Growing up in south-western Sydney, an area known for its rich cultural diversity, has provided Helene Ly from the Centre for Eye Health (CFEH) with an interesting insight into optimising eye care for culturally and linguistically diverse (CALD) communities. Here, she provides mivision with a personal perspective, supported by relevant case studies.
I am immensely proud of my community, particularly of the friendships formed between people of vastly different cultural backgrounds, and the underlying acceptance of this diversity. I could not imagine living anywhere else and am very grateful that I can help my community through my work at the Centre for Eye Health Parramatta. Being able to provide affordable and accessible eye care is immensely rewarding personally, and makes a tangible difference to many in this community who may otherwise risk falling through the cracks of our health system.
I was born in Fairfield Hospital to Vietnamese refugee parents who arrived in Australia in the 1980s as a result of the Vietnam War. Fairfield is self-dubbed a ‘City of New Settlement’, with the suburb housing 73% of the incoming refugee population.1 The neighbours to my left are Iraqi, and we share our grape leaves with them so they can make dolma. The neighbours to my right are Italian, and they share their homegrown tomatoes with us because there is always “way too much”.
Living in this environment has given me valuable experiences that I now realise may not be ingrained in everyone. In this article, I wanted to present some patient case studies to highlight how optometrists can equip themselves to better service patients of CALD backgrounds, in particular vulnerable refugee and asylum seeker populations.
CASE 1 – MINH DANG
Minh Dang,* a 68-year-old man, was referred to me by another Vietnamese optometrist in 2024. He was originally diagnosed with angle recession glaucoma in the right eye following ocular trauma in 2017, but was unfortunately lost to follow-up from his ophthalmologist, and self-ceased the eye drops in 2018.
He was unsure why he needed to continue seeing an ophthalmologist and use eye drops, as his traumatic retinal detachment had been treated with retinal laser. Mr Dang’s clinical information can be found in Table 1 and Figure 1.
Figure 1: Mr Dang’s imaging results show angle recession in the right eye (A), and normal anterior angle anatomy in the left (B). The right optic nerve (C) shows thinning of the superotemporal and inferotemporal rims. The inferior structural loss is concordant with a superior arcuate defect in this eye (D). The left optic nerve (E) is obliquely inserted with no notable glaucomatous damage, and visual fields are unremarkable (F). Cirrus optical coherence tomography retinal nerve fibre layer analysis confirms structural loss superotemporally and inferotemporally in the right eye (G) while the left eye is unremarkable (H).
Table 1. Clinical findings for Minh Dang, a 68-year-old male.
My fluency in Vietnamese has improved significantly since starting work as an optometrist in western Sydney. I am also fortunate enough to have access to an abundance of imaging to help with visual explanation, and this can help to overcome most linguistic shortcomings I may have. To aid communication, I also frequently use the invaluable patient handouts from Vision2020, available in many different languages at: visioninitiative.org.au/health-professionals/about-eye-health.
In Vietnamese, I spoke with Mr Dang about the underlying cause of his glaucoma, and stressed the importance of reducing his intraocular pressure. My ability to speak Vietnamese was pivotal in this consultation, helping him to comprehend why ongoing treatment and care is necessary. In medical settings, information given to the patient can often be overwhelming and having this information presented simply in their preferred language can make a world of difference.
With over 300 languages spoken in Australia, this level of communication during a consultation will typically involve the use of translation services. The responsibility for booking an interpreter lies with the health care provider and can be done in two ways: via the Translating and Interpreting Service (TIS National) and in NSW through the NSW Health Care Interpreting Services (HCIS). The TIS is for private practitioners whereas the HCIS is for consultations within the public health system. Both services are available via phone or in person.2 In certain local government areas (LGAs), the interpreter service is free to use for health care practitioners. Healthify He Puna Waiora is a similar service in New Zealand.
Translation encourages patient autonomy and empowerment, and I recommend that every optometrist explores and uses these resources as appropriate.
Upon understanding his eye conditions better, Mr Dang was very accepting of restarting his glaucoma treatment drops, and happy to be referred to ophthalmology via the public hospital system, where provision of translation services is a requirement.2
CASE 2 – JOSEPH AYAD
Joseph Ayad,* a 44-year-old male, was referred to me by my colleague, Hana Melligi, an optometrist who works at the NSW Refugee Clinic through her role with the Brien Holden Vision Foundation. I am grateful to Hana for her mentorship, for always being open to taking on any questions or concerns I have in this niche of eye care, and for her collaboration on this article.
She referred Mr Ayad for further assessment of haemorrhages at his macula, in the context of diabetes. His relevant ocular findings and scans are in Table 2 and Figure 2.
Figure 2: Mr Ayad’s widefield images (A,B) show blot, dot haemorrhages in both eyes, and exudates at the left posterior pole. These findings are consistent with moderate non-proliferative diabetic retinopathy. Optical coherence tomography (OCT) images indicate no macular oedema in the right eye (C), and non-centre-involved macular oedema in the left (E – central macula, G – superior macula). OCT angiography of the superficial retinal layers shows the presence of microaneurysms in the right (D) and left (F) eyes. Incidental findings include mild arterial attenuation in both eyes.
Table 2. Clinical findings for Joseph Ayad, a 44-year-old male.
Before discussing Mr Ayad further, I wanted to clarify the difference between the terms; ‘refugee’ and ‘asylum seeker’. A refugee is a “person outside their country of nationality, unable or unwilling to return owing to fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion”.3 Asylum seekers are seeking protection as a refugee but have not yet had their claims determined. As an asylum seeker, Mr Ayad did not have access to Medicare and his bridging visa did not allow him to work. Pro bono optometry services (in our case via Brien Holden Foundation and CFEH) exist to ensure patient’s like Mr Ayad don’t fall through the gaps.
Many asylum seekers and refugees have experienced trauma and hardship, and this may manifest in many ways. Mr Ayad is only 44 years of age, but already suffers from heart disease, hypertension, and type 2 diabetes (with associated foot neuropathy).
When performing eye tests on vulnerable populations, it is important to acknowledge the potential adverse health outcomes that may be associated with previous trauma. This may include, but is not limited to malnutrition, chronic pain, poorly managed chronic systemic disease, and psychological disorders such as anxiety, depression, and post-traumatic stress disorder. We should, as we do with every patient who sits in our chair, approach these patients with openness, empathy, and a holistic view of care.
Mr Ayad had complaints of tired and constantly watery eyes and examination revealed moderate non-proliferative diabetic retinopathy (NPDR) in both eyes. There was no macular oedema in the right eye. There was non-centre involving macular oedema in the left, however this eye retained excellent visual acuity.
I explained to Mr Ayad the need to closely monitor his non-centre involving macular oedema. With remote ophthalmological oversight, it was agreed to see him again in 12 weeks, with prompt referral to an ophthalmologist if there was worsening of vision or development of centreinvolving diabetic macular oedema.4 I explained that I would send his results to the Refugee Clinic nurse who would then update all the members in his health care practitioner network (including his GP and endocrinologist) within two weeks. He was happy with our plan and agreed to see me again in three months. In the meantime, he was going to manage his dry eye symptoms and self-monitor with an Amsler grid, but was told to return to see me immediately if there were any changes. In this instance, given the limitations of equipment in a screening clinic, CFEH was able to provide more in-depth imaging with ophthalmological oversight.
SUMMARY
Optometric testing of CALD communities involves culturally responsive practice.5 We need to be self-aware that our own biases and values may be different to others and try to navigate the best care pathway for our patients through open and respectful communication. Both these cases benefited from a patientcentred approach, encouraging understanding of their eye conditions, and promoting a degree of autonomy within their health care.
Culturally responsive practice includes simple acts, like displaying patient resources of different languages in your clinic, to promote safety and inclusion. Seeking out and collaborating with local social services and health agencies can avail you of your local demographics, and help to determine who requires your care the most.5 We should be aware and make available to our CALD patients the abundance of resources available in other languages from support organisations such as Macular Disease Foundation Australia and Glaucoma Australia. (See page 38 for more suggestions.)
Spending some time to identify referral pathways or available resources for patients without access to Medicare can help to break down some of these barriers to health care for this group. Having an awareness of cultural barriers, keeping communication open and respectful, and being flexible and adaptable can make a world of difference to a CALD patient who is trying to navigate a sometimes-overwhelming health care system.
*Patient names changed for anonymity.
Helene Ly B Optom/B Vision Sci (Honours Class I) is a staff optometrist at the Centre for Eye Health.
Ms Ly received her Bachelor of Optometry and Vision Science from the University of New South Wales, receiving the Specsavers Prize for Excellence in Patient Management and the BOC Ophthalmic Instruments Prize. She has worked in corporate optometric practices and joined CFEH in 2022. She is interested in giving affordable and accessible eye care to culturally and linguistically diverse backgrounds, especially in western Sydney.
References
- Fairfield City Council. A city of new settlement (webpage, 2024) available at: fairfieldcity.nsw.gov.au/Business/Town- Centres/Fairfield-City-Centre/A-City-of-New-Settlement [accessed July 2024].
- Medical Council of New South Wales. When should I include an interpreter in a consult? (webpage, 13 March 2022). Available at: mcnsw.org.au/when-should-i-includeinterpreter- consult [accessed July 2024].
- Robinson N. Convention relating to the status of refugees. Institute of Jewish Affairs, 1952.
- Yuen YS, Gilhotra JS, Broadhead G K, et al. (2023). Diabetic macular oedema guidelines: An Australian perspective. Journal of Ophthalmology, 2023, 6329819. doi: 10.1155/2023/6329819.
- Optometry Australia, Truong D, Cultural responsiveness framework for optometrists. 2021. Available at: optometry. org.au/wp-content/uploads/OA-CALD-Framework_ designed-v5.pdf [accessed July 2024].
