Going for Gold: Prof. Nathan Efron

If achievements in optical research were an Olympic event, then Professor Nathan Efron would be an Australian gold medallist.

It was his own diagnosis of type 2 diabetes some years ago that eventually led eminent Australian optometrist Professor Nathan Efron to ground-breaking research into non-invasive ophthalmic diagnosis of diabetic nerve damage. Research that has made the world sit up and take notice.

Ideas generated by discussions with his own diabetes specialist prompted him to investigate linkages between the nerves in the eyes and nerves elsewhere in the body, with the aim of developing a range of relatively simple and non-invasive eye tests to identify neuropathy (or diabetic nerve disease).

Prof. Efron believed… his professional life would be spent outside Australia, but events beyond his control changed all that.

The breakthrough is so profound and important that Prof. Efron is to be honoured with a special award from the American Academy of Optometry for his research into non-invasive ophthalmic diagnosis of diabetic nerve damage.

He will be presented with the Glenn A. Fry Lecture Award, described as Optometry’s Nobel Prize, which recognises a distinguished scientist or clinician’s current research contributions.

But more about this later because it has been a long and distinguished journey that has brought the noted researcher to this point in his wonderful career.

Attracted Young

Had Nathan Efron not been short sighted and had to wear glasses aged 14, he might never have taken an interest in optometry.

“When I finished high school, I wanted to do something in the medical or bio-medical field. I recalled my visits to the optometrist and so optometry attracted my interest,” he said.

Nathan Efron’s results were good enough to get him into the University of Melbourne where he completed an optometry degree with great aplomb, but when it was time to decide what to do with his degree, the new graduate decided against entering the business and clinical world.

“I was so inspired and motivated by the research that was being done in the course and I thought I could contribute more, so I did a PhD straight away. I didn’t go into practice.”

The young Efron’s PhD looked at the oxygen performance of contact lenses, which is still a very important issue.

“I was looking at how contact lenses would deprive the cornea of oxygen and the clinical relevance of that.

“I worked on an experimental paradigm known as the ‘Equivalent Oxygen Percentage’ technique, which had been invented by Professor Dick Hill at the Ohio State University in the USA a few years previously. It was a procedure for measuring how much oxygen there was at the surface of the cornea that needs a contact lens. It had only previously been done on rabbits, but I’d worked out a way to do it on humans so we could have people wearing contact lenses and work out how much oxygen was under that lens. Then we could relate that to how the eye was responding to lens wear.

“The EOP system is not being used today because we have moved on from that, but we used it for quite a long period of time. I suppose the relevance of it was that the work I had done and the work others had done on it provided the whole impetus for developing silicone hydrogel lenses. All my research right through the 1980s demonstrated the cornea wasn’t getting enough oxygen. I published that and others also published similar evidence. Having shown we needed better material, we developed silicone hydrogel contact lenses.”

It was a seminal moment in Nathan Efron’s professional life and the start of a reputation of one of the world’s most published and renowned contact lens experts.

“That (the PhD) took about three or four years, but during that time I was supplementing my income by doing some part-time work. I would work Saturday mornings and during holiday breaks and I actually quite liked clinical work.

“In fact, when I got to the end of my PhD, it was a critical turning point for me. I had to decide: Do I want to continue doing research or maybe get back into clinical work, which I love as well? I was torn between the two.”

Academic Life

Efron ended up choosing research, and a career in academia.

“I managed to get myself a post doctoral appointment at the University of California, Berkley. I worked there for a year as a researcher with Professor Ken Polse, a well known contact lens researcher at the time,” says Prof. Efron.

During that time, Prof. Efron was researching the endothelium, the single layer of cells at the back of the cornea, and how it responds to contact lens wear.”

That work dovetailed into his next appointment. Returning to Sydney, Efron went to work with the renowned Professor Brien Holden and the University of New South Wales. It was a particularly interesting time, because Prof. Holden was just starting up his original research unit, which he called the Cornea and Contact Lens Research Unit.

“The most important project I worked on there became known internationally as the Gothenburg Study. That was a study that demonstrated the long term affects of extended contact lens wear on the cornea. We found that there were lots of changes that occurred in the cornea during extended wear of contact lenses. The main finding of that study was that we had to develop contact lenses that could be disposable and with higher oxygen permeability, which built on the research that I’d already done.

“Over the next 20 years what we recommended from this study actually happened.”

Prof. Efron explains that the study, the brainchild of Prof. Holden, required them to find a large number of people who had been wearing the contact lens in one eye only on an extended wear basis for a long time, so they could compare eyes.

“It was called the Gothenburg Study because Brien Holden knew of a practitioner in Gothenburg, Sweden, who had computerised records, which was very advanced for 1980-81, so they could go to the records and… find the patients. Brien and some other colleagues fron Sydney went there with a suite of specialized equipment to do the testing and asked me to analyse the results back in Sydney. It really excited me.

“As it turned out, when I look back on my career, it was my most highly cited paper. That paper has been cited in literature more than any other paper I have published.”

Moving On

Following the publication of the Gothenburg Study, Prof. Efron had a number of options, but chose to take a post at the University of Melbourne. After all, that’s where his family and friends were and also his favourite AFL team the Carlton Blues.

“That was in 1983 and I was appointed a lecturer. I stayed there until 1989 during which time I was promoted to senior lecturer. I was lecturing in a number of areas, but contact lens education was my main subject.”

Head Hunted

Efron’s reputation in research into contact lenses was growing and in 1989 he received a letter from the University of Manchester asking if he’d be interested in applying for a newly created professorial chair over there. It was specifically created for someone with an international reputation and expertise in contact lenses.

“I’d published a number of papers over the years and had developed an international reputation so I was head hunted. That was very exciting. I was actually enjoying Melbourne and I was working with Dr. Noel Brennan and it was a fantastic collaboration in which we’d published many papers together and I really wanted to continue, but then I had this offer of a professorial chair at a major European university and that eventually won me over. I went there in February 1990.”

On arrival, he established a contact research and consultancy unit known as Eurolens Research, which still exists. In Manchester Prof. Efron developed a close collaboration with Dr Philip Morgan, and commenced international contact lens prescribing surveys in the mid 1990s. They still collaborate on these much cited surveys today. It was a posting that would last for 16 years, during which time he would marry optometrist Suzanne and have two children.

“It was not long after I arrived there that I met my wife Suzanne. I was introduced to her at the BCLA conference in Birmingham. Coincidentally, she had studied optometry at the University of Manchester, where I had been posted.”

During his tenure at Manchester, Prof. Efron spent five years as head of the Department of Optometry and another three years as the Dean of Research of the entire university.

He also served a term as president of the British Contact Lens Association, and nine years on the General Optical Council, which is the registration body for optometrists and opticians the U.K.

Coming Home

Prof. Efron believed that the remainder of his professional life would be spent outside Australia, but events beyond his control changed all that.

“What brought me home was a bit of a push and a bit of a pull,” he explains.

“The University underwent a substantial change. It was merging with another university and at the time they re-positioned optometry in a rather awkward way. They essentially downgraded optometry. They took away its independent status as a department, much to my chagrin.

“I battled tooth and nail to avoid that. I was a senior person at the University at the time. At the same time I received an offer from the Queensland University of Technology (QUT), which is where I am now.

“QUT had just decided to create a whole series of research professorships in all disciplines. The heads of all departments were asked to try to get anyone of excellence who they might know overseas. The head of Optometry at QUT was Professor Leo Carney, my original PhD supervisor back at the University of Melbourne, all those years ago.

“When the research positions came up Leo was on the phone, asking if I’d be interested. I said I would and came back in January 2006 with my family.”

Prof. Efron says his wife and teenage son and daughter, Zoe and Bruce, were more than happy to live on Queensland’s Gold Coast because “we had come here every year to visit my family.

“In 2000, while still based in Manchester, I did a one year sabbatical at QUT. During that year we actually lived on the Gold Coast, so they (his family) knew what it was like and they loved living here.”

Diabetes Award

And that brings us to Prof. Efron’s latest ground-breaking research into non-invasive ophthalmic diagnosis of diabetic nerve damage.

It’s a story that dates back to 2001, when he was still living in the U.K., and relates to his own diabetes.

“I happen to have type 2 diabetes and was diagnosed when I was 35. I am on medication, but not insulin.

“In the late 1990s a new ophthalmic instrument was invented called a Corneal Confocal Microscope. That allowed us to look at the cornea at very high magnification… up to 700 times magnification. You could look at the cornea at a cellular level; you could see individual cell tissue in very fine detail.

“I noticed that you could see very fine nerve fibres inside the cornea, which you couldn’t see before with conventional instruments.

“It occurred to me that maybe you could use this instrument to look at nerve fibres in people who had nerve disease. Being a diabetic, (I knew of) a complication of diabetes called Diabetic Neuropathy – a condition where all the nerves in your extremities – the arms and legs – start to degenerate. You get terrible pain and pin prick sensations and hot and cold sensations. Up to half of all diabetics suffer from this condition, at various levels of severity.

“One day when I went in for my regular diabetic check, I visited my specialist, Professor Rayaz Malik, who was professor of medicine at the University of Manchester and a consultant endocrinologist. I told him of this new instrument, but until then I didn’t realise that he was a world expert in Diabetic Neuropathy. He had simply been my diabetes doctor.

“It was pure co-incidence that I found this out. So we started talking about being able to see these little nerves in the cornea and maybe we could use this to understand more about diabetics and diabetic neuropathy.”

The pair started researching the issue, and the work already had a lot of momentum by the time Prof. Efron moved to QUT.

“We got a few grants and it got bigger and bigger and we got bigger and bigger grants and it became a major collaborative effort between Manchester University and QUT.

“When I got to QUT, I managed to get a major grant from the Juvenile Diabetes Research Foundation – a $5.4 million grant to do a five year longitudinal trial. That would fund a large cohort of patients with and without Diabetic Neuropathy for five years so we could look at the potential for the use of this Corneal Confocal Microscope for monitoring patients over the long term (and measure) the improvement or degeneration of these patients, so it was a very large study between Manchester and QUT.

“That’s my major thrust of research at the moment plus we’re looking at other techniques to look at nerves eslewhere in the eye – to look at nerves in the retina, for example, using a technique called Optical Coherence Tomography.

“There are no actual drugs you can prescribe at the moment to reverse Diabetic Neuropathy so the only way it can be controlled now is to get people on better management. Often people put on a bit of weight or don’t control their glucose levels so well, but if we notice these neuropathic changes, if we urge people to become fitter, lose weight, get their blood pressure under control and manage their diet correctly, and if this succeeds, we notice an improvement in their neuropathy as measured with these various ophthalmic techniques.”

As for the announcement of the presentation of the prestigious Glen A. Fry Lecture Award from the American Academy of Optometry for his research into non-invasive ophthalmic diagnosis of diabetic nerve damage, Prof Efron simply says: “I’m thrilled, humbled and honoured to receive it. This is considered the most important award internationally for current research in the field of optometry.

“The information we gain during this study will be used to validate and develop novel eye tests to detect and monitor a potentially severe complication of diabetes known as peripheral neuropathy.

“We will also learn how nerve fibres change over time in diabetic patients, which will help us better understand peripheral neuropathy.”

Professor Efron is already well-known for his research on contact lenses and has published 14 textbooks on the topic. As a result, contact lens students and clinical optometrists around the world are familiar with his name.

They will soon get to know this gold medal researcher for his current work on diabetes.