greater<br />
for C-KAD, with 42.9% compared to 15.0%<br />
for placebo (p=0.050) at day 120. Positive<br />
best-corrected visual acuity trends and<br />
statistical significance in lens density were<br />
also observed.”<br />
28 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
In cataract surgery<br />
References: 1. Suzuki, H., Oki, K., Shiwa, T., Oharazawa, H. & Takahashi, H. Effect of bottle height on the corneal endothelium during phacoemulsification. J Cataract Refract Surg 35, 2014-2017, doi:10.1016/j.<br />
jcrs.2009.05.057 (2009). 2. Vasavada, V. et al. Real-time dynamic intraocular pressure fluctuations during microcoaxial phacoemulsification using different aspiration flow rates and their impact on early postoperative<br />
outcomes: a randomized clinical trial. J Refract Surg 30, 534-540, doi:10.3928/108159 7X-20140711-06 (2014). 3. Vasavada, A. R. et al. Impact of high and low aspiration parameters on postoperative outcomes<br />
of phacoemulsification: randomized clinical trial. J Cataract Refract Surg 36, 588-593, doi:10.1016/j.jcrs.2009.11.009 (2010). 4. Kokubun, T. et al. The protective effect of normal-IOP cataract surgery on the corneal<br />
endothelium, The 26th Annual Meeting of the Japanese Ophthalmological Society. 5. Miller KM, et al. Experimental study of occlusion break surge volume in 3 different phacoemulsification systems. J Cataract Refract<br />
Surg. 2021:47;1466. 6. Vasavada V et al. Real-time dynamic changes in intraocular pressure after occlusion break: Comparing 2 phacoemulsification systems. J Cataract Refract Surg. 2021;47:1205. 7. JiráskováN &<br />
Stepanov A. Our experience with Active Sentry and Centurion Ozil handpieces. Czech and Slovak Ophthalmology. 2021;77(1):18-21.<br />
Please refer to product direction for use (or operator manual) for list of indications, contraindications and warnings.<br />
© Alcon <strong>2024</strong>. Alcon Laboratories Pty Ltd. Aus: 1800 224 153; Auckland NZ: 0800 809 189. ALC2169 6/24 ANZ-CNT-2400007.
EDUCATION<br />
Desert I-land AUSCRS castaways<br />
By Dr Ben LaHood<br />
AS I STEPPED off the plane onto the sun-kissed shores of<br />
Hamilton Island for the <strong>2024</strong> meeting of the Australasian<br />
Society of Cataract and Refractive Surgeons (AUSCRS), I<br />
couldn’t help but feel a blend of excitement and mild dread.<br />
After all, I was about to immerse myself in a whirlwind of<br />
cutting-edge ophthalmic knowledge while trying not to think<br />
about the fact I was on a beautiful tropical island, but in a dark<br />
lecture hall… So near, yet so far!<br />
Like the Olympic Games’ openings, the AUSCRS opening<br />
ceremony is always something to look forward to. Previous<br />
years have seen the presidents arrive in sports cars or on magic<br />
carpets, usually accompanied by video montages of years gone<br />
by. This year, being on the ‘I-land’ we had a Gilligan’s Islandthemed<br />
video from members of the organising committee. As<br />
someone assigned to wearing a dress and having to dance in<br />
front of the crowd, it would rank pretty highly in terms of my<br />
worst-case scenarios. But this is how AUSCRS rolls. The idea<br />
behind making speakers wear costumes and look silly is to level<br />
the playing field, creating a relaxed atmosphere and removing<br />
the formalities of other meetings.<br />
From IOLs to LOLs<br />
The following morning, we kicked off the meeting in style with<br />
the Barrett/Wolfe Gold Medal Lecture (named after AUSCRS’<br />
founders) given by AUSCRS stalwart Dr Florian Kretz from Germany.<br />
In front of his proud family, Dr Kretz clarified the multiple options<br />
we have for presbyopia-correcting intraocular lenses (IOLs), speaking<br />
on his significant experience and, thankfully, giving us all realistic<br />
expectations of what can be achieved, given that even someone of his<br />
experience still gets refractive surprises. Another unique feature of<br />
AUSCRS is that all sponsors are given a chance to get on stage and<br />
tell the audience about themselves, which is always entertaining as<br />
companies get into the AUSCRS spirit. This year, Rayner’s reps, with<br />
their laugh-out-loud rendition of The Brady Bunch theme song, stole<br />
the show.<br />
Among the meeting’s many famous themed scientific sessions,<br />
these presentations stood out to me and made me think about my<br />
own practice. Singapore’s ever-popular Dr Ronald Yeoh, fresh from<br />
teaching trainees how to deliver a memorable presentation, did just that.<br />
Always a trailblazer with new technology, Dr Yeoh originally described<br />
the pupil-snap sign to indicate posterior capsule rupture during<br />
hydrodissection about 20 years ago. His experience in dealing with such<br />
nightmare scenarios meant<br />
he could suggest methods for<br />
salvaging a dropping nucleus.<br />
He also discussed using OCT<br />
intraoperatively to see a<br />
newly described scroll sign of<br />
ruptured posterior capsule.<br />
We then went on to uncover<br />
the treasure of improving<br />
cataract outcomes. There<br />
was some great debate<br />
around thresholds for using<br />
implantable collamer lenses<br />
(ICLs), even for lower<br />
prescriptions. With so much<br />
variation in comfort with this<br />
procedure, thresholds vary<br />
accordingly. The majority of<br />
Drs David Kent and Ben LaHood as Ginger and<br />
Mary Ann from Gilligan’s Island<br />
the audience said they would<br />
only consider them for high<br />
Fendalton Eye Clinic team at the<br />
Under the Sea gala dinner<br />
refractive errors<br />
not amenable<br />
to other<br />
keratorefractive<br />
methods, but<br />
Germany’s Dr<br />
Lena Beckers<br />
raised the<br />
Eye, eye, cap’n! Drs Dean Corbett, Andrea Ang and Ben LaHood<br />
question of<br />
whether we should expand our range for considering this treatment.<br />
In this session, I discussed my own case series of treating young<br />
pre-presbyopic eyes with unilateral cataract surgery following trauma<br />
associated with implantation of an extended depth of focus IOL.<br />
Although the outcomes were very good, these eyes can certainly throw<br />
some unexpected drama at you. The session ended with the legend of<br />
IOL calculation himself, Professor Graham Barrett, from the University<br />
of Western Australia. Spoiler alert: the future of IOL calculation<br />
includes more AI than you can shake a stick at, which is great, unless<br />
that AI starts recommending eye drops to stop cataract formation!<br />
Offshore pearls<br />
Some of the international invited speakers gave us some pearls of<br />
wisdom in the first day’s afternoon session. Dr Elizabeth Yeu, Virginia,<br />
US, showed her strategies for IOL exchange – an operation which<br />
none of us enjoy but which is sometimes necessary. One of the most<br />
difficult and potentially hazardous parts of the operation is to dissect<br />
the capsule away from the haptics of the existing IOL. Dr Yeu showed<br />
that sometimes she will resort to amputating and leaving haptics behind<br />
in order to preserve the capsular bag. It’s nice to know that even such a<br />
skilled and experienced surgeon sometimes has problems too.<br />
Singapore Eye Research Institute’s Distinguished Professor Jod<br />
Mehta advised waiting as long as possible with multifocal IOLs before<br />
exchanging them, as dysphotopsias often become much more tolerable<br />
and the lens can be left in place. That’s easier to say than do when you<br />
have an unhappy patient sitting in front of you, but the facts and figures<br />
he presented were very compelling.<br />
Continued on p32<br />
30 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
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EDUCATION<br />
Continued from p30<br />
It was great to see AUSCRS having a session dedicated to<br />
lenticule-based keratorefractive surgery for the first time.<br />
These procedures to remove a lenticule of corneal stroma<br />
to alter the refractive state of the eye go by a different name<br />
from each company, but all aim to achieve the same goal of<br />
spectacular vision. We are still in the stages of refining our<br />
predictive models and determining which biometric factors<br />
are the most important inputs. Talks on adjusting energy<br />
settings and the impact of energy output on corneal healing<br />
were fascinating. Dr Kishore Pradhan, founder, medical director<br />
and a senior refractive surgeon at Matrika Eye Center, Kathmandu,<br />
used machine-learning models to determine which factors to put into his<br />
own nomogram for determining lenticule parameters. While his work<br />
appeared complex – and worrying that we will all soon need maths PhDs<br />
to do laser surgery – I applaud people like Dr Pradhan, who, through<br />
their own hard work, make outcomes better for all laser surgeons.<br />
Well, well, well<br />
Surprisingly, one of the most controversial sessions of the meeting was<br />
focused on wellbeing and thriving in ophthalmology. AUSCRS copresident<br />
Dr Jacqueline Beltz and Dr Jo Mitchell – high-performance<br />
coach, psychologist and previous AUSCRS advanced trainee mentor<br />
– hosted this section on sharing experiences: the good, the bad and<br />
the upsetting. The discussion from presenters around the struggles<br />
during training, and lack of support at times, received varied audience<br />
responses. I found the negative feedback surprising, but every story<br />
needs a villain to bring people together and the AUSCRS family got<br />
through a heated discussion together in the end.<br />
I may be incredibly biased, as I was hosting the session, but<br />
‘Technological icebergs: navigating updates in surgery’ was jam-packed<br />
full of interesting points. Not to mention the Titanic theme, which<br />
involved a re-enactment of the famous movie scene at the front of<br />
the ship with Germany’s Dr David Beckers and Australia’s Associate<br />
Professor Smita Agarwal as Jack and Rose, as well as the violinists going<br />
down with the ‘ship’. Dr Luke Anderson (UK) asked whether cataract<br />
surgeons should be doing minimally invasive glaucoma surgery (we<br />
all agreed they should), while Dr Beckers talked about how AI will<br />
realistically be used in the clinic and A/Prof Agarwal spoke on her<br />
cataract surgeries now being done at physiological intraocular pressure.<br />
Dr David Kent wins Best Sport award from co-presidents<br />
Prof Gerard Sutton and Dr Jacqui Beltz for having to dress<br />
up as a woman twice<br />
CAIRS and<br />
crosslinking<br />
In the ‘Shark<br />
Tank’ session, we<br />
were fortunate to<br />
hear from two of<br />
the world’s most<br />
experienced surgeons<br />
in their own areas<br />
of managing<br />
irregular corneas. Dr<br />
David Gunn from<br />
Brisbane discussed<br />
his work with<br />
corneal allogenic<br />
intrastromal ring<br />
segments (CAIRS) to<br />
manage keratoconic<br />
eyes, while Dr John<br />
Kanellopoulos from<br />
Greece discussed<br />
his Athens protocol<br />
for crosslinking<br />
and using laser<br />
treatments to<br />
Dr Sean Every winning<br />
the film festival award<br />
regularise corneas. Both have provided us with so much knowledge and<br />
revolutionised the way we look after ectatic corneas.<br />
Two of the things I love most about AUSCRS are a good rigorous<br />
debate without fear of upsetting anyone and the film festival. Both were<br />
top notch this year and rounded out the final sessions.<br />
This year’s debate was about immediately sequential bilateral cataract<br />
surgery (ISBCS). It was such a great crowd to hold the debate in front<br />
of, since these are likely the surgeons doing the majority of the cataract<br />
surgery in Australasia. So it was surprising that the crowd favourite<br />
was delayed surgery rather than doing both on the same day. I would<br />
much prefer to do ISBCS, but the stumbling block in my area is that<br />
day surgeries would earn less, so it is discouraged. We shall see what the<br />
future holds, as surely it’s the way forward for our patients.<br />
The film festival is the final part of the programme, with points given<br />
for content and entertainment value. Having won it myself last year, it<br />
was nice to see another Kiwi pick up this year’s gong. Christchurch’s Dr<br />
Sean Every delivered a pirate-infused, Kiwi-accent-laden poem while<br />
describing heroic surgery to explant and implant a lens in an extremely<br />
difficult case. Dr Every is a vitreoretinal surgeon but clearly didn’t lose<br />
too many points from the judges for his transition to refractive surgery!<br />
Aqueous humour<br />
President Professor Gerard Sutton, Gina Sutton,<br />
Jane Patterson and Dr David Kent<br />
With all of the science and debate out of the way, it was finally time to<br />
let our hair down and party. The aquatic-themed costumes throughout<br />
the sessions were great but the gala dinner saw some incredible and<br />
hilarious efforts. We had amazing jellyfish and turtles and mermaids<br />
galore for the under-the-sea-themed event. Sydney’s Dr Alison Chiu,<br />
always a fan favourite, won the best costume prize as Ursula the sea<br />
witch. We partied and danced into the night. Being all shipwrecked on<br />
the same island, there was no escaping seeing each other all looking<br />
worse for wear at the airport on our way home in the morning.<br />
As the conference came to a close, I couldn’t help but reflect on the<br />
wealth of knowledge gained, the connections made and the fact that I<br />
had acquired a large turtle costume I probably won’t wear again. The<br />
<strong>2024</strong> AUSCRS meeting was not just an opportunity to learn, it was a<br />
reminder of why we do what we do: connecting with peers, exchanging<br />
ideas and occasionally finding ourselves taking a fishing charter instead<br />
of sitting in lectures.<br />
AUSCRS 2025 will be held in Darwin from 16–19 July. I can’t wait to<br />
see how we will top this year on Hamilton Island, but I’m confident it<br />
will be even bigger and better yet again!<br />
Dr Ben LaHood is an Australasian-trained consultant ophthalmologist based in<br />
Adelaide, with subspeciality fellowship training in laser vision correction and<br />
refractive cataract surgery and a special interest in astigmatism correction. He<br />
was named among The Ophthalmologist’s annual Power List of the world’s top 100<br />
industry leaders in 2023 and <strong>2024</strong>.<br />
32 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
NEWS<br />
The perils of<br />
keratopigmentation<br />
THE AMERICAN ACADEMY of Ophthalmology (AAO) has warned that<br />
keratopigmentation, a cosmetic procedure to change a patient’s eye<br />
colour by ‘tattooing’ the iris, carries serious risks including cataract,<br />
elevated IOP leading to glaucoma, corneal damage leading to vision<br />
loss, and infection. Other concerns include light sensitivity, plus<br />
leakage of, and allergic reactions to, the dye.<br />
US online retailer Overnight Glasses claims its research showed<br />
eye-colour-change surgery (including keratopigmentation, cosmetic<br />
iris implants and laser pigment removal) topped its list of most<br />
dangerous cosmetic procedures, with a complication rate of 92.3%.<br />
However, New York-based ophthalmologist Dr Alexander<br />
Movshovich told CNN Health that, having performed his own version<br />
of keratopigmentation on more than 1,000 patients, none of them has<br />
reported serious problems related<br />
to the procedure. Dr Movshovich<br />
said he developed a surgical<br />
instrument that creates a tiny<br />
channel in the cornea for pigment<br />
injection, which he said he closes<br />
at the end of the procedure.<br />
Keratopigmentation has been<br />
popular in parts of Europe for<br />
over a decade, but has recently<br />
taken off in the US, thanks to<br />
patients sharing their new eye<br />
colours on social media, according<br />
to CNN Health. The hashtag<br />
#keratopigmentation appears on<br />
571 TikTok posts.<br />
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in 5 cases of dementia in the<br />
elderly could be attributed to<br />
vision impairment.<br />
The study, published in JAMA<br />
Ophthalmology, found up to<br />
19% of dementia cases could<br />
be attributable to one or more<br />
types of vision loss. Researchers<br />
noted dementia could have been<br />
prevented in nearly 20% of cases,<br />
had loss of vision been addressed.<br />
“While not proving a causeand-effect<br />
relationship, these<br />
findings support inclusion of<br />
multiple objective measures of<br />
vision impairments, including<br />
contrast sensitivity and visual<br />
acuity, to capture the total<br />
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NZOPTICS.CO.NZ | 33
NEWS<br />
Biomarkers predictive of glaucoma<br />
treatment response<br />
RESEARCHERS FROM University College London (UCL) and<br />
Moorfields Eye Hospital have identified biomarkers that may<br />
predict which glaucoma patients are at higher risk of continued<br />
vision loss, despite conventional treatment.<br />
The study, published in Nature Medicine, examined whether<br />
mitochondrial function in white blood cells is lower in people with<br />
glaucoma than in healthy patients and whether it is associated with<br />
the rate at which glaucoma patients lose vision.<br />
Enrolling 139 participants diagnosed with glaucoma and on<br />
treatment to lower intraocular pressure (IOP), plus 50 healthy<br />
individuals as controls, researchers measured how well cells in<br />
the blood use oxygen, how much vision was lost over time, and<br />
nicotinamide adenine dinucleotide (NAD*) levels.<br />
They discovered peripheral blood mononuclear cells use oxygen<br />
differently in people with glaucoma and that people whose blood<br />
cells used less oxygen tended to lose their vision faster, even if they<br />
were on IOP-lowering treatment. This measurement explained 13%<br />
of the differences in how fast patients lost vision, they said.<br />
Additionally, the blood cells of people with glaucoma were found<br />
to have lower levels of NAD compared to those without glaucoma.<br />
These lower NAD levels were also linked to the lower oxygen use in<br />
the blood cells.<br />
“White blood cell mitochondrial function and NAD levels, if<br />
introduced as a clinical test, would enable clinicians to predict<br />
which patients are at higher<br />
risk of continued vision<br />
loss, allowing them to<br />
be prioritised for more<br />
intensive monitoring<br />
and treatment,” said<br />
senior author<br />
Professor David<br />
Garway-Heath. “If<br />
further research shows<br />
that low mitochondrial<br />
function or low NAD levels<br />
are a cause for glaucoma,<br />
then this opens the way for<br />
new treatments.”<br />
UCL and Moorfields Eye<br />
Hospital are currently leading a<br />
Mitochondrial function was<br />
associated with glaucoma<br />
treatment response<br />
major clinical trial to establish whether high-dose vitamin B3 can boost<br />
mitochondrial function and reduce vision loss in glaucoma, he added.<br />
“We hope that this will open a new avenue for treatment of glaucoma<br />
patients which does not depend on lowering the eye pressure.”<br />
*The NAD molecule is derived from vitamin B3 and helps cells<br />
produce energy.<br />
BOOK REVIEW<br />
Steinert’s Cataract Surgery, 4th edition<br />
Edited by Professor Sumit Garg and Dr Douglas Koch | Reviewed by Professor Charles McGhee<br />
STEINERT’S CATARACT SURGERY is an excellent 530-page hardback<br />
textbook pioneered by the late Professor Roger Steinert. This edition<br />
is edited by Professor Sumit Garg and Dr Douglas Koch, both doyens<br />
in the field of cataract surgery. The editors have assembled an<br />
extensive group of expert contributors, not only from North America,<br />
but also from around the world, to add 10 new chapters and update<br />
this more international edition.<br />
The book is particularly well organised, being divided into eight<br />
logical, progressive sections, including: preoperative considerations,<br />
intraocular lenses, anaesthesia and initial steps, nuclear disassembly,<br />
astigmatism management, complex cases, intraoperative<br />
complications and postoperative complications. Each section is<br />
subdivided into several short chapters, each composed of relatively<br />
short, easily readable paragraphs with copious high-quality colour<br />
illustrations. Each chapter is also accompanied by links to several<br />
online videos which provide a veritable library, bringing a very<br />
contemporary and easily digestible feel to the whole product.<br />
Each chapter’s well thought-through structure reveals the<br />
expertise of its highly respected author. If one had any small gripes,<br />
it would be that the typeface is small and, therefore, slightly dense<br />
and intimidating to read when you have two to three pages without<br />
illustrations; plus, some of the images are clearly from older editions<br />
and could be updated. That said, it is an easy read, with most of its<br />
56 chapters readily explored and their key points assimilated within<br />
30–60 minutes. Combing through the reference section, it is notable<br />
that most chapters are well referenced and generally very up to date<br />
– no small feat in a subject area that changes very quickly.<br />
The readership of this book likely consists of two main groups.<br />
Firstly, residents and other trainees embarking on cataract surgery<br />
who wish to have a<br />
comprehensive, well-written<br />
source with illustrative<br />
videos that can provide<br />
all the key information in<br />
one place. These topics<br />
might include cataract<br />
development, intraocular<br />
lens design, biometry,<br />
phacoemulsification<br />
techniques and surgical complications. This text covers<br />
all those areas well and certainly could be read in conjunction<br />
with clinical practice to provide a strong basis for cataract surgery<br />
training. The second group is more established practitioners<br />
seeking an update in some areas, but who do not necessarily wish<br />
to peruse multiple publications to find a comprehensive summary<br />
to form an opinion. This book will serve that group well and a copy<br />
certainly should be kept in the office or department library to be<br />
dipped into. Overall, I genuinely enjoyed reading Steinert’s Cataract<br />
Surgery 4th edition and recommend it highly for those involved in<br />
the management of cataract.<br />
Professor Charles McGhee heads the Department of<br />
Ophthalmology and is director of the New Zealand<br />
National Eye Centre at the University of Auckland. His<br />
interests include keratoconus, corneal diseases and corneal<br />
transplantation, complex cataract and anterior segment<br />
trauma, and complex anterior segment pathology, including<br />
iris and conjunctival melanoma and other rare anterior<br />
segment tumours, for which he receives nationwide referrals.<br />
34 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
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NEWS<br />
EYE ON OPHTHALMOLOGY<br />
Glaucoma – improving control with stents,<br />
trabs, and tubes<br />
By Dr Hussain Patel<br />
GLAUCOMA MANAGEMENT HAS traditionally been<br />
focused on medical therapy as initial treatment with<br />
intensification until maximum tolerated medical therapy<br />
(MTMT) is reached. Often patients end up taking multiple<br />
eyedrops several times a day, which can sometimes lead to<br />
issues with side effects and adverse events, poor adherence,<br />
inconvenience and reduction in quality-of-life measures.<br />
The results from the ‘Laser in glaucoma and ocular<br />
hypertension trial’ (LiGHT) indicated that selective laser<br />
trabeculoplasty (SLT) may offer better glaucoma control<br />
over medical therapy in the initial treatment of primary<br />
open-angle glaucoma (POAG) and ocular hypertension<br />
(OHT) 1 . The development of safer and less invasive surgical<br />
options, termed minimally invasive glaucoma surgery<br />
(MIGS) has enabled surgical intervention at an earlier stage<br />
as an alternative to intensive medical therapy.<br />
Although medical treatment still remains an important<br />
part of glaucoma care, these newer developments are leading to a<br />
paradigm shift in glaucoma management, where we are able to offer<br />
patients safe and effective alternatives if they are struggling with multiple<br />
daily eyedrop usage. Many MIGS procedures are now readily available<br />
for clinical use in New Zealand and have become an essential part of our<br />
current glaucoma management armamentarium.<br />
MIGS<br />
Fig 1. The iStent inject<br />
MIGS refers to a group of newer glaucoma procedures considered<br />
less invasive in comparison to traditional glaucoma surgery, while<br />
still providing meaningful intraocular pressure (IOP) lowering. They<br />
have been developed to bridge the gap between initial medical and<br />
SLT treatment and the more invasive options of trabeculectomy and<br />
tube-shunt surgery. The different MIGS procedures share common<br />
characteristics, including a high safety profile, minimal disruption of<br />
normal anatomical structures, ease of use and rapid recovery time.<br />
MIGS may be combined with cataract surgery or be performed as<br />
standalone procedures.<br />
MIGS procedures have been developed to target almost every aspect<br />
of both the conventional and uveoscleral aqueous outflow pathways. The<br />
most common MIGS devices currently used in New Zealand include the<br />
iStent (Glaukos), Kahook Dual Blade (KDB, New World Medical) and the<br />
Preserflo MicroShunt (Santen).<br />
The safety and efficacy of iStent is now well established. Meta-analysis<br />
data confirms the superiority of iStent with cataract surgery over cataract<br />
surgery alone, in terms of both absolute IOP lowering and number of<br />
medications needed for glaucoma control 2 . The clinical benefits are often<br />
sustained for many years post-operatively 2 . The current generation of<br />
iStent (iStent inject W) allows for two devices to be injected into the TM<br />
of the same eye using a single pre-loaded injector. A recent prospective<br />
randomised multi-surgeon trial demonstrated that with the use of two<br />
iStent injects in the same eye, it is also safe and effective as a standalone<br />
procedure (without cataract surgery) for the treatment of mild to<br />
moderate glaucoma 3 .<br />
iStent technology has progressed further with the introduction of the<br />
iStent infinite, which enables three iStents to be injected into the TM<br />
with the same injector. Research has shown this leads to additional IOP<br />
lowering and better glaucoma control than what was achieved with two<br />
iStents 4 . This could potentially play a role in patients with more advanced<br />
glaucoma and evidence suggests it may be effective even in patients<br />
with previous failed glaucoma surgery 4 .<br />
KDB<br />
The KDB is another MIGS procedure targeting the TM and would be<br />
considered an alternative to iStent. The KDB is a specifically designed<br />
iStent<br />
iStent is a MIGS device implanted into the trabecular<br />
meshwork (TM) to enable drainage of aqueous humour<br />
from the anterior chamber directly into Schlemm’s canal,<br />
bypassing the TM (Fig 1). It is recommended for patients<br />
with mild to moderate POAG, OHT, normal-tension<br />
glaucoma (NTG), pseudoexfoliative glaucoma (PXG) and<br />
pigmentary glaucoma (PG). iStent is contraindicated in<br />
patients with angle-closure glaucoma and most forms<br />
of secondary glaucoma other than PXG/PG. As the iStent<br />
is most commonly used in combination with cataract<br />
surgery, the patients most suitable would be those who<br />
also have visually significant cataract along with being<br />
on multiple glaucoma eye drops and/or having<br />
uncontrolled glaucoma.<br />
Fig 2. Kahook Dual Blade goniotomy<br />
36 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
Professors<br />
Charles McGhee<br />
& Dipika Dr Jie Zhang, Patel,<br />
series editors<br />
goniotomy blade that allows the ab interno<br />
(via anterior chamber) removal of a strip<br />
of TM while minimising collateral damage<br />
to surrounding structures (Fig 2). By<br />
removing a section of TM, the KDB allows<br />
aqueous drainage directly into the collector<br />
channels of Schlemm’s canal and the distal<br />
outflow system. KDB can be performed as<br />
a standalone procedure or combined with<br />
cataract surgery. Similar to iStent, the ideal<br />
patient has mild to moderate open-angle<br />
glaucoma, is on multiple medications and<br />
undergoing cataract surgery.<br />
Clinical studies have demonstrated a high<br />
safety profile comparable to other MIGS<br />
procedures and enhanced safety when<br />
compared to trabeculectomy 5 . The clinical<br />
efficacy, in terms of long-term IOP lowering<br />
and reduction in number of medications,<br />
is also comparable to other MIGS procedures 5 . KDB may be effective in<br />
severe or refractory glaucoma and hence like the iStent infinite it could<br />
provide a possible alternative in high-risk eyes that would otherwise<br />
need more invasive surgery 6 .<br />
Preserflo MicroShunt<br />
The Preserflo MicroShunt can be considered the next level in MIGS<br />
intervention when iStent or KDB is unsuitable or unsuccessful for a<br />
particular patient. The Preserflo device provides greater IOP lowering<br />
than these other MIGS devices and is best suited to patients with<br />
uncontrolled moderate to advanced glaucoma. Preserflo is considered a<br />
more direct alternative to trabeculectomy than other MIGS procedures.<br />
The device is a ‘microtube’ made from biocompatible material<br />
known as ‘SIBS’ (synthetic polymer of poly(styrene-block-isobutyleneblock-styrene))<br />
and is 8.5mm long with a 350mm outer diameter and<br />
70mm lumen. These dimensions were designed to allow adequate<br />
outflow while preventing hypotony. The Preserflo is implanted<br />
subconjunctivally through a scleral tunnel so that the proximal tip rests<br />
in the anterior chamber and the distal end sits under the conjunctiva and<br />
the Tenon capsule approximately 6mm from the limbus (Fig 3A). Aqueous<br />
drains from the anterior chamber to the subconjunctival space, resulting<br />
in the formation of a bleb much like with a trabeculectomy – hence<br />
mitomycin-C application within the sub-conjunctival space at the time<br />
of surgery is required. Unlike trabeculectomy, there is no need for scleral<br />
flap formation, sclerotomy or iridectomy as part of the procedure.<br />
Preserflo requires less operating time and post-operative additional<br />
measures, has a faster recovery time and a lower risk of intraoperative<br />
and post-operative complications, compared to trabeculectomy 7-9 .<br />
Several clinical trials evaluating Preserflo have demonstrated a high<br />
safety profile and effectiveness at controlling glaucoma over many years<br />
of follow up 7-9 . The complete success rate (no additional medications<br />
to achieve target IOP) was reported to be between 75–80% and the<br />
qualified success rate (requiring additional medications) was over 90%<br />
in these studies at least two years after surgery. However, Preserflo does<br />
not result in the same level of IOP lowering that can be achieved with<br />
trabeculectomy, hence for patients who require a low target IOP, the<br />
latter option is still preferred 9 .<br />
Fig 3. The Preserflo MicroShunt (A) in comparison to a traditional tube-shunt (Paul tube in the sulcus) (B)<br />
Traditional tube-shunt surgery (Ahmed, Baerveldt, Molteno and Paul<br />
implants) will also continue to play an essential role due to their different<br />
clinical indications. In particular, patients with complex secondary<br />
glaucoma (eg, active neovascular or uveitic glaucoma) have far better<br />
outcomes with tube-shunt surgery than with trabeculectomy. Other<br />
indications include conjunctival scarring precluding filtration surgery or<br />
previous failed trabeculectomy.<br />
In contrast to Preserflo, these tubes have a much larger lumen<br />
diameter and an external plate implanted subconjunctivally, which<br />
allows for formation of an external reservoir. Tube-shunts are available in<br />
different sizes, material and design, with some being valved and others<br />
non-valved. The Paul tube (Fig 3B) is a relatively new device with a lumen<br />
diameter (0.1mm) somewhat midway between the Preserflo (70μm)<br />
and other tubes (0.3mm) and has been well-adopted as it maintains the<br />
clinical effectiveness of other tube-shunts while having a lower risk of<br />
hypotony and other post-operative complications.<br />
References<br />
1. Gazzard G et al. Selective laser trabeculoplasty versus drops for newly diagnosed ocular hypertension and<br />
glaucoma: the LiGHT RCT. Health Technol Assess. 2019;23(31):1–102<br />
2. Malvankar-Mehta, M.S, Iordanous, Y, Chen, Y.N et al. iStent with Phacoemulsification versus<br />
Phacoemulsification Alone for Patients with Glaucoma and Cataract: A Meta-Analysis. PLoS<br />
ONE 2015, 10, e0131770<br />
3. Fechtner, R.D, Voskanyan, L, Vold, S.D et al. Five-Year, Prospective, Randomized, Multi-Surgeon<br />
Trial of Two Trabecular Bypass Stents versus Prostaglandin for Newly Diagnosed Open-Angle<br />
Glaucoma. Ophthalmol. Glaucoma 2019, 2, 156–166.<br />
4. Sarkisian, S.R.; Grover, D.S.; Gallardo, M.J et al. iStent infinite Study Group. Effectiveness and Safety of<br />
iStent Infinite Trabecular Micro-Bypass for Uncontrolled Glaucoma. J. Glaucoma 2023, 32, 9–18.<br />
5. Dorairaj S, Radcliffe NM, Grover DS et al. A Review of Excisional Goniotomy Performed with the Kahook<br />
Dual Blade for Glaucoma Management. J Curr Glaucoma Pract 2022; 16 (1):59-64.<br />
6. Bravetti, G.E., Gillmann, K., Salinas, L. et al. Surgical outcomes of excisional goniotomy using the kahook<br />
dual blade in severe and refractory glaucoma: 12-month results. Eye 37, 1608–1613 (2023).<br />
7. Beckers H.J.M., Aptel F., Webers C.A.B., Bluwol E et al. Safety and Effectiveness of the PRESERFLO(R)<br />
MicroShunt in Primary Open-Angle Glaucoma: Results from a 2-Year Multicenter Study. Ophthalmol.<br />
Glaucoma. 2021.<br />
8. Gubser, P.A., Pfeiffer, V., Hug, S. et al. PRESERFLO MicroShunt implantation versus trabeculectomy for<br />
primary open-angle glaucoma: a two-year follow-up study. Eye and Vis 10, 50 (2023).<br />
9. Khan, A. & Khan, A.U. (<strong>2024</strong>) Comparing the safety and efficacy of Preserflo Microshunt implantation<br />
and trabeculectomy for glaucoma: A systematic review and meta-analysis. Acta Ophthalmologica, 102,<br />
e443–e451.<br />
The current role of trabeculectomy and tube-shunt surgery<br />
With the advent of MIGS there has been a decreasing trend in the need<br />
for trabeculectomy. However, it has long been considered the gold<br />
standard of glaucoma surgery and still has an important role to play.<br />
Trabeculectomy is the preferred option in patients with uncontrolled<br />
moderate to advanced glaucoma on MTMT who require a low target IOP.<br />
Furthermore, trabeculectomy may be necessary when access to MIGS is<br />
not possible or as a subsequent step if previous MIGS was unsuccessful.<br />
Dr Hussain Patel is a glaucoma and cataract specialist at<br />
Eye Surgery Associates and Greenlane Clinical Centre in<br />
Auckland. He is also a senior lecturer with the Department of<br />
Ophthalmology, University of Auckland.<br />
NZOPTICS.CO.NZ | 37
NEWS<br />
Melanoma prediction with a<br />
smartphone?<br />
(L to R) Professor Minas Coroneo AO and study participant Peter Phillips. Credit: Prince of<br />
Wales Hospital<br />
RESEARCHERS AT AUSTRALIA’S Prince of Wales Hospital have<br />
begun a study of a prototype smartphone-based tool to assess ultraviolet<br />
(UV) damage to the eye, which can be an early predictor for skin cancer.<br />
Despite the country having some of the world’s highest levels of<br />
UV radiation, with skin cancer and eye diseases impacting millions of<br />
Australians, there are currently no readily available, objective means of<br />
assessing early ocular UV damage, said Professor Minas Coroneo AO,<br />
study lead and the hospital’s head of ophthalmology. “Our team was one<br />
of the first to document that the UV-related conditions affecting the eye,<br />
such as pterygium and one type of cataract, could be an early sign of<br />
skin cancer, decades before its manifestation,” he said.<br />
The team’s optical add-on can be retrofitted to smartphones, enabling<br />
instant and portable UV eye damage detection, he said. The study,<br />
made possible thanks to a $125,000 grant from Prince of Wales Hospital<br />
Foundation, is currently recruiting participants.<br />
Otago Region<br />
Eye Clinics<br />
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Queenstown<br />
0800 343 6464<br />
visionspecialist.co.nz<br />
Dunedin & Ōamaru<br />
0800 343 6464<br />
odocseyes.co.nz<br />
New Queenstown eye<br />
clinic opens<br />
EXPANDING BEYOND<br />
DUNEDIN, Otago<br />
Vision Specialist is<br />
opening a new eye<br />
specialist clinic in<br />
Queenstown. Located<br />
in the city centre’s<br />
Queenstown Medical<br />
Centre, the clinic aims to<br />
provide comprehensive<br />
eyecare services to the<br />
Central Otago and<br />
Lakes regions.<br />
“We are thrilled to<br />
bring our expertise<br />
and advanced<br />
treatment options to<br />
Queenstown,” said<br />
founder and consultant<br />
ophthalmologist, Dr<br />
Sheng Hong. “Our goal<br />
is to provide exceptional<br />
personalised care to every<br />
patient, ensuring the best<br />
possible outcomes.”<br />
Dr Sheng Hong (L) with nurse Danielle Wilson,<br />
ophthalmic technician Gabriel Bilkey and nurse<br />
Melanie Peck outside the new Queenstown<br />
eye clinic<br />
The clinic offers cornea, cataract, uveitis, glaucoma, eyelid,<br />
retina and paediatric ophthalmology specialist services. The<br />
Queenstown team also includes Drs Mimi Chiu, Ammar Binsadiq<br />
and Harry Bradshaw.<br />
World’s first spiral IOL<br />
designed with AI<br />
RAYNER, A GLOBAL<br />
manufacturer of<br />
cataract surgery<br />
products, has launched<br />
a world-first spiral<br />
intraocular lens<br />
(IOL) designed using<br />
artificial intelligence<br />
(AI): RayOne Galaxy<br />
and Galaxy Toric.<br />
Introduced at this<br />
year’s European Society of Cataract and Refractive Surgeons (ESCRS)<br />
congress in Barcelona, the RayOne Galaxy IOL comes to market 75 years<br />
after Rayner pioneered the first IOL with ophthalmologist and inventor<br />
Sir Harold Ridley.<br />
However, unlike in Sir Harold’s day, this new lens was designed<br />
using a proprietary AI engine trained on patient outcomes, which the<br />
company said delivers “a continuous full range of vision with minimised<br />
dysphotopsia, achieved through a non-diffractive optic with 0% light loss’’.<br />
Everyone has read about the life-changing potential of AI, but this<br />
is a real-world example of technology impacting the outcomes of<br />
patients, said Tim Clover, Rayner CEO. “RayOne Galaxy represents a nextgeneration<br />
technology in intraocular lenses to enable patients to see<br />
without spectacles.”<br />
RayOne Galaxy is available in a wide range of toric powers and comes<br />
fully preloaded in the same single-use injector system as the RayOne<br />
family of lenses, said the company.<br />
38 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
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NZOPTICS.CO.NZ | 39
NEWS<br />
MIGS – in the surgeon’s seat!<br />
By Susanne Bradley<br />
RE:VISION’S FIRST minimally<br />
invasive glaucoma surgery (MIGS)<br />
dry lab workshop provided<br />
keen optometrists with a unique<br />
opportunity to put their surgical<br />
skills to the test. A bit like speed<br />
dating, optometrists moved<br />
between six stations, inserting<br />
Glaukos’ latest iStent infinite and<br />
Preserflo as well as trying their<br />
hand at using the Kahook Dual<br />
Blade before examining four<br />
volunteer MIGS patients.<br />
Passionate shared-care<br />
advocate Dr Divya Perumal<br />
said the workshop had been a<br />
dream of hers for a long time.<br />
Enhancing optometrists’ MIGS<br />
knowledge is important since<br />
MIGS patients are ideal candidates<br />
for co-management, she said.<br />
“A collaborative approach between<br />
optometrists and ophthalmologists<br />
in evaluating, educating and<br />
Re:Vision hosts Jennifer Silvester, Dr Mo Ziaei, Elkie Wong, Dr Divya Perumal,<br />
Nick Mathew, and Glaukos’ Chris Money<br />
managing patients undergoing MIGS leads to better outcomes, efficient<br />
use of resources, enhanced patient satisfaction and better continuity of<br />
care,” she said.<br />
Discussing pre- and post-surgery considerations and different surgery<br />
techniques, Dr Perumal said MIGS candidates are patients with mild to<br />
moderate glaucoma and glaucoma patients with cataracts who want to<br />
get off medication, have poor medication compliance or are medication<br />
Guided by Dr Divya Perumal, Paula Farrar<br />
manoeuvres the slightly floppy Preserflo stent<br />
into place<br />
Vandana Kumar handles the Kahook Dual Blade<br />
intolerant, are challenged in attending regular follow-ups or want a<br />
faster post-operative recovery.<br />
One important aspect of the optometrist’s role in a shared-care<br />
arrangements is education and counselling, said Dr Perumal, including<br />
informing patients of the benefits and risks and advising them of<br />
realistic outcomes. “MIGS is not cataract surgery, it’s a lifetime process,”<br />
she concluded.<br />
Optique’s acquisition creates one-stop shop<br />
OPTIQUE LINE HAS acquired key<br />
assets from McCann Optical Parts,<br />
including plant, equipment and<br />
inventory, allowing it to expand its<br />
offering with an extensive range of<br />
tailored optical accessories.<br />
“We believe this integration will<br />
enhance our services, allowing us<br />
to deliver more tailored solutions<br />
meeting the unique needs of<br />
our customers in New Zealand,”<br />
said Optique Line’s director John<br />
Nicola. “The purchase is a perfect<br />
fit for Optique Line, allowing<br />
our account managers to offer a<br />
comprehensive, one-stop shop. The<br />
team is committed to creating a<br />
seamless transition,” he said. “Greg Optique Line’s John Nicola at O=Mega19<br />
McCann and his team have provided<br />
exceptional expertise and service for many years and we plan to<br />
continue their great work.”<br />
The former McCann Optical Parts will be represented in New<br />
Zealand by Optique Line’s account manager Vicki Evans.<br />
Partner programme boost<br />
In other news, Optique Line’s Supply & Fit<br />
tiered partner programme is rewarding<br />
loyal customers with the addition of gold<br />
and platinum benefits. A gold partner<br />
(who constantly maintains 60-plus pieces<br />
of stock) will receive $200 account credit<br />
every two years and a two-year warranty covering manufacturing<br />
defects and material faults. A platinum partner (who constantly<br />
maintains 100-plus pieces of stock) will receive $500 account credit<br />
every two years and an unconditional two-year warranty.<br />
40 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
ALWAYS READ THE LABEL AND FOLLOW THE DIRECTIONS FOR USE.<br />
LASTS 6 MONTHS<br />
AFTER OPENING<br />
*For up to 16 hours. ^Based on laboratory studies on selected organisms. **Compared to Opti-Free Replenish Multi-Purpose Disinfecting Solution ECONOMY PACK. References: 1. Lally, J. et al. A new lens<br />
care solution provides moisture and comfort with today’s CLs. Optician 2011. 241 (62960): 42-46. 2. Resnick, S. What makes OPTI-FREE PureMoist MPDS an attractive solution. Review of Cornea & Contact<br />
Lenses September 2011. 3. Subbaraman, L. et al. In Vitro Efficiency of Contact Lens Care Solutions in Removing Cholesterol Deposits from Silicone Hydrogel Contact Lenses. Contact Lens & Anterior Eye 36<br />
(2013) e16-46. 4. Rosenthal, A. et al. Broad Spectrum Antimicrobial Activity of a New Multi-Purpose Disinfecting Solution. CLAO 2000. 26(3). 5. Codling, C. et al. Aspects of the Antimicrobial Mechanisms of<br />
a Polyquaternium and Amidoamine. JAC 2003(51):1153-1158. 6. Gabriel, M. et al. Effect of Contact Lenses and Lens Cases on Disinfection Efficacy of Four Multipurpose Disinfection Solutions. ARVO 2013.<br />
7. Kern, J. et al. Antimicrobial properties of a novel contact lens disinfecting solution, OPTI-FREE EverMoist. BCLA 2011. 8. Gabriel, M. et al. Antimicrobial Efficacy of Multipurpose Disinfecting Solutions in the<br />
Presence of Contact Lenses and Lens Cases. Eye and Contact Lens 2016;0: 1-7. ©<strong>2024</strong> Alcon Laboratories Pty Ltd. AUS: 1800 224 153; Auckland NZ: 0800 101 106. ANZ-OFM-2400008
BUSINESS<br />
Brought to you<br />
by the IOGroup<br />
BEST PRACTICE, MADE EASY<br />
The bottom line: business focus<br />
fundamentals – part one<br />
By Lynden Mason, with Teréze Taber<br />
OPERATING A SUCCESSFUL practice<br />
requires so much more than just<br />
clinical expertise. One of the biggest<br />
challenges for business owners is<br />
balancing time working on their<br />
business – not just in it.<br />
Instead of feeling overwhelmed by<br />
the numerous hats you’re expected<br />
to wear as a business owner, let me<br />
introduce you to the business focus<br />
fundamentals, or BFFs (can you tell<br />
I have teenage daughters?). It’s not<br />
perhaps the most sophisticated<br />
abbreviation, but it’s a simple tool<br />
you can refer to daily by asking: am I<br />
spending enough time developing a healthy relationship with my BFFs<br />
and, therefore, my business?<br />
I have spent 20 years owning and operating businesses in New<br />
Zealand, both as an optometrist and an entrepreneur. After growing<br />
a group of 10 optometry practices and selling to Luxottica in 2010, I<br />
then switched to another field. Initially, I opened one hairdressing salon<br />
and rebranded it Vivo. Over the next decade, I expanded Vivo into a<br />
nationwide group (I never picked up a pair of scissors or learned how to<br />
dye hair!). As time went on, I focused on certain principles and realised<br />
they could be relied upon in any business operation. However, they’re<br />
easily diluted by the numerous pressures that every business owner has<br />
on their time, finances and energy. Throw in a recession and a cost-ofliving<br />
crisis and it’s fair to say things feel a little stressful right now. But if<br />
you focus on the BFFs, they are a proven, effective and simple maxim for<br />
keeping your clinic profitable, no matter the financial climate.<br />
The BFFs include vision and strategy, financial management<br />
recruitment, staff development and training, branding, marketing, client<br />
experience, inventory/supplier management and time management (to<br />
enable you to juggle all of these things!).<br />
In the first of this series, Teréze and I will help you become comfortable<br />
with the BFFs.<br />
Financial statements and management<br />
This is the place to start; and it’s a biggie. A financially viable business<br />
model allows us to provide sustainable care for our clients, while<br />
personally being able to enjoy the success of our labour. However, it’s<br />
our experience that many business owners don’t have a good grip on<br />
their numbers.<br />
Financial statements are normally provided by your accountant at the<br />
end of the financial year. You likely glance at the numbers swimming<br />
on the page, swear a little at the cost of IRD compliance and the tax bill<br />
you’ve incurred, then swirl your signature at the ‘sign here’ Post-it note.<br />
That’s a wrap for this year, let’s get back into the practice…<br />
Not so fast! Financial statements are an absolute treasure trove of<br />
information. Because they’re done at the end of a financial period, by<br />
the time you receive them they’re technically out of date. But think of<br />
them this way: would you see a patient<br />
without taking a clinical history? Of<br />
course not – it’s the first thing you’d<br />
do. A clinical history allows you to<br />
understand so much about the client:<br />
what has happened; predisposing<br />
risk factors; challenges they may be<br />
facing; areas that need assistance and<br />
attention; and identifying trends. It<br />
also gives you an idea of the demands<br />
of the patient’s lifestyle and their<br />
hoped-for outcomes.<br />
It’s a game-changer to adopt the<br />
same perspective with the numbers in<br />
your financial statement by recognising<br />
they reflect your business’ actions and behaviours. As well as offering<br />
signposts, financial statements offer areas we call levers or drivers. For<br />
example, a typical optometry practice’s fixed costs are high, with wages<br />
and overheads both sizable monthly outgoings. To meet these expenses,<br />
a critical area to focus on in the profit and loss statement is your cost of<br />
goods (COG) and gross profit margin (GPM). This margin is a vital lever. For<br />
an optometry practice, there’s minimal COG related to eye examinations, so<br />
the main COG relate to retail: frames, lenses and contact lenses. The GPM is<br />
what’s left once you’ve paid your suppliers for these items.<br />
We encourage owners to review this area monthly, with laser focus. The<br />
two ways to influence this number is to either buy goods for less or sell<br />
goods for more. Ideally, both! This means constantly looking at your<br />
product mix, talking to your suppliers, looking at your pricing strategy<br />
and communicating sales focus areas to your team. What’s the bottom<br />
line for your COG margin? The lower the better, of course, but an ideal<br />
goal is 25–35%, which means a GPM of 65–75%.<br />
For optometry practices, therefore, a very important formula to<br />
increase the overall profitability and value of your business, is to reduce<br />
COG to increase GPM. It might not be as simple as it sounds, but it’s a<br />
fundamental focus. A warning here: it may require some uncomfortable<br />
and challenging conversations and changing your established habits.<br />
This is the power and importance of financial statements – to see the<br />
signposts, help you to set about changing key drivers and pulling the<br />
available levers. Over the coming months, we’ll continue to unpack the<br />
BFFs that are going to work hard for you, just like good friends.<br />
Lynden Mason is the co-founder and former co-owner of Vivo,<br />
a large Southern Hemisphere group of privately owned hair<br />
salons. An optometrist, he started his career by growing 10<br />
optometry clinics across the North Island.<br />
Lynden@behindthebrand.co.nz<br />
Teréze Taber – a former television producer – is a passionate<br />
content writer and brand specialist. With Lynden, she is now<br />
focused on their private consultancy practice, Behind the Brand.<br />
Tereze@behindthebrand.co.nz<br />
To learn more about the IOGroup, contact Neil Human:<br />
0210 292 8683 neil.human@iogroup.co.nz<br />
42 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong><br />
THE INDEPENDENT<br />
OPTOMETRY GROUP
NEWS<br />
Visual reality<br />
BERLIN-BASED STARTUP Even<br />
Realities has released its first Rxable<br />
smartglasses, the G1.<br />
Currently available in a<br />
classic rounded panto shape,<br />
the G1 offers a digital display<br />
superimposed onto the wearer’s<br />
view via the prescription lens. This<br />
is usually only visible when receiving<br />
a new notification from the user’s phone,<br />
but upon tilting the head upwards the wearer can bring up the time,<br />
date, ambient temperature and a summary of any unaddressed phone<br />
notifications. In a YouTube video, frame stylist and manager of UK<br />
optometrist The Spectacle Factory, Robert Sands explained that since<br />
the green LED-style display appears to be in the distance, rather than on<br />
the actual lenses, the wearer is not required to refocus, which he said is<br />
far less tiring on the eyes.<br />
The G1 can also provide real-time translation on screen when<br />
listening to someone speaking in another language, or act as a<br />
teleprompter for speeches and presentations, suggested Sands. An<br />
onboard AI-driven digital assistant, can be activated and respond to the<br />
wearer’s questions by tapping the left end tip, while tapping the right<br />
end tip records a voice note. Having come to market in August this year,<br />
G1’s most recent updates include navigation for walkers and cyclists.<br />
The smartglasses’ battery packs are located in the end tips of the<br />
lightweight magnesium frame, meaning they’re inconspicuous while<br />
helping to balance them on the face, said Sands.<br />
The G1 retails at US$599 (NZ$962), with prescription lenses an extra<br />
US$150 (NZ$241).<br />
Gelflex new distributor for<br />
NaturalVue multifocal<br />
US-BASED VISIONEERING Technologies Inc (VTI) has appointed Gelflex<br />
as its Australia and New Zealand distribution partner for the NaturalVue<br />
multifocal 1-day contact lenses. Gelflex, through Ophthalmic Instrument<br />
Company, is now New Zealand’s exclusive NaturalVue distributor.<br />
“We are thrilled to provide our customers with VTI’s portfolio of<br />
products,” said David Masel, managing director, Gelflex. “The unique<br />
extended depth of focus design of the NaturalVue multifocal provides<br />
practitioners the ability to serve a wide range of patient types – from<br />
progressing myopes to advanced presbyopia – all with one lens.”<br />
Masel said the<br />
product has been<br />
well received by<br />
practitioners and<br />
fits in perfectly<br />
with Gelflex’s suite<br />
of offerings. “By<br />
partnering with VTI,<br />
we now offer our<br />
customers another<br />
way to differentiate<br />
their practices and<br />
reflect our ongoing<br />
commitment to<br />
investing in and<br />
supporting the<br />
specialty lens<br />
industry,” he added.<br />
NZOPTICS.CO.NZ | 43
EDUCATION<br />
Strengthening bonds to enhance acute care<br />
By Vicky Wang<br />
ON A CHILLY August evening,<br />
Greenlane Eye Clinic proudly<br />
hosted its inaugural seminar on<br />
emergency eyecare, aimed at<br />
enhancing collaboration between<br />
community optometrists and our<br />
acute eyecare team. The event<br />
began with a warm welcome<br />
from our hospital team, including<br />
optometrists Richard Johnson,<br />
Reuben Gordon, Robyn Stirling,<br />
Deborah Chan, Tracey Jones,<br />
Harpreet Singh and myself.<br />
Dr Kathleeya Stang-Veldhouse,<br />
a lead ophthalmologist in<br />
our Acute Eye Service (AES),<br />
noted the service receives over<br />
60 referrals per day from community optometrists and GPs. Her<br />
presentation detailed the AES structure, including referral guidelines,<br />
triage procedures and the essentials of a quality referral. The service is<br />
supported by a diverse team of consultants, fellows, both training and<br />
non-training registrars, junior research fellows, nurse practitioners,<br />
clinical nurse specialists, optometrists and acute clinic nurses. Each role<br />
is crucial in ensuring timely and effective patient care.<br />
Not a walk-in service<br />
Dr Stang-Veldhouse emphasised the clinic is not a walk-in service<br />
– referrals should be made via HealthLink or phone consult (after<br />
which an online referral is still required). Patients without such<br />
referrals will undergo triage by nurses and senior clinicians and, if no<br />
immediate issue is identified, they may be advised to return to their<br />
GP or optometrist, or be rescheduled into the Acute Referrals Clinic or<br />
another subspecialty clinic as appropriate.<br />
Several ocular emergencies require same-day assessment, including<br />
open-globe/penetrating eye injuries, chemical injuries, endophthalmitis,<br />
acute angle closure and macula-on retinal detachment. Inpatients and<br />
the very young, very old, or very ill are given priority. A thorough<br />
referral includes the patient’s name, date of birth, NHI number, a<br />
concise history of symptoms, vital signs of the eye, visual acuity and<br />
intraocular pressure.<br />
Dr Stang-Veldhouse urged practitioners not to take offence if<br />
additional information is requested. “Due to our limited resources,<br />
certain pertinent details are required to triage referrals accordingly,”<br />
she explained. Community optometrists should also inform<br />
patients of expected wait times of at least two hours (and sometimes<br />
exceeding five). Non-urgent cases may be rescheduled.<br />
Our second speaker, nurse practitioner Kathryn Millichamp,<br />
presented her research on ocular emergencies. She analysed 7,641<br />
cases presenting to the Greenlane Clinic over a six-month period.<br />
Her findings included the following distributions of true ophthalmic<br />
emergencies: chemical injury, 1.88% (n=123, with 2 out of 123 requiring<br />
admission); acute angle closure crisis, 0.11% (n=7); orbital cellulitis,<br />
0.06% (n=4); endophthalmitis/hypopyon, 0.03% (n=2); penetrating<br />
eye injury/globe rupture, 0.015% (n=1). Other conditions requiring<br />
same-day review included: uveitis, 13% (n=871); blunt trauma, 10.5%<br />
(n=687); keratitis, 9.3% (n=610); preseptal cellulitis, 2.2% (n=145);<br />
retinal detachment, 0.52% (n=34).<br />
Millichamp also discussed vision loss due to systemic or vascular<br />
causes, which accounted for 4.2% of cases. She demonstrated the<br />
management of chemical injuries, detailing the appropriate on-site care,<br />
practices in optometry and protocols upon patient arrival at Greenlane.<br />
She also explained red flags for ocular trauma and vision loss and<br />
provided tips for effective referrals, emphasising the importance of<br />
L-R: Dr Vince Wilkinson, Kathryn Millichamp (front), Richard Johnson (back), Carly Henley,<br />
Vicky Wang, Dr Kathleeya Stang-Veldhouse and Robyn Stirling<br />
comprehensive information in<br />
managing ocular emergencies.<br />
An eye for detail<br />
Carly Henley, the Allied Health<br />
Unit manager, oversees a team<br />
of 34 professionals, including<br />
optometrists, orthoptists and<br />
ophthalmic technicians. A UKqualified<br />
orthoptist with over<br />
28 years of experience in both<br />
paediatric and adult binocular<br />
vision disorders, she discussed<br />
the triaging of paediatric referrals.<br />
She stressed the importance of<br />
including detailed information<br />
to help the Greenlane team accurately identify and prioritise acute<br />
paediatric ocular conditions.<br />
Essential referral details include:<br />
• Previous ocular history<br />
• Family history of eye problems (eg, refractive error, squint,<br />
patching or significant conditions like infantile glaucoma, cataract, or<br />
retinoblastoma)<br />
• General health and medical history, including developmental issues<br />
• Birth history (eg, gestational age, delivery details, birth weight and<br />
any complications).<br />
Henley also reviewed the paediatric referral guidelines on Healthpoint,<br />
which assist optometrists in gathering critical information to ensure<br />
appropriate triage. She highlighted the importance of thorough clinical<br />
examination and attentive listening to symptoms.<br />
Dr Vince Wilkinson, a junior medical retina fellow at Greenlane,<br />
provided an update on herpes zoster ophthalmicus (HZO). He<br />
explained that approximately 1 in 3 of adults will develop shingles*.<br />
Of those, 10–20% will experience HZO, which can lead to moderate<br />
vision loss (≤6/15) in 9.6% of cases and severe vision loss (≤6/60) in<br />
3.6%. Risk factors for vision loss in HZO include poor presenting visual<br />
acuity, older age, uveitis and immunosuppression. Complications can<br />
include corneal scarring, corneal perforation and secondary glaucoma.<br />
Dr Wilkinson stressed that antiviral treatment within 72 hours of<br />
symptoms developing is crucial to reduce the risk of vision loss and<br />
cerebrovascular accidents, particularly for individuals under 40. He also<br />
noted that HZO relapses occur in about 20% of cases, highlighting the<br />
importance of timely treatment and vaccination.<br />
Richard Johnson, a senior hospital optometrist, presented three<br />
challenging case studies: diabetic vitreous haemorrhage, phacomorphic<br />
glaucoma and hypertensive retinopathy. Despite each initially<br />
presenting with diverse clinical signs, the correct diagnoses were made<br />
and good outcomes were achieved. Johnson’s key takeaway was to avoid<br />
assuming previous diagnoses are correct and ensure clinical findings<br />
align with the current diagnosis.<br />
Attendees were invited to observe various hospital clinics, including<br />
emergency, paediatric, advanced contact lens, postoperative and<br />
low vision.<br />
*See pages 14 and 26 for more on shingles<br />
Vicky Wang is a therapeutically qualified optometrist currently<br />
working for Health NZ Te Whatu Ora Auckland.<br />
44 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
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NZOPTICS.CO.NZ | 45
EDUCATION<br />
Genes and gems with Retina Specialists<br />
By Naomi Meltzer<br />
RETINA SPECIALISTS’ WINTER<br />
educational evening for<br />
optometrists had both genes and<br />
gems on the menu.<br />
Associate Professor Andrea<br />
Vincent kicked the evening off with<br />
a story fit to tug the heart strings. It<br />
concerned a two-year-old boy from<br />
Christchurch with suspected early<br />
onset Leber congenital amaurosis<br />
(LCA), a group of inherited retinal<br />
diseases characterised by severely<br />
impaired vision or blindness, typically<br />
presenting between birth and five<br />
years of age. The condition causes<br />
degeneration and/or dysfunction of<br />
photoreceptors and, in some cases,<br />
other body organs, such as kidneys,<br />
may become affected. There are four<br />
common gene mutations associated with LCA, including RPE65.<br />
At the time of referral, no measure of vision could be obtained, but<br />
the prognosis was that because he had two mutations of the gene he<br />
would generally have few photoreceptors left by the time he was five. In<br />
effect, left untreated, he would have had no usable vision by the time he<br />
started school.<br />
The boy appeared to be 4–5 dioptres hypermetropic and rubbed<br />
or poked his eyes a lot, which is typical of children with LCA and can<br />
potentially cause associated corneal and other ocular damage. In<br />
December 2017, Spark Therapeutics obtained FDA approval for Luxturna<br />
(voretigene neparvovec), a gene therapy which has improved vision in<br />
children and young adults with the RPE65 mutation. The adenovirusmediated<br />
gene augmentation therapy is injected under the retina. Cells<br />
with the non-functioning gene are invaded by a functioning gene that<br />
replaces the non-functioning gene to make the cell function normally. Of<br />
course, that is only viable while there are still functioning photoreceptors<br />
to work with, which means time is of the essence.<br />
There are thought to be only three patients in New Zealand with<br />
this genetic variant but, at the time of writing, Pharmac will not fund<br />
the $700,000-per-eye Luxturna treatment. Fortunately A/Prof Vincent<br />
became aware that Moorfields have treated one eye only in each of four<br />
children with this rare disease with Luxturna, which has been approved<br />
by the European Medical Agency (EMA).<br />
Moorfields agreed to treat this boy on a “compassionate use on trial”<br />
basis. The family had to pay for the travel costs to the UK, but not the<br />
treatment. Four months later, the vision in the treated right eye was 25%<br />
better than at the start of the trial. On 6 June this year, the second eye<br />
was treated. The child appears to be favouring the right eye, so some<br />
Stuart and Carolyn Campbell<br />
Retina Specialists’ Drs Rachel Barnes and Leo Sheck and A/Prof Andrea Vincent<br />
Anh Dao Le, Alice Ku and Kathreena Lim<br />
amblyopia is likely from the delay in<br />
treating the left eye, but he is making<br />
progress, indicating he appears<br />
to have some photoreceptors still<br />
working. OCT showed a thin layer of<br />
residual photoreceptors.<br />
The parents, however, need<br />
answers quickly. They want to know<br />
if he will go blind and whether other<br />
members of the family will develop it<br />
or potentially be born with the same<br />
genetic issue. Can anything be done<br />
to slow down the process and what<br />
decisions do they need to make,<br />
in terms of the child’s educational<br />
pathways? Clinicians also need to<br />
know what else might be happening<br />
in this child’s body that may be<br />
associated with the retinal changes.<br />
When a child presents with unexplained loss of vision, the search for<br />
inherited disorders begins. Many countries do not have access to genetic<br />
testing and, in a small country such as New Zealand, the numbers of<br />
cases with such rare genetic disorders can be infinitesimal, which not<br />
only emphasises the need for geneticists such as A/Prof Vincent to<br />
have international connections, but also to have the tools to make a<br />
timely diagnosis.<br />
A/Prof Vincent explained that even when she gets a referral with<br />
a diagnosis, she prefers to start with a blank sheet and not assume<br />
anything, otherwise she can be led down the wrong path with an<br />
unconscious bias. The starting point is always to look at the rest of the<br />
family; however, this information may be patchy. Autofluorescence helps<br />
a lot, as it gives much more detail of the changes occurring at the macula,<br />
she said.<br />
Asked how long the treatment will last, she replied, “How long is a<br />
piece of string? We just don’t know because we only have approximately<br />
seven years of data.” Hopefully, we will get an answer in future<br />
educational evenings. Watch this space!<br />
Watch and learn<br />
Dr Rachel Barnes continued with some interactive case studies<br />
for those who like to test their IT skills at the same time as their<br />
optometric knowledge.<br />
Her case concerned a 26-year-old who presented with sudden vision<br />
loss in one eye after a two-week history of mild upper respiratory<br />
infection. OCT showed a big central cyst within the bacillary layer of the<br />
retina (Fig 1). This is typical of acute posterior multifocal placoid pigment<br />
epitheliopathy (APMPPE), a form of cystic retinal oedema. Usually bilateral,<br />
it mostly appears in a person’s second<br />
to fourth decade, often after a virus<br />
and, importantly, may be associated<br />
with cerebral vasculitis.<br />
A bacillary layer detachment (a<br />
term coined as recently as 2018) is<br />
separation of the bacillary layer of the<br />
retina due to a relative weakness in the<br />
myeloid layer. There is a breakdown<br />
of the retinal pigment epithelium<br />
blood retina barrier while the external<br />
limiting membrane is preserved,<br />
allowing fluid to get into the intraretinal<br />
space. The fluid can often look<br />
quite turbid.<br />
46 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
Fig 1. Bacillary layer detachment. A retinal cyst usually resolves in 4–8 weeks, but steroids may hasten the process<br />
The one that nearly got away!<br />
The next case history was about a middle-aged male who’d had a routine<br />
normal dilated examination one year before presenting for his annual<br />
examination related to a history of rheumatoid arthritis.<br />
On this occasion he reported recently attending an A&E clinic for<br />
vague discomfort and blur in one eye. He was given ocular lubricants,<br />
which appeared to resolve the issue, though not entirely.<br />
Dr Barnes noted what appeared to be a group of inferiorly located<br />
dilated episcleral vessels that could be taken for mild blepharitis, possible<br />
episcleritis or even an odd-appearing early pterygium. Dilation revealed<br />
what was lurking below the surface: dilated sentinel episcleral vessels<br />
were disproportionately dilated, with tortuous episcleral blood vessels,<br />
which provided a clue for the presence of an underlying asymptomatic<br />
occult ciliary body melanoma.<br />
Dr Barnes confessed her blood runs cold every time she looks at the<br />
slide of ‘the one that nearly got away’.<br />
to track effectiveness, since<br />
there is no obvious change in<br />
fundus appearance or vision.<br />
A pathway for assessment<br />
of functional change is by<br />
doing microperimetry, which<br />
is available through the<br />
University of Auckland.<br />
The treatment is also not<br />
without risk of infection<br />
and potential neovascular<br />
transformation, said Dr Sheck.<br />
Ultimately, the best outcome<br />
at this stage is that progression<br />
of GA is slowed. It’s certainly a<br />
hard sell for the average patient with GA, even if they have deep pockets!<br />
There is a strong case for the ‘wait and see’ approach, unless there is an<br />
urgent reason to take the deep dive.<br />
However, there is a route to apply for continued treatments for<br />
patients who have already started treatment overseas. If they need<br />
treatment and are well informed, the drug can be accessed. Patients who<br />
have GA and have previously been treated for neovascular maculopathy<br />
are, at present, excluded from trials. It’s good to know that progress is<br />
being made.<br />
Naomi Meltzer is an optometrist who runs an independent<br />
practice specialising in low-vision consultancy. She is a regular<br />
contributor to NZ Optics.<br />
Assessment and treatment of geographic atrophy<br />
Dr Leo Sheck advocated the use of autofluorescence as the best imaging<br />
modality for assessing geographic atrophy (GA). His experience with the<br />
use of C3 (Syfovre) and C5 (Izervay) inhibitors, which are FDA- (but not yet<br />
Medsafe-) approved<br />
treatments for GA,<br />
is that there are<br />
practical problems,<br />
quite apart from the<br />
expense (self-funding<br />
at approximately<br />
$3,000 per injection,<br />
plus transportation<br />
from the US).<br />
One problem is<br />
deciding when to<br />
start treatment. It<br />
is also very difficult<br />
Tiffany Ong and Eva Woodward<br />
Specialised.<br />
Experts.<br />
Care.<br />
The Centre of Excellence<br />
in the Care and<br />
Treatment of Retinal<br />
Diseases in New Zealand<br />
retinaspecialists.co.nz<br />
Richard Chinn, John Adam and Dennis Oliver<br />
NZOPTICS.CO.NZ | 47
DISPENSING MATTERS<br />
The dispensing optician’s role in the<br />
remake puzzle<br />
By Virgilia Readett<br />
TIME, MONEY AND reduced productivity – this is what a spectacle<br />
remake costs a store, optical laboratories and customer. With the<br />
precision required – and intricate balance of priorities needed for a pair<br />
of specs to perform to their full potential – it has long been accepted<br />
that remakes are unavoidable. However, dispensing opticians (DOs)<br />
play a vital role in reducing remake rates. The DO’s skill set cannot be<br />
overstated in the success of spectacle functionality. By looking deeper<br />
at the importance of the DO’s role in the dispensing process we can find<br />
numerous solutions to reduce remake rates.<br />
Nicole Hibbert, Shamir Academy training manager, explains poor<br />
frame selection is one factor leading to less than perfect vision and a<br />
lack of comfort for the customer, increasing remake rates. Unnecessary<br />
thickness, weight, aberrations and field-of-view restrictions can all be<br />
reduced through expert frame selection, she says. “It’s useful for DOs to<br />
be aware of limitations and best practice when ordering. For instance,<br />
mid to high minus Rx ordered in a curved frame, or a similar Rx ordered<br />
with a high height in a large frame will result in thick lenses. These kinds<br />
of issues result in remakes.”<br />
Frame selection is a balance of fashion, feel, financials and function.<br />
• Fashion – appropriate frames will meet the customer’s<br />
aesthetic preferences<br />
• Feel – they will feel comfortable. DOs can ensure they are the<br />
appropriate dimensions for the customer’s anatomy and complement<br />
this with expert frame adjustments<br />
• Financials – with the increasing cost of living, customers may be<br />
investing in a longer-term frame – a statement worn for many years,<br />
unlike clothing that can be changed more readily. Careful and considered<br />
frame selection will improve a successful full-cycle dispense – one that<br />
leads to future dispenses rather than a remake<br />
• Function – the frames will allow the lenses to perform as intended,<br />
while reducing potential problems. Appropriate frame depth must be<br />
allowed for the required lens design<br />
As an aesthetic representation of their identity, frames require unique<br />
levels of assistance for each customer. Some will require multiple visits<br />
of extended length and opinions from various DOs, family and friends.<br />
Others will decline assistance and select independently within minutes.<br />
High-level interpersonal skills will allow a DO to read the customer and<br />
adapt their approach accordingly. A skilled DO able to find a frame<br />
that satisfies the customer’s requirements will instil confidence in the<br />
selection while reducing the potential for remakes.<br />
Questions vs assumptions<br />
Open and closed questions will aid a good dispense. Lifestyle questions<br />
will make sure outcomes exceed the customer’s expectations and<br />
prevent remakes due to issues where the spectacles are not fit<br />
for purpose.<br />
There isn’t a checklist of which lifestyle questions to ask every<br />
customer; questions flow naturally from one from the other, specific to<br />
the customer’s needs. A good starting point is looking deeper at the<br />
intended purpose of the spectacles. If they are for reading, what is the<br />
reading material and how far away will it be? The leadership team at<br />
Specsavers Erina Fair, Australia, identified this as an area for improvement,<br />
according to retail manager and Australasian College of Optical<br />
Dispensing (ACOD) trainer and assessor Rayleen Tamblyn. “We required<br />
all optometrists to include intermediate adds in the prescription, to<br />
determine working distance and correct Rx for visual display unit usage.<br />
This significantly reduced the number of specs being made as readers<br />
(which should have been made as single-vision intermediate).”<br />
If the patient is looking for distance lenses, what activities will they<br />
be wearing them for? Would they benefit from lens treatments tailored<br />
for that specific task? If, like many customers, they are needing specs for<br />
multiple tasks and distances, have you offered the most suitable design<br />
rather than your go-to lens?<br />
Knowing the product and the nuances of each progressive design is<br />
key to reducing remakes, says Hibbert. This is echoed by Glenn Bolton,<br />
48 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
Inappropriate amounts of pantoscopic angle will negatively impact the performance of the lens. Left shows an inappropriate<br />
amount (0) while right shows an appropriate amount (12). Credit: April Petrusma.<br />
compared to the test vertex will<br />
significantly change the effective<br />
prescription experienced by the<br />
customer. Care in adjustments and<br />
potential prescription compensation<br />
should also be taken into<br />
account here.<br />
Considering we are ordering<br />
precise measurements in increments<br />
of fractions of a millimetre, the<br />
importance of conducting a high<br />
level, appropriate final fit cannot be<br />
overstated. While not responsible<br />
for the refraction and the intended<br />
prescription, DOs are the gatekeepers<br />
of the effective prescription.<br />
Precision measurements and careful<br />
frame adjustment will ensure the<br />
prescription can function as intended.<br />
Shamir New Zealand managing director, who says he has seen a need for<br />
greater understanding in occupational designs.<br />
Ethical dispensing practice is a common theme discussed by ACOD<br />
students in their assessment pieces. It is ethical to sell customers what<br />
they require, so it is important for DOs to keep in mind that our duty<br />
of care is to recommend the best optical product for them. This means<br />
that upsells for higher-bracket lenses, lens treatments and, in some<br />
instances, additional pairs are ethical recommendations. When tailored to<br />
a customer’s specific needs, such recommendations will reduce the need<br />
to remake.<br />
Tim Thurn, Essilor Luxottica’s<br />
medical and professional relations<br />
director ANZ, says customers not<br />
only want your advice, they need it!<br />
“Fortunately, you have a broad range<br />
of products, services and<br />
clinical skills to meet those needs…<br />
however, personalisation begins<br />
with an in-depth understanding of<br />
the patient” 1 .<br />
DO fundamentals for final fit<br />
Final fitting is a vital skill for DOs. Done well, it sets the spectacles up<br />
for success. Done poorly, it sets them up for failure. When the topic<br />
is taught in ACOD classes, there are students who flag that it’s not<br />
common practice to do so within their store prior to taking dispensing<br />
measurements. A range of reasons is given, the primary one being lack<br />
of time. Consider the full picture of the dispensing lifecycle: selection,<br />
dispense, collection and either return business or troubleshoot and<br />
potential remake. It’s not hard to make the point that more time<br />
invested in the initial stages not only saves time in troubleshooting<br />
later, but also money in potential remakes, customer satisfaction and<br />
trust in your practice.<br />
Investigating time management and patient expectations, Thurn<br />
says, “When asked ‘How long does an eye test take?’, the common<br />
answer is ‘about 30 minutes’. However, it is not unusual for a patient to<br />
spend upwards of an hour or more in your practice” 2 . Here, the age-old<br />
saying rings true: under-promise and over-deliver. If we quote a longer<br />
timeframe as our norm, we set realistic expectations for the customer so<br />
they won’t be rushed, nor will the DO feel pressure to take shortcuts with<br />
adjustments and measurements.<br />
“Consider the optical ramifications of our adjustments, particularly in<br />
areas of pantoscopic angle and vertex distance,” say Wilson and Daras<br />
in Practical Optical Dispensing 3 . Inappropriate amounts of pantoscopic<br />
angle will create undue amounts of oblique astigmatism, negatively<br />
impacting the performance of the lens. DOs play a vital role in minimising<br />
this aberration by ensuring appropriate ranges of pantoscopic angle<br />
are applied. For higher prescriptions, changes in the vertex distance<br />
Measurements for success<br />
While not responsible for the<br />
refraction and the intended<br />
prescription, DOs are the gatekeepers<br />
of the effective prescription<br />
Dispensing tools have come a long way from the humble pupillary<br />
distance (PD) rule. Advancements in manual tools have improved ease,<br />
accuracy and professionalism, while digital measuring systems offer<br />
precision measurements. But they are tools nonetheless and their<br />
precision and accuracy depend on the DO using them.<br />
There is a clear and pressing need to capture accurate measurements<br />
and provide these details on orders. The Shamir New Zealand<br />
laboratory provided data showing approximately 80% of orders provide<br />
monocular PDs. This means the<br />
accuracy of 20% of orders could<br />
be improved – there is definitely<br />
potential in remake reduction by<br />
conducting and including this<br />
fundamental measurement. As<br />
Bolton explains, “If a lens design<br />
can be compensated with the<br />
binocular vision dysfunction, panto<br />
and wrap, then the measurements<br />
need to be provided. Close to<br />
50% provide the full measurements.” Given the high price tag of lenses<br />
requiring these measurements, there is a massive opportunity to reduce<br />
potential remakes and costs by taking them accurately and including<br />
when required.<br />
Conclusion<br />
ACOD director and teacher James Gibbins describes DOs as, “Frames,<br />
lenses and completed spectacles experts”. For these areas, we have the<br />
ability to alleviate and reduce spectacle remakes. Not only will expert<br />
frame and lens recommendations, adjustments and measurements see<br />
a reduction in remakes, but an increase in customer satisfaction, store<br />
profitability and store-to-laboratory productivity.<br />
References<br />
1. Thurn T. The Power of Personalisation, MiVision, 30 September 2018<br />
2. Thurn T. Practice Possibilities: Don’t Miss the Future, MiVision, 31 August 2018<br />
3. Wilson D and Daras S. Practical Optical Dispensing (3rd Ed). The Open Training and Education Network,<br />
2014.<br />
Virgilia Readett, in optics since 2012, is an ACOD teacher.<br />
She holds a Certificate IV in Optical Dispensing, Certificate<br />
IV in Training & Assessing and a Bachelor of Arts, majoring in<br />
communications.<br />
NZOPTICS.CO.NZ | 49
STYLE NEWS<br />
Embracing colourful hues<br />
Looking ahead to 2025, Dutz<br />
predicts a resurgence of retro<br />
styles, minimalist designs,<br />
bold and oversized frames,<br />
geometric shapes and vibrant<br />
palettes will dominate the<br />
eyewear market. The brand’s<br />
latest collection ticks all of<br />
these boxes, it said, offering<br />
individual, modern designs<br />
with a timeless appeal. The coral<br />
red solid lining of model DZ2346-<br />
46, featured here, pops against<br />
translucent aqua and burgundy with<br />
hints of brown for a striking yet elegant look.<br />
Distributed by Dynamic Eyewear.<br />
Making waves with new sun range<br />
An official partner to the 37th America’s Cup, Etnia Barcelona’s limited<br />
edition America’s Cup capsule collection is out now. Made with recyclable<br />
materials, the glasses come with high-definition polarised blue mineral<br />
lenses offering 100% UV protection. Designed for a perfect day on the<br />
water, the lenses also have anti-scratch and anti-glare treatments, as well<br />
as oleophobic and hydrophobic treatment to reduce fingerprints and<br />
repel water.<br />
Etnia Barcelona is distributed by CMI Optical.<br />
Distributed by Euro Optics – a Division of VMD Ltd<br />
Saving the world from<br />
mediocre eyewear<br />
New York-based eyewear<br />
designer and The Eyewear<br />
Forum editor Maarten<br />
Weidema has released<br />
a second edition in<br />
the Amazing Eyewear<br />
coffee table book series.<br />
Having completed it<br />
in just three years, he said he is “on a mission to save the world from<br />
mediocre eyewear” and aims to inspire, connect and celebrate the best of<br />
independent eyewear design.<br />
With over 250 pages capturing the evolving world of eyewear<br />
design, Weidema delves into industry-changing innovations such as<br />
artificial intelligence, full-colour 3D-printed frames and sustainability<br />
initiatives, plus the technical nuances of eyewear design. Mixing<br />
established and emerging names, he highlights 25 unique independent<br />
eyewear brands, all pursuing their passions without support from the<br />
mainstream fashion industry.<br />
For more, see http://tefmagazine.com<br />
Z_Optical 50 trade | press_91,5x136mm.indd NEW ZEALAND 1OPTICS OCTOBER <strong>2024</strong><br />
27-08-<strong>2024</strong> 09:19:28
La Dolce Vita<br />
Inspired by the famously<br />
carefree Italian lifestyle,<br />
Woodys’ latest campaign<br />
and collection, La Dolce<br />
Vita, exudes delicious<br />
colours and quirky<br />
shapes. The round,<br />
milled acetate frame<br />
Hella, pictured here,<br />
features German fiveaxis<br />
hinges and Woodys’<br />
wood inlays on the<br />
temple tips. Available in<br />
a range of fresh, striking<br />
colour combinations.<br />
Distributed by Phoenix<br />
Eyewear.<br />
Young tennis star face of Lacoste<br />
French tennis talent Arthur Fils is the face of Lacoste’s new eyewear<br />
collection, The Line. Now 20 years old, Fils became the youngest player<br />
in the men’s top 50 ranking after winning his first ATP title aged just<br />
19. “Arthur matches his exceptional achievements on the court with<br />
his charming attitude, perfectly embodying Lacoste’s DNA,” said the<br />
company. The Line combines timeless, classic shapes elevated by<br />
transparent tortoise colourations, typical of Lacoste’s versatility and style.<br />
Distributed by Titan Optical, Marchon Eyewear’s agent in New Zealand.<br />
The apple of your eye<br />
Maison Lafont’s latest children’s<br />
collection is a delight to behold,<br />
full of fun and fashionable options<br />
for young wearers. Committed<br />
to creating a sustainable and<br />
eco-friendly future, each new<br />
collection from the brand<br />
increases the use of bio-based<br />
and renewable materials. Stylish<br />
new model Pomme’s unique<br />
bevelling makes it anything but<br />
ordinary and will surely appeal to<br />
young girls (size 46). Available in a<br />
selection of bright, contemporary<br />
colours and patterns.<br />
Distributed by Little Peach.<br />
A Parisian state of mind<br />
Elle Eyewear’s latest vintage<br />
and wave motifs signal new<br />
Bohemian influences. For instant<br />
Parisian-inspired glamour, the<br />
soft rectangular model (EL13564)<br />
featured here is made of light<br />
acetate. Available in green, wine<br />
and brown, its large temples<br />
reveal metal details with<br />
botanical engravings and eyecatching<br />
patterns.<br />
Distributed by Phoenix Eyewear.<br />
AUG <strong>2024</strong> - Half page verticle wide NZ OPTICS - PD.indd 2<br />
0800 447 272 @eyesrightoptical<br />
NEW RELEASE<br />
OUT NOW!<br />
View all of our collections and<br />
order online with ease at<br />
www.eyesright.com.au<br />
6/09/<strong>2024</strong> 9:16:01 AM<br />
NZOPTICS.CO.NZ | 51
NEWS<br />
Stars in<br />
their eyes<br />
By Luke Wang and Hector Leong<br />
THE NEW ZEALAND Optometry<br />
Student Society (NZOSS) hosted<br />
a sparkling annual Eyeball at<br />
Auckland Hilton Hotel at the end<br />
of August. Themed ‘Starry Night’,<br />
the evening was filled with celestialstyle<br />
decorations and sound-tracked<br />
by a DJ. Distinguished guests from<br />
the School of Optometry and Vision<br />
Science (SOVS) dressed up for a<br />
night of spectacle, which included<br />
an open bar, lavish buffet and<br />
dazzling dance floor.<br />
The Eyeball provided a rare<br />
opportunity for students and staff<br />
to come together and socialise with<br />
future colleagues and sponsors.<br />
It would not have been possible<br />
without our sponsors: a huge thank<br />
you to our diamond sponsor,<br />
Specsavers, also sponsoring merch<br />
for our students; our gold sponsor,<br />
EssilorLuxottica, also sponsoring<br />
prizes for the best partners; our<br />
silver sponsor, the New Zealand<br />
Association of Optometrists; and<br />
bronze sponsors Bailey Nelson<br />
and Ocula. Prizes for categories<br />
including the best-dressed duo in<br />
A sparkling part V class<br />
NZOSS <strong>2024</strong> team: Sarah Yang, Emily Kamimura, Joanna<br />
Cao, Hana Shin, Shivon Mudaliar, Manishka Sharma (back),<br />
Shubham Gupta, Hector Leong, Luke Wang, Jabez Zeleke,<br />
Joshua Lobo (front)<br />
each cohort were provided by Oscar Wylee, Coopervision and Optimed.<br />
The success of the night was contingent also on NZOSS executive team’s<br />
months of planning.<br />
SOVS clinic supervisors and lecturers: Adina Giurgiu, Dr Alyssa Lie,<br />
Zaria Bradley, Kristine Hammond, Bhavini Solanki, Dr Wanda Lam<br />
and John McLennan<br />
Hector Leong and Luke Wang are the NZOSS <strong>2024</strong> president and vice president,<br />
respectively.<br />
Superior aesthetics and UV protection<br />
HOYA VISION CARE Australia & New Zealand’s Hi-Vision Sun Pro lens<br />
coating is now available on its Sensity lenses, offering enhanced<br />
aesthetics and UV protection this spring and summer.<br />
The anti-reflective coating offers double-sided UV protection<br />
and improves the aesthetics and<br />
convenience of the outdoor<br />
tinting, due to the neutral<br />
reflection in dark state and<br />
the increased contrast<br />
it provides, said Craig<br />
Chick, managing<br />
director, Hoya Vision<br />
Care ANZ. “Hi-Vision<br />
Sun Pro will elevate<br />
Sensity aesthetics<br />
to the next level in<br />
the darkened state of<br />
the lens.”<br />
The Hi-Vision Sun Pro<br />
coating not only prevents<br />
UV transmission through the<br />
lens but also reduces the amount<br />
of UV rays reflected into the eyes from the back surface, providing<br />
comprehensive protection, he added. “The expansion of the Hi-<br />
Vision Sun Pro coating to our Sensity lenses in Australia and New<br />
Zealand underscores Hoya’s commitment to supporting eyecare<br />
professionals and delivering innovative products that meet the<br />
evolving needs of their patients.”<br />
The coating is scratch-resistant for durability and repels water,<br />
grease and dirt, making the lenses easy to clean, Hoya said. The<br />
Hi-Vision Sun Pro coating is now available on all Hoya Sensity<br />
lenses, excluding Sensity Shine, as well as on its tinted and<br />
polarised lenses.<br />
Hoya Order Centre up and running<br />
Adding to the Hoya Hub, the Hoya Order Centre is now available<br />
to partners. Also available through the hub and integrated with<br />
Hoya Consultation Centre 360 is the Hoya Digital Fitting app.<br />
Using a smart centration software, it allows practitioners to take<br />
fast, accurate and precise fitting measurements. “The Hoya Digital<br />
Fitting app delivers a comfortable and technologically advanced<br />
experience for the patient and is easy to use by practice staff,” the<br />
company said. No jig or other attachments are required to capture<br />
position of wear measurements.<br />
52 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
CLASSIFIEDS<br />
For sale / vacancies<br />
To advertise in<br />
NZ Optics classified<br />
section contact<br />
Susanne Bradley<br />
susanne@nzoptics.co.nz<br />
SUMMER CALLING -<br />
LOCUM AVAILABLE<br />
Christchurch-based Optometrist<br />
available for sessional work<br />
locally or block work further<br />
afield.<br />
I have 20 years experience in<br />
full-scope optometry, in both<br />
independent and corporate<br />
environments. I’m enthusiastic<br />
and enjoy being part of a team<br />
delivering excellent outcomes<br />
for patients.<br />
Contact: robertamcIlraith@<br />
gmail.com or 021323812.<br />
Join our vibrant team in Timaru, where lifestyle meets career satisfaction!<br />
Nestled near the beach, ski fields and lakes, we seek two passionate<br />
optometrists to embrace flexible hours and work-life balance.<br />
No weekends, just Monday to Friday.<br />
Our independent practice prioritises community eye health, offering<br />
diverse cases from pathology to myopia control. We empower<br />
optometrists to pursue their interests and excel in their expertise. Be<br />
part of a client-focused team dedicated to delivering exceptional care.<br />
Enjoy an attractive package tailored to your needs. Express your<br />
interest in shaping your future with us by contacting us at<br />
vanessa@canonstreet.co.nz<br />
OPTOMETRIST WANTED<br />
New Plymouth/Taranaki<br />
Mountain, surf and an outstanding cultural environment.<br />
We are looking for an experienced Optometrist to join our long<br />
established independent family practice of sixty years plus.<br />
Our well-equipped practice has an exceptional reputation for service,<br />
an awesome Dispensing Optician with over 30 years experience and an<br />
ancillary staff like no other!<br />
Weekends are a no no and our hours are flexible for the right applicant.<br />
Our ethos - ‘ Service Matters - People Matter ‘.<br />
Sounds like you? Full-time or part-time considered.<br />
Apply in the first instance to Michael Warner,<br />
fitzroyopticians@gmail.com. For more, ring 06 7584974.<br />
OPTOMETRIST OPPORTUNITY!<br />
Whitianga<br />
Our thriving independent practice in the picturesque town of Whitianga<br />
is searching for a passionate Optometrist to join our dedicated team.<br />
You’ll work alongside an experienced team including a Dispensing<br />
Optician and a rare opportunity to collaborate with our regular visiting<br />
Ophthalmologist to refine patient care.<br />
Enjoy a competitive salary, a supportive work environment and the<br />
unbeatable work-life balance that comes with living in one of New<br />
Zealand’s most beautiful coastal towns. To top that there are no late<br />
nights or weekends and you get to enjoy a day off every second week to<br />
make the most of what life has to offer here. Step into a role where your<br />
expertise is valued, your lifestyle is prioritised, and your career can truly<br />
flourish. This friendly community is ready to welcome you.<br />
Please send CV to lynette@mbo.co.nz or contact Glen 0275929125.<br />
Comprehensive functional low vision consultation<br />
Wide range of LV aids from traditional magnifiers<br />
to world leading technology<br />
Information and support<br />
Phone (09) 520 5208 or 0800 555 546 Email info@lowvisionservices.nz<br />
www.lowvisionservices.nz<br />
A Call for<br />
Donations<br />
Manual Lensmeters<br />
We are looking to support our graduates<br />
throughout the Pacific region by<br />
equipping them with manual lensmeters<br />
to enable the delivery of refraction<br />
services in rural communities.<br />
If you would like to kindly donate a used<br />
but fully functional unit, please contact Yves Yang:<br />
T +64 21 228 4768 E yyang@hollows.nz<br />
LOOKING FOR A CHANGE?<br />
The Optical Co in Australia is hiring Optometrists!<br />
We are the Eyes and Ears division of Healthia, Australia’s largest allied<br />
health provider, with a network of 350+ stores across optometry,<br />
audiology, podiatry and physiotherapy. We are actively building our<br />
team and want the very best people to join and share in our success.<br />
Our current vacancies are in some of the most picturesque and<br />
liveable communities in Australia, including Helensvale, Hervey Bay<br />
and Maryborough (QLD)– so you get the benefits of a great lifestyle<br />
as well as being supported by the structure and resources of an allied<br />
healthcare leader.<br />
We offer: extensive learning and development opportunities; support to<br />
build clinical skills and careers (inc a Clinic Class Shareholder partnership<br />
model); attractive remuneration including incentives and relocation<br />
assistance; discounts on private health insurance and products; and<br />
down-to-earth culture and great working relationships.<br />
As an Optometrist with us, you will be at the heart of the practice,<br />
working alongside a highly skilled team and with the latest tools and<br />
technology, to provide our patients with superior eyecare.<br />
We are looking for Optoms who are: qualified in New Zealand and<br />
eligible to emigrate to Australia; able to examine, prescribe, recommend<br />
and refer (when required) to ensure the best solutions for our patient’s<br />
needs; adept at building strong working relationships with patients and<br />
colleagues; and clinically-focused and driven to build career success.<br />
Visit https://theopticalcompany.com.au/ for more info and contact<br />
StephanieM@theopticalco.com.au for a confidential discussion!<br />
NZOPTICS.CO.NZ | 53
Chalkeyes presents…<br />
The Nothing that is not there …<br />
By Trevor Plumbly<br />
GIVEN A CLEAR trot, I shall be 83 this year. Apart from<br />
‘seeing’ the difference between bright light and black, I’m now<br />
a ‘total blindy’, which brings on the need for a bit of reflection.<br />
A couple of things have forced the issue, the first being<br />
when Pam popped away for four days in December and left<br />
me with a bit of a wake-up call. The dependency thing’s a<br />
given these days, so it was down to the grandkids to pick<br />
up the slack. Catering was easy – fish and chips, KFC and<br />
McDonald’s, with the single-malt nightcap placed to hand as<br />
they left. All in all, I think it went rather well, to the extent<br />
that one remarked to Pam, “He’s amazing! He never moans”.<br />
That may be true of the vast majority of blindies, but it<br />
certainly doesn’t apply to me. Judiciously used, I reckon a<br />
good moan can be as mentally stimulating as The Guardian’s<br />
cryptic crossword.<br />
The ‘it is what it is’ philosophy doesn’t really do it for me;<br />
when it comes to sight loss, I’m more: ‘it ain’t what it is’, which,<br />
up to this point, has worked pretty well. The second ‘challenge’<br />
(God, I hate that word!) is that I’ve developed a hearing<br />
problem. I can cope with ‘see no evil’ and even ‘hear no evil’ but it’s<br />
tough not to speak it when you can’t find the brand-new hearing aids. In<br />
the past I’ve found groping blindly and muttering oaths doesn’t help, so<br />
the safest course is to seek the safety of the armchair. Once there, there’s<br />
little else to do but reflect, but that can lead to what I consider one of the<br />
most pernicious aspects of sight loss: Nothing!<br />
‘Nothing’ is not in the blindy DIY books. It’s not a treatable symptom,<br />
more one of those things waiting to whack you when you don’t need it.<br />
In my case it interrupts the re-grouping process in times of that form of<br />
stress, monopolising parts of the brain, accusing me of inactivity while<br />
smothering the parts struggling to remember where I left the hearing<br />
aids. I reckon Nothing’s been around for ages, as far as blindies are<br />
concerned but, in my opinion, it’s been totally overlooked in the pursuit<br />
of breakthroughs and warm, PC fuzzies. Chronic sufferers should be<br />
schooled against Nothing – anything from iPad updates to ill-matched<br />
chargers can bring on an attack. While it doesn’t rank up there with<br />
Charles Bonnet’s revelations, there must be something there for the<br />
enquiring academic and the possibility of a paper or two. I will, of<br />
course, be happy to assist in any way with the research on this one.<br />
…the Nothing that is there<br />
In my experience, Nothing fights dirty. Once I’ve retreated to the<br />
armchair, it lays siege, blocking off constructive or independent thought.<br />
Thus, my “Don’t just sit here! Get off your butt and look for them”, gets a<br />
retort from Nothing, like “Why not wait for Pam to come home?”<br />
In an effort to shed a bit of light on the matter, I mentioned it to a few<br />
people in our support group, but nobody owned up to experiencing it.<br />
I consider myself many things but psychologically unique is not one of<br />
them, so my first thought was that, like the first outing with the white<br />
cane, it was an acceptance thing. My second theory didn’t fit so well – it<br />
shifted things back to me, since the possibility existed that all those<br />
other blindies were too busy doing stuff for Nothing to have any effect.<br />
And there’s no doubt they’re all busier than I am. Camille is a retired<br />
journalist and, as with most of that calling, shows a seemingly limitless<br />
curiosity in all manner of worldly things. Plus, she’s highly social, to the<br />
point that I often suspect her of being capable of holding two phone<br />
conversations at the same time. Peter, a retired mechanic, is an ‘out<br />
there’ blindy – swimming, biking and travelling to Brisbane or Bali<br />
– it’s all the same to him. It’s distinctly possible he doesn’t even own<br />
an armchair.<br />
Susan is the brainiac blindy. A retired audiologist and thoroughly<br />
organised, she does stuff I don’t, like travel by bus and join protest<br />
marches. And with her addiction to word games and near resident<br />
status at the public library, there seems little chance of Nothing finding<br />
much of a role there. Finally, there’s Janet, another ‘out there’ blindy –<br />
art teacher, artist and recent book author. Janet’s what’s best described as<br />
‘active’; she also does stuff I don’t, like sit through committee meetings<br />
and brave theatre access. Last I heard, she was off to the Highland<br />
Games in Hamilton – not to compete, of course, but even at 80-plus I<br />
wouldn’t put it past her.<br />
...and how I deal with it<br />
It seems to me that those guys, defeating the threat of Nothing when<br />
it comes to sight loss, attack it with ‘busy’. For me, though, it’s to be<br />
coped with rather than defeated. Although I think optometrists and<br />
the good folk at the Blind Foundation should be fully au fait with the<br />
thing, as with most things blindy, it boils down to personal choice, so<br />
I’ve opted for a tri-party truce between the keyboard, the armchair and<br />
Glenmorangie. Meantime, there are questions I need to consider from<br />
politicians and the like, such as, do I consider myself handicapped or<br />
disabled? It’s a tricky one – there might be nothing in it but, like I said,<br />
ya gotta watch that Nothing!<br />
Born in the UK, our ‘white-caner’ columnist, retired Dunedin<br />
antiques dealer Trevor Plumbly, was diagnosed with retinitis<br />
pigmentosa more than 20 years ago and now lives in Auckland.<br />
54 | NEW ZEALAND OPTICS OCTOBER <strong>2024</strong>
NEW ZEALAND<br />
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NZOPTICS.CO.NZ | 55
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