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Tuesday / November 12.
Homemifeature“We Can Do More” Professor Paul Mitchell and his Quest to Tackle AMD

“We Can Do More” Professor Paul Mitchell and his Quest to Tackle AMD

It seems that Professor Fred Hollows has even more to be thanked for than we realise. In 1985, a young Paul Mitchell entered the world of ophthalmology, at the legendary Kiwi’s behest.

But as Melanie Kell found out, Prof Mitchell wasn’t always destined to be an ophthalmologist.

non-adherence is our problem… It is one of the most important issues that I think all ophthalmologists need to address

Over almost 40 years, Professor Paul Mitchell AO has carved out an enviable career that has perfectly blended the best of all aspects of eye health: public, private, and academia.

Now “well past most people’s retirement age”, his multiple roles include Director of the Centre for Vision Research at The Westmead Institute for Medical Research in Sydney. With his wife Dr Suriya Foran (also an ophthalmologist), he operates Australia’s biggest ophthalmic clinic to bulk bill all patients needing anti-VEGF injections.

But it took a legendary figure to set in train a course of events that would ultimately create another giant of ophthalmology, who would become globally recognised for his extraordinary contributions to public health, ophthalmic epidemiology, and clinical research into macular diseases.

“I trained at the University of New South Wales in medicine. Fred Hollows was one of our tutors, and at the end of my third year, he needed some people to help him out west of New South Wales – Brewarrina, Enngonia etc. One of my colleagues, Glen Gole, and I went with Fred on one of these trips as medical students.

“I became quite interested in ophthalmology after that, although I thought I would probably become a specialist physician.”

Later, while working as a junior medical officer at Prince of Wales (POW) Hospital, the young Dr Mitchell bumped into Prof Hollows again, who asked whether he’d thought about pursuing a career in ophthalmology.

“Really, I’d almost lost the thought of doing ophthalmology. But it kindled an idea that, ‘Yeah, maybe this is a good specialty. It’s a great mix between medicine and surgery’.”

Both Dr Mitchell and Dr Gole picked up on Prof Hollows’ suggestion, and took the primary exam, which was necessary to train in ophthalmology at the time.

“I remember working, probably the hardest I’ve ever worked, on studying for that exam,”

Prof Mitchell said. “And I passed it. Then Glen Gole and I, the two of us together, actually got employed by Fred as registrars in his clinic the following year. So, I did my training under Fred at Prince of Wales.”

At that time, POW was the only hospital in Australia to have a laser machine, and, having recently been recognised as a suitable treatment for patients with diabetic retinopathy, young Dr Mitchell was tasked with its facilitation.

A Research Career Is Born

It was while working in this area, during his second year, that he met Professor Paul Moffitt from University of Newcastle, NSW and his career took another turn.

Prof Moffitt was looking for someone to conduct a survey to find out more about the high prevalence of diabetes in his area, the disease characteristics, and then to help start a treatment service.

That study opened Prof Mitchell’s eyes to the potential for further research, specifically an Australian prevalence survey of age-related macular degeneration (AMD), being a key cause of blindness. It also exposed him to Professor Ron Klein, a famous epidemiologist from Wisconsin in the United States, who, at that time, had just completed the Beaver Dam Eye Study, which looked at all eye diseases but was particularly focussed on AMD.

“I went across to Wisconsin and had a look at the way they did their survey, and I thought, ‘Well, we could actually do something similar’.”

For Prof Mitchell, the stars were aligned.

Although there were very few academic jobs in Sydney, one came up at Westmead the following year. He applied, was duly appointed Associate Professor, and was successful in obtaining a grant to commence a population study of eye disease, which came to be known as The Blue Mountains Eye Study.

By broadening the remit that had been used for the Beaver Dam Eye Study, Prof Mitchell’s study gathered comprehensive data on the frequency, risk factors, impacts, and outcomes of macular degeneration primarily, as well as other eye diseases, including glaucoma, diabetic retinopathy, and cataract. The survey, which started in 1992 and followed a population across two postcodes in the Blue Mountains for up to 15 years, also investigated hearing loss.

“It became the leading data in Australia on (macular degeneration). The Blue Mountains Eye Study altogether has published some 600 papers – a massive output. And still, we’re still publishing data from it,” Prof Mitchell said.

A new version of the study – the National Eye Health Survey – is now underway to gather current data on eye diseases and hearing loss. And while Prof Mitchell, as Lead Investigator, is intimately involved, it’s the hands on work in his private clinic that now takes up most of his time.

The Greatest Advances, The Great Challenges

During his career, and especially in the past two decades, Prof Mitchell has seen the development of exceptional technology and treatments for neovascular age-related macular degeneration (nAMD), which together have saved the sight of thousands of people worldwide, bringing social and financial benefits to individuals, families, communities, and entire economies.

However, he said, there is still much more to be done, simply because despite the availability of treatment, many people who need it simply aren’t getting it.

Indeed, in Australia, according to data from the Pharmaceutical Benefits Scheme, around 40% of people who commence treatment for nAMD stop treatment in the second or third year.

As medical professionals, “non-adherence is our problem”, said Prof Mitchell. “It is one of the most important issues that I think all ophthalmologists need to address. How can we keep people on long-term therapy?

“I really think we can’t blame people for this.

What we need to do is blame ourselves for not educating people well enough, for not making it clear to them that this is critical, for not doing it in a way that they keep coming back.

I mean, I strongly believe that this still needs to be our responsibility… But keeping people on board, it’s a challenge day in, day out.”

Barriers to Break Down

Factors leading people to drop out of treatment include a lack of awareness about the need for ongoing treatment to manage the relentless nature of the disease, high out-of-pocket costs and discomfort associated with the injection procedure. Logistics such as transport issues, the time of day that treatment is provided (which may pose problems getting to the clinic) and the amount of time required to be in the clinic also play a significant role.

In regional and remote areas, some people have to travel significant distances to attend their appointments.

“I think we’ve got to address all the factors which we know are important in causing people to want to stop. We’ve got to talk to people about them and try to talk them into continuing (treatment) if we can.

“And, of course, where it is futile, to recognize that and to consider cessation. But if we do stop a patient’s treatment, we’ve got to make sure we follow them appropriately to make sure there is no recurrence,” Prof Mitchell said.

Nurturing patients to this extent takes valuable time in a busy ophthalmology practice, which of course costs money. So how can someone like Prof Paul Mitchell afford to provide every patient with a bulk-billed anti-VEGF treatment?

“Although we see a very large number of people, we actually are getting people through fairly quickly. And I think this is because we have sufficient staff on board, with orthoptists and nurses, to really make sure that we can do this efficiently. And we’ve got high productivity as a result.

“High productivity really makes a massive difference, particularly if you’re reducing the cost for people. It’s a major issue.”

To maximise productivity across his clinic, Prof Mitchell encourages all staff to engage with patients who have concerns, to answer their questions or facilitate provision of information.

“People are a little bit reluctant sometimes to tell the doctor, but they will tell the nurse about the concern they have. And, of course, this is important. If we know that there’s some underlying problem that we’re not satisfying, then I think that at least we can get that message.”

More Than A Team Effort

Realising that boosting productivity and educating patients relies on more than the team within his clinic, Prof Mitchell is careful to include both his colleagues and his patients in their disease management.

“I find it helpful to always copy my letters (to GPs and optometrists) to the patient. In the letter, I’ll say, ‘This is really important to continue.’ And I’ll mention to the GP, ‘I’m grateful for your encouragement to keep her coming according to the schedule.’

But I send that copy to the patient. Most ophthalmologists don’t do this. I think this is very helpful.

“The patients can read it. And even though they won’t understand the medical bits, they will understand the final bit, which says, ‘I’ve made these further appointments. It’s critical that she keeps coming back. This is helping to stop this eye progressing and continued visual loss.’ And I think this… does help to educate people better than we can in the short time they’re in the clinic.”

Optometrists are also in a key position to follow patients under treatment, particularly if the treatment interval is being extended, to encourage adherence to treatment schedules, and provide an early diagnosis in the event of nAMD in the fellow eye. “Large, soft drusen and pigmentary changes are predictors of progression and thanks to new technology, we know there will be evidence of new vessel under the macula in about one in eight fellow eyes of those being treated for the disease – in other words, the fellow eye that doesn’t have neovascular AMD will have a subclinical CNV (choroidal neovasularisation) present,” explained Prof Mitchell.

“We know from studies that those eyes with a subclinical CNV are five to 10 times more likely to progress to symptomatic neovascular AMD than eyes without that sign.

“So, once we can see the sign, that’s not an indication to start treatment, but it is an indication to follow people more closely.

“We don’t have to monitor for this ourselves (as ophthalmologists). It can be done with the help of optometrists. They can be reviewing people to make sure they’re not getting fluid, getting a haemorrhage, or getting symptomatic changes.”

Given that the second eye is often the one that will ultimately determine a patient’s final best vision, he urged optometrists to be vigilant when monitoring patients with nAMD and educating them about typical symptoms of change that require attention.

“The distortion of straight lines, a dark or grey patch in their vision, or sudden worsening of the vision of the fellow eye is a really important symptom,” Prof Mitchell said.

It’s at this point that all parties involved must be proactive – from the optometrist who advises the patient on the need to see their ophthalmologist within days, if possible, to the receptionist at the ophthalmology clinic who knows to fit the patient in with haste.

“Often, people say, ‘Well, I’m coming back (to the ophthalmologist) in five or six weeks.

I‘ll leave it till then.’ By that stage, the fellow eye will have progressed, and the vision will be way down.

“And, of course, we know that the most important predictor of final vision is the vision a patient had when we started treatment… getting people with good starting vision or better starting vision will be the way to keep people seeing well.

“If a patient is being treated in the right eye, but you see signs in the left, you need to say, ‘Forget about your next appointment. You need to be seen early and urgently if you get symptoms in your good eye’… I mean, it might be a false alarm, but it’s better to see people for a false alarm than to miss out on being able to treat the disease at an optimal time.”

Sight Saving, Life Saving, Money Saving

Prof Mitchell said it’s time for governments to take vision impairment more seriously because achieving optimal results from treatment is not just about saving sight – it’s about extending life expectancy, maintaining quality of life, and reducing the impact and costs for the individual, their family, and the entire economy.

“Non-correctable vision loss leads to a loss of ability to live independently, loss of driving licence, increased falls, increased hip fractures, decreased quality of life, increased depression, increased mortality. All the studies showed that vision impairment in the better eye is an independent risk factor for dying after accounting for all the other reasons people die, like cancer… if you actually reverse vision impairment, people live longer. So, it increases survival.”

Currently, the NSW Government has not signed the Pharmaceutical Benefits Scheme agreement to fund medicines for outpatients in public hospitals. It is the only state in Australia that has refused to join the scheme.

This means nAMD patients in NSW who are unable to afford to pay for anti-VEGF treatments have few options. While some privately owned clinics (such as Prof Mitchell’s and teaching hospitals) provide bulk-billed treatment, they simply can’t meet demand.

But according to Prof Mitchell, even in the other Australian States that have signed the PBS agreement, treatment capacity through the public health system remains extremely limited.

While recognising the massive financial responsibilities governments are currently grappling with, Prof Mitchell hopes that with more evidence-based studies, they will soon realise the indirect cost savings that would come from making treatments available in the public system.

“Even though the other States have signed, and theoretically, they should be available, they don’t make many clinics available. So, they’re not that much better off than New South Wales. And look, these diseases – diabetic retinopathy and macular degeneration – still are the leading cause of blindness in Australia. So, it is quite important for this to be looked at.”

It’s Going To Be Fantastic

While Prof Mitchell is quick to acknowledge that many others his age are now in retirement or the twilight of their careers, for him, there’s no switching off yet.

“You know, I’ve been around for a long time.

But look, I quite enjoy what we’re doing right now. We’re seeing a lot of people who fall through the cracks and would otherwise probably not get treatment. So, I’m happy to keep going.”

He also has three young children – aged 10, 13, and 14, as well as two in their late 30s – to keep him young at heart.

“I tell you, the children… I’m probably not spending as much time with them as I should, but they’re an absolute joy, of course… It’s an extraordinary experience at my age to have a 10-year-old daughter.”

Contemplating a time when his youngest children have grown up, he said, ophthalmology is “going to be fantastic”.

“One of the things that’s happened during my career is that new treatments have come along at a really good time.

“First, laser treatment transformed management of diabetic retinopathy. Then the next thing was anti-VEGF. And at the same time, it came with better imaging, OCT, and then OCT angiography… We are now able to treat people amazingly well with better imaging and amazingly better treatments. And I would expect that the trend for improved treatments will continue… some we can predict now, and some will come out of left field.

“But I would think that anyone doing ophthalmology now would be looking at a lifetime of new discoveries and new treatment options. It’s going to be fantastic. I’d like to be doing it, but I won’t be.”

“I’ve had a fellow every year for almost the last 20 years, and they’ve all been fantastic people. They’ve done fantastic work. And they’re working as retina specialists. So, they’ll see it.

And I’m sure we’re going to see some major advances in treatment of eye disease and retinal disease, including AMD.”

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