Specsavers demonstrated its might at the organisation’s 2023 annual clinical conference, presenting impressive evidence for the positive outcomes being achieved in eye health throughout Australia and New Zealand.
With a speaker lineup comprising some of the country’s best ophthalmologists, 1,000 delegates in attendance were empowered to do even more.
Around 12% of all optometrists in Australia and New Zealand attended the 2023 Specsavers Clinical Conference – close enough to 300 on site in Sydney, and another 700 online – from Perth to Auckland, from Darwin to Invercargill.
Leading ophthalmologists shared their expertise, emphasising the critical role that optometrists play in collaborative patient care. They encouraged optometrists to get to know ophthalmologists in their area, to be unafraid to ask questions about specific cases, and to expect two-way communication about the patients in their shared care.
In his welcome presentation, Dr Ben Ashby highlighted Specsavers’ contribution to community eye health. Over the past 12 months alone, its optometrists have cared for over 5.2 million Australians and New Zealanders.
In early 2020, Specsavers set a five-year-goal to achieve a 95% detection rate of avoidable blindness. Dr Ashby reported that just 3.5 years on, the company has already achieved a 90% detection rate.
Another five-year milestone set at the time was to improve eye health accessibility and deliver eye care to an additional one million people. This milestone has been achieved in the past 12 months, with Dr Ashby reporting that of the extra million patients seen, over 500,000 people have gained better sight due to spectacle correction and 70,000 have been referred on to ophthalmology for treatment they wouldn’t otherwise have been received. Additionally, more than 700,000 appointments have been registered to KeepSight for patients with diabetes since the program was established in 2018, and 160,000 cases of glaucoma have been first diagnosed in the last five years.
Demonstrating its commitment to partnerships, Specsavers has now contributed AU$7.8 million to the work of The Fred Hollows Foundation in Australia and Aotearoa through support office, patient and store donations. Dr Ashby said the Specsavers partnership with The Foundation continues to grow with increasing opportunities for optometrists to travel to remote communities to provide care and a plan for more to be done in stores to close the gap in eye health outcomes for First Nations patients.
Further improving eye care accessibility, over the past year Specsavers has been piloting an eye health model that has been developed to target the 100 stores in Australia and New Zealand that can’t get enough optometrists to meet the demands of the community. In the model which runs alongside normal optometry practice, the eye test follows the same process, scans and procedures as a normal eye test. The only difference is that the person in the room with the patients is a clinical technician and the optometrist is dialling in from another location. The remote eye care optometrist can see the patient’s scans and test results as well as remotely control parts of the eye test from afar. They can even see the patient’s eye lid, surface and retinal structures thanks to highdefinition cameras integrated into the eye testing technology. Next year the pilot will be expanded to “a more remote location to put it through its rigours”, Dr Ashby announced.
MYOPIA MANAGEMENT
To help counter what is regularly described as a pandemic, Dr Ashby reported that Specsavers has made myopia management “so affordable that we now have one in five children on myopia management”. On this note, the clinical program commenced with an entertaining presentation by Dr Rushmia Karim (Vision Eye Institute NSW), on myopia management.
Dr Karim spoke about the complications of myopia, the missed opportunities, and rising financial costs incurred (for vision correction and refractive surgery) if an individual’s myopia is left to progress without treatment.
She stressed the need to encourage early intervention because vision loss caused by myopia in most instances cannot be reversed – the sooner myopia is controlled, the better the long-term outcomes.
“There’s no single gene that causes myopia, we can’t change the patient’s genetics, but we can change the lifestyle/environmental component of myopia” she said, emphasising that these changes– such as spending time outdoors and applying the 20:20:20 rule (20 minutes of near work followed by 20 seconds looking 20 feet – or six metres – away) – cost nothing.
Dr Karim recommended optometrists provide patients and carers with information on lifestyle and environment interventions available from the World Society of Paediatricians and Ophthalmology Strabismus.
With increasing numbers of myopic young adults expected, Dr Karim spoke about counselling patients on the safety of driving while being treated for myopia progression.
“Hoya MiyoSmart is approved (to be worn while driving) in the United States, but the jury is out in Australia. And the issue is we are going to have patients on dual therapy (i.e. myopia control contact lenses and atropine).
“We don’t have guidelines (or evidence for those over the age of 16) but I say to patients that if you want to be on these treatments, you can’t drive a car.”
DRY EYE DISEASE
Dr Ashby reported that dry eye disease affects around 30% of Specsavers’ patients and to date store optometrists have been limited to offering lifestyle advice and eye drops. To the delight of many in the room, he announced that over the next year Specsavers will be piloting intense pulsed light treatment in a number of practices.
In her presentation on paediatric care, Dr Shanel Sharma (Eye and Laser Surgeons NSW), reported a noticeable increase in the number of young people presenting with dry eye.
“I see at least half a dozen kids a week with dry eye, and it’s largely because we’ve become a society of starers. We don’t talk to people anymore, we text them… when we talk, we blink 12 times a minute; when we stare (at a screen) we blink twice a minute… The tear film is only designed to last 10 seconds, when we stare, we don’t blink for 30 seconds.”
Other behavioural changes causing dry eye include looking up at big screen televisions or computer screens, which forces our eyes to be wide open. In days past, when we looked down on to smaller TVs across the room, our lids lowered, providing protection. We used to walk away during the ads giving our eyes a break. Now we stare at the screen as we hit the fast-forward button.
Indoors, air conditioning lowers humidity and exacerbates dry eye. Also, increasing air flow over the eye with air conditioning, fans, and air purifiers can promote increased evaporation and dry eye.
Dr Sharma said we need to remind patients to blink more frequently. “Turn the page or scroll then blink; position the computer screen so you’re looking down, put out bowls of water – this is the behavioural stuff that doesn’t cost anything, but it works.”
She reported that over the past three years, neurologists have identified a link between dry eye disease and migraine.
“Superficial punctate epithelial erosions can activate the receptors on the cornea that trigger migraines… those small microabrasions can trigger a migraine.”
CO-MANAGING GLAUCOMA
Dr Shenton Chew (Auckland Eye) spoke about the importance of collaborative care for glaucoma suspects and those with stable early and moderate glaucoma, particularly as resources increasingly come under pressure.
Reinforcing the need to follow the glaucoma patient pathway developed by the Royal Australian and New Zealand College of Ophthalmologists (RANZCO), he said, “Collaborative care is there to safeguard both the patient and the optometrist… It requires a specific plan created by the ophthalmologist and offered to both the patient and the optometrist” and “optometrists should feel empowered to ask for specifics about the patient in front of them”.
He went on to discuss the various diagnostic tools for glaucoma, including tonometry, gonioscopy, perimetry, and optical coherence tomography, and ways to determine structural and functional stability for patients who are potentially unstable and require input from an ophthalmologist.
With many options for treatment, there is “a delicate balance” required “to prevent visual disability and minimise treatment burden,” he said.
LOVING KERATOCONUS
Dr Brendan Cronin was tasked with discussing his favourite subject: keratoconus. He said treatments have come along way for this disease, which is most prevalent among racial groups including Māori and Polynesians. Family history is also a risk factor.
“Once upon a time it was a bad disease. But there are so many new and exciting approaches to treat patients with keratoconus now; their quality of life is excellent, and their vision is excellent,” he said.
Dr Cronin reiterated the need to educate keratoconus patients on the danger of eye rubbing, which thins the cornea. To control rubbing, ocular allergies needed to be controlled with a preventative medication and a reliever as needed. He suggested “cheap eye drops” kept in the fridge as a ‘go to’ for these patients.
Mild karatoconics are less likely to progress because they have thicker, stronger corneas. More advanced keratoconics have thinner corneas and are, therefore, more likely to progress. If a patient stops rubbing their eyes keratoconus may stop progressing, however this isn’t always the case.
Modern 3D mapped scleral lenses provide “generally outstanding” vision if allergies are controlled and they can be tolerated.
If you have controlled a patient’s allergies and their refraction continues to change, this is sufficient reason to refer for crosslinking. This procedure stiffens and strengthens the steeper parts of the cornea, and the biomechanics also get stronger accordingly.
He said, “with customised corneal crosslinking, 60% of your patients will get improved best corrected vision”.
“If they are under 25, refer now; if they are older than 35 and with good vision, then watch them.”
A new solution, which Dr Cronin was particularly excited about, is corneal allogenic intrastromal ring segments (CAIRS), which is minimally invasive keratoconus surgery.
With CAIRS, “You don’t weaken, the cornea you strengthen it; you don’t remove corneal tissue, you make a tunnel and add it… you can customise crosslinking, then do CAIRS, then tweak with topography guided phototherapeutic keratectomy…
“So try the contact lenses first, and then there are so many options.”
LOOKING FOR MOLES
About 6% of the Caucasian population has choroidal naevus, and one in 8,000 will transform into melanoma. Patients often describe seeing shimmers – fairy lights in oranges and blues; or an effect similar to water reflecting off a road.
Adjunct Associate Professor Lindsay McGrath (Terrace Eye Centre, Queensland) introduced a mnemonic, that is gaining popularity, to help optometrists determine when to refer a patient with a suspected choroidal melanoma on to an ophthalmologist:
MOLES refers to:
Mushroom shape
Orange pigment
Large size
Enlargement
Subretinal fluid
She said the mushroom shape distinguishes choroidal melanoma from other choroidal tumours. It “pushes through a tiny break in the Bruch’s membrane, then explodes out like a mushroom cloud”.
Grade each of these factors from one to three, then calculate the total. An overall score of two or more grades the naevus as high risk or probable melanoma, and must be referred on.
Encouraging referral of any suspected choroidal melanoma she said, “Anything we see that we’re not worried about we will return them to you with a treatment plan. You can always send them back if you are worried about anything in the future.”
OPTIC NERVE STROKE (ION) AND SLEEP APNOEA
Dr Kate Reid (Optic Nerve Canberra), spoke about two types of optic nerve stroke. Arteritic ischaemic optic neuropathy (AION), usually due to giant cell arteritis (GCA) in patients over the age of 50, is typically seen in older Caucasian women. Although it accounts for a minority of optic nerve stroke, the chance of severe visual loss from this vasculitis or artery wall inflammation is high, and the fellow eye is also at risk. GCA symptoms include headache, shoulder girdle muscle pain, night sweats, unintentional weight loss, jaw claudication, and transient visual obscurations prior to painless visual loss. However, in 20% of AION due to GCA there is no systemic history. Urgent treatment with steroid is essential to protect the fellow eye.
A more common form of optic nerve stroke is non-arteritic ischaemic optic neuropathy (NAION), which is due to fluctuating blood pressure. Nearly all patients with NAION will have obstructive sleep apnoea, a sleep disorder where breathing is repeatedly interrupted. It is characterised by loud snoring and episodes of stopping breathing. Sleep apnoea ‘tells’ in a patient’s physical appearance include increased body mass index, increased neck circumference, floppy eyelid syndrome, older age, and gender, with men more commonly affected. The STOP-Bang Questionnaire is another easy way to screen for the condition.1 Formal testing for sleep apnoea with an overnight sleep study must be actively pursued in NAION presentations.
A 20-year Australian study shows that untreated moderate-severe sleep apnoea is a truly severe threat to health. Among other things, it increases the risk of both stroke and cancer three-fold. Sleep apnoea adversely impacts quality of life and mood, as well as safety on the road and at work. It also greatly increases the risk of NAION, glaucoma, retinal vein occlusion, and diabetic retinopathy. Dr Reid asked optometrists to talk about the risks of sleep apnoea with all patients who appear to be at risk of the condition. These patients should be strongly encouraged to seek a sleep study via their GP or from a pharmacy service, noting that many options for treatment exist besides a continuous positive airway pressure (CPAP) machine and mask. Identifying a patient’s sleep apnoea may result in saving not only their sight, but their life.
REVERSING METABOLIC DYSFUNCTION
Ophthalmologist Dr James Muecke AM, Lieutenant Governor of South Australia and founder of Sight for All, is passionate about demedicating patients – particularly those with type 2 diabetes. This disease damages blood vessels throughout the body, including the retina, and can steal sight immediately, sometimes permanently.
Nearly two million people in Australia have type 2 diabetes, yet well over half aren’t having their annual eye examination, he said.
Dr Muecke said type 2 diabetes directly costs Australia’s health system over AU$20 billion every year,2 and “probably many fold higher when you consider the costs of heart attack, dementia, stroke, and cancer associated with this disease”.
He questioned the Australian Dietary Guidelines3 which recommend a diet comprising up to 65% carbohydrates and instead implored the government to “take action to reduce consumption of sugary drinks, ultra-processed substances, and food cooked in seed oils”.
Reflecting on his own history of “a fatty liver” he said, obesity is not the key issue here – you can be thin and still have metabolic dysfunction or even type 2 diabetes. It’s all about the type of calories in our diet, specifically fructose and seed oils.
Having delved into the biochemistry, Dr Muecke told the audience that metabolic dysfunction can be reversed naturally by avoiding the energy-dense nutrient-poor foods mentioned above and only eating real food with a prescribed daily intake of less than 50g of carbohydrates.
He said there are now more than 100 controlled clinical studies reinforcing this approach – one study showed 53.5% of participants were still in remission after two years on a low carb healthy natural fat diet.
With his own patients, and in collaboration with general practitioners, endocrinologists, and a nutritionist, he has seen some extraordinary results. Just one example is a patient who is now off his insulin and all other diabetes medications and feels better than he ever has. He even has improved eyesight. Improvement in diabetes-related macular oedema is possible because reducing blood glucose levels can give rise to healing of the vascular damage and reduced leakage from blood vessels at the macula.
Additionally, to help prevent metabolic dysfunction, he recommended intermittent fasting, which causes insulin levels to drop, thereby mobilising fat from stores; resistance training to protect against sarcopenia; adopting healthy sleep patterns; and to “get out into the morning sun to create vitamin D”.
Dr Muecke reported the success of therapeutic carbohydrate reduction in reducing diabetesrelated macular oedema in over 30 of his patients, with some achieving complete recovery of oedema and visual acuity.
“This has never been reported before. For me as a clinician, this is one of the most exciting things I’ve been involved in. This is remission in action,” he told the audience.
He also described positive outcomes from the same approach taken by his patients with retinal vein occlusion and macular oedema who had been receiving regular anti-VEGF injections for at least two years. Over 50% of the 45 patients had pre-diabetes or type 2 diabetes (indicating a significant degree of metabolic dysfunction) and 60% of the remainder had insulin resistance, a key metabolic dysfunction driving type 2 diabetes (fasting blood insulin level over 5.5).
“Almost universally, we find that patients who adopt therapeutic carbohydrate reduction seriously, experience an improvement in their macular oedema.”
He said a series of studies on this work will be published in the near future.
Dr Muecke said awareness of the ability to reverse metabolic dysfunction and put type 2 diabetes into remission is now critical among health practitioners and implored optometrists to encourage patients at risk of, or living with the condition, to discuss the opportunity afforded by low-carb healthyfat diets with their GPs. He also suggested requesting a fasting blood insulin test for patients with retinal vein occlusion.
“As an eye specialist, I never want to see another patient, another Aussie, another fellow human go needlessly blind due to diabetes-related eye disease. We can all help with the ultimate aim of making Australia #type2diabetesfree”.
References
- Available at: stopbang.ca/osa/screening.php [accessed 1 Nov 2023].
- Diabetes Australia, AIHW data shows diabetes costs the health system almost $2.5B per annum, available at: diabetesaustralia.com.au/news/aihw-data-showsdiabetes-costs-the-health-system-almost-2-5b-perannum/#:~:text=“The%20Australian%20health%20 system%20spends,stroke%20which%20costs%20 %24660%20million [accessed 1 Nov 2023].
- eatforhealth.gov.au/guidelines/australian-guidehealthy-eating.
