Brien Holden Vision Institute – The Past Guiding the Future

When Professor Brien Holden passed away unexpectedly on 27 July 2015, the Brien Holden Vision Institute (BHVI) already had plenty on its plate. Royalties from silicone hydrogen gel contact lens material were beginning to dry up, government funding had been reduced and support from the private and corporate sector was suffering due to economic downturn.

The executive was looking for new opportunities to bring in revenue that would support its research, education and public health programs but the plans were barely in place. Enter Professor Kovin Naidoo. Having worked with the Brien Holden Vision Institute from Durban South Africa for 21 years, primarily on public health, Prof Naidoo had been integral to growing the organisation’s global presence and was familiar with its looming financial challenges. Recently elevated to the role of CEO elect he was to shadow Prof. Holden and take on some of his tasks as the institute’s founder prepared to wind back.

“Following the sudden death of a founder like Brien, who had been so integral to the organisation, it was natural for the executive to re-look at what we do – and so we engaged in a strategic process to restructure the organisation,” said Prof. Naidoo. “We have created multiple tiers of leadership, with more responsibility and a new focus. We have reduced the number of projects we are working on and we are really going after the things that make sense for us in terms of our research activity… The three major areas we have agreed to focus on are presbyopia, myopia and ocular comfort (associated with dry eye).”

He describes the model as a ‘hybrid’: BHVI is taking its own intellectual property (IP) to potential industry partners that have the resources to help with commercialisation

Bolstering the Coffers

The executive also decided that partnerships were the most financially sustainable way to move forward.

“Our philosophy is partner or perish. We live in a resource-limited world right now and as a result of that we should make every effort to prudently use resources,” said Professor Naidoo. “Our strategy is to aggressively drive the Institute in certain areas, so it makes sense to enter into innovative partnerships with industry that realise more value more quickly than we can achieve on our own.”

He describes the model as a ‘hybrid’: BHVI is taking its own intellectual property (IP) to potential industry partners that have the resources to help with commercialisation. Additionally, it is inviting individual optometrists and organisations to bring their ideas and IP to the BHVI for assistance with research, development and commercialisation.

The Institute has developed an extended depth of focus (EDOF) contact lens platform, and is commercialising this in collaboration with SEED Co., in Japan. The next generation EDOF platform is on the way. EDOF contact lenses have been designed to meet the needs of the growing presbyope market and to provide optimal visual performance from distance to near with minimal ghosting.

A novel comfort agent, GML, for dry eye is another opportunity the Institute hopes will bolster its coffers. “We are engaging companies to look at how it can be integrated into products for treatment of general dry eye. It’s a broad space but we have a very focused area of involvement in it,” said Prof. Naidoo.

Interestingly, collaboration is nothing new to the Institute. “An area of Brien’s life not spoken about, not understood, is that most of the Institute’s innovations were achieved in collaboration with others and we were not always the majority beneficiary of that collaboration, even though it appeared that way.”

The concept of partnering to bring IP of other entities to commercialisation is not new to BHVI but is expanding as the result of a roadshow. “Shortly after Professor Holden’s passing, we showcased our capacity in research and development to major optical companies. Their reaction was positive, so we are now making our systems and approaches to clinical trials, data analysis etc. available to them. We might do joint venture research, or run a clinical trial with a large optical firm that doesn’t have the capacity to do it on their own. That’s providing us with multiple streams of income rather than the royalties alone that we once relied on.

“In the short time that we’ve been putting that message out, we are already getting people coming to us, seeing us a vehicle that can support their research.”

Indeed, the Institute has been engaged by established clinics around the world to undertake studies. “We are, for example, working with partners in Japan and China. The studies are conducted in their centres but we manage the process and bring all our resources and structure to it. Working with local people in this way can lead to other collaborative projects and we’re already seeing this occur.”

Prof. Naidoo said these international collaborations also foster more innovative thinking. “We’re constantly interacting with people with different ideas from different parts of the world – so while we’re out there helping our local partners – their contributions are helping us too.”

Thinking Out of the Box

Of course the income that’s now coming back into the Institute is not for profit. As is the history of the Institute, it is being ploughed back into its endeavours to achieve greater access to eye health for all.

While that’s not surprising for a social enterprise, it’s the innovative approach to the effort that has made BHVI so important on the global stage, and this is what attracted Prof. Naidoo to Prof. Holden and his organisation right from the start.

Having achieved a doctorate in optometry and a Masters in public health out of the US, he had returned to South Africa with some ‘out of the box’ approaches to public health and was looking to establish an NGO and community based program while also engaging in research at the University of KwaZulu-Natal (formerly the University of Durban-Westville).

“At that time in Africa our profession was very focused on the private health sector, and we had a protectionist approach to it. I was asked to speak in South Korea and I presented some alternative thinking about how we train people etc.

“It was my first conference as an academic and it was a most deflating experience because people were not happy with what I said. But the next day Brien quoted me positively in his presentation … he and I had dinner and over dinner he asked me what I was planning to do; I mentioned my intention to start an NGO.”

Prof. Holden had been working on an idea that would provide access to contact lenses for people in developing countries but he’d realised his work would be futile unless eye care services could also be delivered. He wanted to establish an NGO.

“He suggested we work together, he from Australia and me from Africa… he returned to Sydney, established the International Center for Eyecare Education, then contacted me and said I’ve registered it, will you register in Africa and join me in what we’re doing. It made sense to collaborate, and it was a significant advantage that Brien had resources that could be channeled from some of the income generated by his research so I could get things done quicker.

“I was very attracted to Brien’s approach: rather than sending someone from Australia to do a job, he invested in developing local leadership, in collaboration.”

That approach permeates all aspects of the Institute’s work with an emphasis on establishing optometry schools to educate across the spectrum from eye screeners to optometrists in countries where often, the profession has not previously existed.

“Right from the beginning, we came into the space with a different thinking – the programs needed to be sustainable and we were prepared to invest in less sexy programs that other funders didn’t want to invest in, because the returns were long term. Unlike others, we took a systems approach – our view was that if you want to make change you need to look at all the different components that impact on society and, rather than putting a flag on one component, work out how to contribute to all those components to get the outcome required.”

Prof. Naidoo gave the example of working to improve eye health in a developing country. “An NGO might say that screening children or establishing vision centres is the solution to improve eye health. At the Institute, our approach has always been to do a situational analysis to determine what is needed – we might find that eye health services in both the private and public sector need to be developed and so we come up with solutions and work with people across these different levels. We have never been paranoid about working with the private sector, or as optometrists, working with other health professionals to develop collaborative solutions – whether they are ophthalmologists, nurses, public health, doctors etc.

Prof. Naidoo said this approach has grown optometry’s role in the delivery of global eye health.

“In 1998 optometry wasn’t even at the table of the World Health Organization (WHO) or at the table of the International Agency for Prevention of Blindness (IAPB), both were primarily focused on ophthalmology.

“But Brien was aggressive at getting refractive error on the WHO agenda. We went to meetings and we engaged WHO, and we said, ‘here’s a major public health challenge, here’s an area where optometry can make significant contribution to blindness and vision impairment’. I think that really helped… I think that it resulted in a different way of thinking and in the acceptance of optometry as an important player in the eye health team.

“A couple of years later I was elected as IAPB Chair for Africa and through that the IAPB in Africa ended up with a group promoting optometry as part of the international agency.”

BHVI’s more recent collaboration with the likes of Essilor Vision for Life to establish Our Children’s Vision, and supported by Bono from U2 and eyewear brand REVO, demonstrates the Institute’s continued commitment to, and the strength in, working with the private sector. Established in 2016, Our Children’s Vision already has almost 70 partners throughout the world and has reached an extraordinary 10 million children to provide eye health screening and vision correction. Importantly, Prof. Naidoo says, it’s starting to reach a critical mass to advocate for policy change.

Tackling Myopia

Prof. Brien Holden’s ambition to increase awareness of myopia and its increasing prevalence was no secret. In 2016, The Impact of Myopia and High Myopia report was produced as a result of a joint World Health Organization – Brien Holden Vision Institute Global Scientific Meeting on Myopia. One of Brien’s final papers, published in Ophthalmology highlighted the fact that five billion people would have myopia and one billion people would be highly myopic by 2050, a five-fold increase from 2000.

Prof. Naidoo says myopia will continue to be the Institute’s flagship project with an integrated program of research and development into control and prevention, public health advocacy and education being rolled out world-wide.

“This profession stands at the threshold of addressing probably what is one of the biggest public health crisis that the modern world has faced and it’s unique because it affects both the developed and the developing world. I think history will judge us very harshly if we don’t rise to this occasion, which means we must take a multi-faceted approach.

He said training health professionals in eye screening and patient education will be critical to ensure myopia is prevented and managed.

“We will be doing a lot of health promotion work in this space – we will release tools and materials for practitioners to give to patients, because we believe that rather than treating myopia, practitioners need to manage it, and that’s a paradigm shift that not a lot of practitioners are ready for… so rather than a once off dispensing of contact lenses or spectacles, you’re going to have to interact with parents to promote the fact that children need to spend more time outdoors and when appropriate, they wear their spectacles – you can’t just dispense and leave them to get on with it.

“It’s exciting and it’s also complex and challenging because we’re working with the developed and the developing world, and because we will develop a truly global collaboration to tackle a truly global problem.

“I don’t see any organisation with the breadth of activity, experience or exposure that we have to make a difference, however we can only make a significant difference if we partner with every orgnisation or company that wants to partner with us by providing expertise, resources or cash. In South Africa for example, JC Decaux is giving free billboards across South Africa to promote our messages and myopia will be one of those. In Australia we would like to partner with optometrists, and also with medical insurance companies to talk to their members, we need to look at multiple opportunities to communicate with people to address myopia as a critical health issue.”

He said individual practitioners who reach out to their patients directly, beyond just an eye examination and provision of spectacles, to help them manage myopia will make an enormous difference to the health and prosperity of future generations. “This is a much better way than any political initiative to justify the importance of optometry: we know what the trend is, we know half of the world will be myopic by 2050, it’s our challenge to show how we can reverse that trend.”