Feature, Report

2020: a year like no other

Insight takes a look at the innovations, breakthroughs, setbacks, events and stories that shaped the Australian ophthalmic sector in 2020.

2020 has been a tough year for the nation and its businesses, first ravaged by bushfires before being brought to their knees by the ongoing public health pandemic.

But – as it has done through previous downturns and disasters – the eyecare sector has proven resilient as Australians continue to place great importance on their eye health.

While concerns remain about the backlog of undiagnosed and untreated conditions, we have seen a new frontier in ophthalmic treatments emerge, while eye health practitioners have received some of the country’s highest honours.

Insight examines what made headlines this year across business, therapies, technology, policy, leadership, research and Indigenous eye health.

Business

For many optometry and ophthalmology practices and their suppliers, the stress and uncertainty endured through March, April and May will remain one of the defining periods of 2020.

As state and federal governments took unprecedented action to bring the COVID-19 outbreak under control, eye health providers were limited to urgent cases and required to usher in a raft of costly hygiene and infection protocols, the likes of which they have never seen before.

The government announced unprecedented measures in March to bring COVID-19 under control, shutting down elective surgery and limiting eyecare services.

A survey to gauge the pandemic’s impact on the eyecare sector and quantify industry confidence demonstrated that half felt the pandemic had a ‘very negative’ effect on businesses and the industry was split on how long it would take for their businesses to return to normal levels of service.

Despite these concerns, when business resumed in June, practice owners reported record sales, with the size of the rebound surprising many several months on. However, a second wave forced Victoria into lockdown again from August to October, causing more pain.

COVID-19 also delayed the Federal Budget announcement until October, with the government unveiling a fiscal plan aimed at creating jobs and kick-starting investment.

In addition to an immediate asset write-off on the full value of new equipment, one of the most notable items was a 50% wage subsidy for practices that employ and train new optical dispensers.

As Australia emerged from the pandemic, Specsavers unveiled further expansion plans, with five new stores in Seaford and Port Lincoln in South Australia, Warwick in Queensland, Newcastle in New South Wales and Belgrave in Victoria, with more to be announced.

Australia began to reopen in June after the first lockdown, leading to a record surge in eye appointments and product sales.

The Australian Competition and Consumer Commission (ACCC) also put several eyecare businesses under the microscope.

First, it cleared Ellex Medical Lasers’ $100 million sale of its laser and ultrasound business to French technology company Lumibird in June, with Ellex subsequently changing its name to Nova Eye Medical and focusing on glaucoma.

In September, the ACCC ordered Oscar Wylee to pay $3.5 million in penalties for making false or misleading representations about its charitable donations and affiliations. In the same month, the authority approved a merger between global pharmaceutical companies Mylan and Pfizer-owned Upjohn on the condition that they sell two glaucoma treatments (Xalatan and Xalacom) to Aspen to appease competition concerns.

Just as Insight went to print, Australian firm The Optical Company (TOC) announced it had been acquired by ASX-listed allied health group Healthia for $43 million. TOC is a 14-year-old vertically integrated optical group specialising in optometry services, retail and eyewear distribution, which operates 41 stores under multiple names.

Therapies

Aside from COVID-19, another marquee moment of 2020 occurred in August when the Therapeutics Goods Administration (TGA) approved Australia’s first true gene therapy, Luxturna, for a rare form of inherited retinal disease. With many similar therapies in active clinical trials, it’s anticipated that this could open the floodgates for other forms of retinal disease.

The following month Novartis announced TGA approval of Lucentis (ranibizumab) for treating proliferative diabetic retinopathy in adults. It is the first pharmacological therapy in Australia for the vision-threatening complication of diabetes – and the sixth indication for Lucentis.

Earlier in the year, Australian regulators approved another Novartis’ therapy – anti-VEGF treatment Beovu (brolucizumab) – for neovascular age-related macular degeneration (nAMD). However, the company is still pursuing a Pharmaceutical Benefits Scheme (PBS) listing after the Pharmaceutical Benefits Advisory Committee (PBAC) recommended not to list the therapy on several occasions.

In the dry eye segment, Sun Pharma’s Cequa (ciclosporin 900 microgram/ mL) became the first TGA-approved immunosuppressant for the treatment of moderate-to-severe dry eye. And the highly anticipated Xiidra finally reached Australian shores and is being marketed by Novartis.

Technology

The technological advance that created most fanfare was Alcon’s new AcrySof IQ Vivity Extended Vision IOL, which some Australian ophthalmologists have billed as a new class in presbyopia-correcting intraocular lens (IOL) technology due to its ability to negate visual disturbances – the bane of many EDOF and multifocal IOL designs.

In the spectacle lens segment, Hoya introduced its new myopia control lens MiyoSmart, developed on the back of a two-year double-blind randomised clinical trial in Hong Kong that showed wearing defocus spectacle lenses daily significantly slows progression and axial elongation in myopic children aged eight to 13. Children wearing defocus lenses reportedly had 60% less myopia progression compared with those wearing single-vision lenses.

Melbourne-based OCT manufacturer Cylite continued to chase European and a subsequent TGA approval for its Hyperparallel OCT (HP-OCT) system, which snared Engineers Australia’s top award in November.

In Hobart, optometrist Mr Ben Armitage revealed he is working with designers in Melbourne to develop the third prototype of a patented handheld device to test driver vision by the roadside, known as Acuidrive.

Policy

In a major win for glaucoma patients, the Australian Society of Ophthalmologists (ASO) and other stakeholders in May successfully lobbied the Federal Government to support a recommendation for standalone minimally invasive glaucoma surgery (MIGS) under Medicare. As a result, Australia become the first major developed economy to universally approve the procedure in both public and private settings.

This came after a 2017 change in item number regulations threatened funding for all MIGS procedures. The issue was only partially addressed in 2018 when the government approved a new item number but limited its availability to those simultaneously undergoing cataract surgery, prompting the ASO to take further action.

The Federal Government approved standalone MIGS under Medicare in May, after advocacy from the sector.

The optometric sector didn’t have the same luck in its own battle with Medicare. With the pandemic limiting patient movements, Optometry Australia was joined by Specsavers, Luxottica and Diabetes Australia in advocating for inclusion of optometry-specific telehealth items during the pandemic period and when face-to-face care wasn’t accessible.

Despite much optimism – and the fact rebates were created for other health services – it never eventuated. This was viewed as a missed opportunity, with OA stating the Federal Government’s reticence was exacerbating the sector’s recovery.

Meanwhile, the sector continues to eagerly await the final report of the MBS Taskforce Reviews into ophthalmology and optometry items.

The most controversial proposals relate to ophthalmology, which – if approved – could result in a dramatic drop in the fee for intravitreal injections and allow trained optometrists and nurses to perform the procedure.

People and leadership

This year’s most notable accolade went to South Australian eye surgeon and Sight for All co-founder Dr James Muecke who was named Australian of Year for his efforts to reduce rates of preventable blindness both locally and abroad.

South Australian ophthalmologist Dr James Muecke was announced Australian of the Year.

Muecke has also supported lobbying of the South Australian state government to develop Adelaide’s first dedicated public eye hospital. Spearheaded by his colleague Professor Robert Casson, the new outpatient facility would be based in the CBD and replace ophthalmology departments within larger general hospitals in Adelaide.

In June, RANZCO Fellows Dr Harold Spiro and Dr Arthur Briner, both from Queensland, were each awarded the Medal of the Order of Australia (OAM) in the Queen’s Birthday Honours. NSW optometrist Dr William Trinh received an OAM for service to international humanitarian medical programs and optometry, while theatre nurse Ms Alison Plain was recognised for her service to Indonesia through the Sumba Eye Program.

Professor Nitin Verma became the new RANZCO president in October, taking over from Associate Professor Heather Mack, the first female to hold the position in the college’s 50-year history. Verma is a prominent ophthalmologist based in Hobert who co-developed one of the world’s first foldable intraocular lenses (IOL) made from silicon in 1985 and set up the East Timor Eye Program in 2000.

Leadership at the ASO also changed hands; vice-president Associate Professor Ashish Agar stepped into the role of president, while his predecessor Dr Peter Sumich became his deputy.

Elective surgery

In late March, Prime Minister Scott Morrison took the unprecedented step to suspend all non-critical elective surgeries as the health sector braced for a looming public health emergency in response to the COVID-19 pandemic.

Within days, RANZCO published new triage guidelines and warned of the potential ramifications for ophthalmologists that performed unnecessary procedures during the government-imposed suspension.

After a month-long pause, in late April, the college released a new resource to help ophthalmologists navigate the return of elective eye surgery, cautioning that operating lists and through-put would be restricted by social distancing and infective precautions.

The subsequent backlog of patients became a major concern, reaching fever pitch in early July when most state governments unveiled a multimillion-dollar elective surgery blitz to tackle the growing problem.

Public treatment in private hospitals and after-hours surgery lists subsequently emerged as key methods of addressing ballooning waiting lists. However, it was not initially well-received in NSW where medical lobbyists stated that surgeons in private hospitals would be reluctant to help clear the public elective surgery backlog at Medicare rates.

Before the issue could be debated further, the second COVID-19 crisis struck Victoria in July, resulting in a series of announcements that ultimately placed a ban on all Category 3 and non-urgent Category 2 surgeries.

More than two months later, the Victorian Government announced a gradual return to elective surgery with limits on capacity.

Research

The pandemic sparked a multitude of studies investigating ocular manifestations and the risk of transmission to eyecare practitioners.

Aerosol and spatter generation in some ophthalmic procedures had been a concern during the COVID-19 pandemic, but University of Auckland researchers found no visible contamination above the neckline of cataract surgeons performing phacoemulsification.

In separate research led by Australia’s Professor Mark Willcox, a review of evidence indicated the eye is an unlikely site for SARS‐CoV‐2 infection, suggesting coronaviruses are unlikely to bind to ocular surface cells to initiate infection.

Internationally, one small study revealed the potential for asymptomatic carriers who have passed COVID-19 triage to leave traces of viral material in the ophthalmology exam room – even after wiping down chin and forehead rests between patients.

A group of international ophthalmologists developed a video simulation demonstrating that slit lamp breath shields did not provide full protection from respiratory droplets, but spread was minimised significantly when patients wore a mask.

In other research, Australia’s first myopia management survey (conducted in 2016 and results released in 2020) revealed single‐vision distance spectacles are the mainstay of myopia correction in school‐ aged children, despite awareness among practitioners of the potential effectiveness of other interventions.

And it was also revealed that Australian agencies are collaborating with technology firm Big Picture Medical in a $12 million project to develop an AI-assisted platform that can reduce inappropriate patient management and cut the false-positive rate at the primary point-of-care.

Indigenous eye health

In February, a long-term plan to establish the first eye health clinic outside of the Perth metropolitan region came to fruition when Lions Outback Vision commenced work on transforming a former backpacker accommodation into a new eye health clinic in Broome.

New AIHW data showed more Indigenous Australians are accessing eye health services than ever before.

Known as the North West Hub, it will feature at least two resident ophthalmologists available for 24-hour emergency support. Through a hub-and-spoke model, it will also service six towns through outreach services, while providing access to ophthalmology and telehealth clinics, seminar rooms and space for community diabetic health education.

In June, there were fears the cataract surgery backlog could unfairly disadvantage Aboriginal and Torres Strait Islander patients. With public wait times expected to blow out by up to two years, RANZCO and The Fred Hollows Foundation jointly encouraged private hospitals to offer capacity and encouraged ophthalmologists to bulk bill Indigenous patients.

Then last month [November], the Australian Institute of Health and Welfare published its fourth annual report into Indigenous eye health measures showing that more Indigenous Australians are accessing eye health services than ever before, with significant strides reported in cataract surgery rates and the suppression of trachoma.