Optometrists across Australia and New Zealand mark their calendars each year for the Specsavers Clinical Conference, considered one of the cornerstones of professional development in Australian primary eyecare.
Specsavers Clinical Conference (SCC), now in its 12th year, continued with the hybrid model of previous years and welcomed almost 1,000 delegates, including 300 in-person at Hotel Sofitel Sydney Darling Harbour and 700 online.
The conference featured a prominent speaker line-up, with the experts imparting knowledge across the full scope of optometric practice from disease diagnosis, patient communication, rapport, and collaborative care.
SCC commenced with newly titled Specsavers ANZ clinical services director Dr Ben Ashby welcoming delegates and commemorating notable milestones across the business.
He celebrated highlights in Specsavers’ five-year plan to bolster its accessible and affordable eyecare model. He said that decreasing rates of avoidable blindness, increasing detection rates, and improving eyecare accessibility for the 10 million Australians and New Zealanders currently not accessing eyecare constituted part of the company’s long-term goals.
“We set ourselves the ambitious goal to get to a 95% detection rate of avoidable blindness. And I’m very proud to congratulate all of our optometrists at this three-and-a-half-year mark of our five-year journey to now be at 90% detection for these conditions,” he said.
Ashby said that among the reasons of a larger number of referrals to specialist services, is an increase in patients at Specsavers stores.
“We have now provided care for 5.2 million people over the last 12 months with an additional one million people now accessing eyecare,” he said.
Around 500,000 of them are now in vision correction, living better lives with better sight and 70,000 have been referred to ophthalmologists for treatments they wouldn’t have otherwise had.
Key partnerships were also acknowledged, including KeepSight which Specsavers has supported since its 2018 inception. The Diabetes Australia-coordinated program is a national eye screening initiative for Australians living with diabetes.
“Specsavers optometrists have now registered over 700,000 visits of their patients with diabetes. The reminders being sent out by KeepSight are increasing the return-rate of people with diabetes by 20%,” Ashby said.
“What that means is that over the last year, where our optometrists have found 20,000 cases of advanced diabetic retinopathy that needed treatment by ophthalmologists, 4,000 of those cases would have been missed if it wasn’t for the KeepSight program.”
Finally, Ashby discussed opportunities for Specsavers to elevate its accessible eyecare model. He said that expanding access to eyecare for patients in regional and remote locations is on the agenda for next year, which involves solving the maldistribution of optometrists through technology advancements.
“Remote care is for those 100 stores across Australia and New Zealand that can’t get enough optometry cover to service their local communities,” he said.
“We think this is a massive opportunity to improve access to eyecare in places that we can’t currently get optometrists. We’ve been piloting the model for a year already and next year we’re going to be taking it to an even more remote location to really put it through its rigours.”
Education – the first line of myopia treatment
Dr Rushmia Karim, ophthalmologist at the Vision Eye Institute in Sydney, kickstarted the conference by contrasting the evidence available on myopia to its real-world realities. She explored the genetic and environmental components of the disease and the intersect between environmental and lifestyle factors that result in its progression.
Karim began with data that demonstrated the benefits of outdoor exposure on slowing progression, and the challenges associated with communicating this with parents. These conversations can be more arduous relative to the simpler process of prescribing glasses, but she encouraged optometrists to discuss outdoor light exposure.
“Going outside costs nothing. Yet it’s the most difficult conversation to have with parents,” Karim said. “As clinicians, it’s not just about bottom dollar, it’s about trying to provide holistic care, and changing this lifestyle that we’ve created as a society.”
Karim recommends Hoya MiYOSMART myopia management lenses as a first line treatment for her patient cohort from ages eight to 12. She cites the prescription of Hoya MiYOSMART lenses as a lateral transfer for the child if they are already wearing glasses. Good tolerability, no associated risks, as well as a proven ability to slow progression, are among its most attractive features.
“Generally, with Hoya MiYOSMART, a third of patients can have a reduction in their in myopia over two years,” Karim said.
For the second line of treatment for myopia management, Karim recommends atropine with consideration of dose response. She advises beginning with EIKANCE 0.01%, to provide a lower dose and determine tolerance, and then progressing to 0.025% or 0.05% in order to tailor the treatment based on myopia progression and dose tolerance.
CooperVision’s MiSIGHT lenses were also as a reasonable alternative to spectacle lens interventions, according to Karim. While the risk of use is relatively low, she recommends an emphasis on appropriate handling and hygiene when prescribing to children.
“When you start prescribing a contact lens to a child, you really have to counsel them properly. No foreign body in the eye is risk-free.”
Ortho-keratology (ortho-k) generally receive good reception in rural communities due to the social stigma of wearing glasses among children, which is essentially non-existent in metropolitan communities, Karim says. However, again she noted the importance of communication regarding the potential risk of keratitis infections posed by ortho-k.
“It’s really important for you to discuss adverse reactions with parents. Not every ortho-k patient is going to have an infection. But an infection can be catastrophic,” Karim stated.
Moving on to basics in the clinic and diagnosing myopia, Karim said there was a prevalence of under correction, and when patients are referred to her, they tend to be more myopic than prescribed.
However, above all, education is key in myopia management.
“We really need to set expectations early in children and parents. It’s genetics plus lifestyle and we really have to hone in on the lifestyle part.”
Reinforcing optometric-ophthalmic relationships
Dr Shenton Chew, a glaucoma surgeon at Auckland Eye, discussed how to optimise the glaucoma collaborative care model between optometrists and ophthalmologists.
With glaucoma being the leading cause of preventable blindness, there is a substantial burden for the eye health sector to grapple with – and therefore a role for optometry to play. Chew emphasised the cumulative value each profession provides in glaucoma management and treatment.
“Collaborative care is there to safeguard both the patient and optometrists,” he said.
He defined collaborative care as the “delegation to optometrists some part of the regular monitoring of patients in stable glaucoma, or in glaucoma that is likely to develop that requires a specific plan created by the ophthalmologist, and as agreed to by both the patient and the clinicians”.
Chew outlined different categories of candidates for collaborative care as per RANZCO’s glaucoma referral pathway.
The first cohort constitutes patients suspicious for glaucoma, either due to optic disc appearance and/or OCT scanning, or repeatable visual field loss in a glaucomatous pattern. Identification of glaucoma risk factors can help stratify these patients further to help workout the best timeframe for follow-up.
One of these identifiers are disc haemorrhages, which can be easy to overlook. Although they can be associated with other conditions such as vitreous traction, posterior vascular disease, and diabetes, when they present in glaucoma, it represents a progressive issue.
The next cohort in the collaborative care model are those with early-to-moderate glaucoma.
Chew recommended striking a balance between prevention of visual disability and minimisation of treatment burden in this cohort of patients. He said shifting the lens towards treatment minimisation will circumvent compliance and convenience issues.
“We certainly don’t want these patients to be on multiple classes of eye drops, just to get a lower pressure number to achieve the target IOP that was set, when the target might be a thing that needs to be shifted,” he said.
“Severe side effects aside, there’s going to be issues with compliance and convenience, and this is why there’s been a paradigm shift in the ophthalmology world towards laser as first line treatment in the form of selective laser trabeculoplasty (SLT). As a first line treatment, there was less disease progression and better intraocular pressure control.”
Further to this, the landmark Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial in the UK – that ultimately recommended SLT as a first-line glaucoma intervention – published six-year results in September 2022 further demonstrating the clinical effectiveness of the treatment.
Chew himself cites SLT as a superior alternative to eye drops. However, fear among patients remains a barrier to uptake. Thus, it is necessary for optometrists to communicate it as a simple, office-based procedure that doesn’t hurt.
“Compliance to the drops remains a big issue. Shockingly, one Australian study indicated that 50% of eye drop prescriptions remain unfilled by patients,” he said.
Chew said communication can overcome these compliance issues, using an analogy to hammer home the message.
“There are barriers: the therapy can have significant side effects, the disease is asymptomatic, so they get no positive reinforcement using the drops. But we can modify patient factors to improve compliance, such as improving their understanding,” he said.
“I think they really get it when you explain to them that your eyes are the camera, your brain is like the TV screen, and glaucoma is the damaged HD cable that connects the two – you can’t switch it out at the local hardware store.”
If lack of compliance can be attributed to memory issues, optometrists can recommend setting alarms on patients’ mobile phones or getting family members involved if it’s a dementia issue.
“Instead of asking, ‘do you miss your drops?’, I might trick them a little and ask; ‘on a seven-day stretch, would you have missed your drops once or twice a day?’”
The final cohort of patients encompass advanced to acute glaucoma. Chew said the most significant learning point for optometrists is when to designate patients to this category based on symptoms.
For example, a patient who presents with an asymptomatic, but very high IOP reading does not need an acute assessment and can follow the routine referral pathway. The optometrist might choose to initiate eyedrop treatment as an interim measure and re-take the patient’s IOP in a week to ensure that they can safely wait for their ophthalmic assessment.
Contrarily, if a patient presents with symptoms and with a relatively high IOP, this needs to be seen acutely after discussion with the local on-call ophthalmology service.
Diet modification is the new medicine
“As an eye specialist, I never want to see another patient, another Aussie, another fellow human go needlessly blind due to their type 2 diabetes.”
Adelaide-based ophthalmologist and 2020 Australian of the Year, Dr James Muecke, used the stage to drive awareness of the intersect between poor diet and vision loss.
Muecke is passionate about “de-medicating” patients, particularly those with type 2 diabetes, and reversing the vision loss associated with the disease through dietary adjustments.
For context, Muecke used an anecdote of one his patients, Mr Neil Hansell, an everyday Aussie who constructs light machinery for a living and has a wife and four kids. At the age of 50, Hansell woke up one morning blind in both eyes, with the realisation that he’d spend the rest of his life in darkness as the result of his type 2 diabetes.
Hansell lost his driving license, his independence and the ability to teach the javelin – a longstanding passion of his.
“The thing that upsets him more than anything is that he can no longer see the beautiful smiles on the faces of his wife and grandkids,” Muecke said.
Muecke said the consequences of the disease are very much avoidable. However, poor compliance with retinal screening protocols is a key driver of vision loss.
“The problem is, of the roughly two million people in Australia and New Zealand with diabetes, well over half are not having their regular all-important sight-saving eye checks,” he said.
He also pointed to a shift in global dietary advice after 1980, moving from a low carb healthy fat dietary recommendation to one which is high in carbs and infused with industrially produced seed oils.
Rather than seeing a decline in chronic disease, there has been an upward trend of heart attacks since the implementation of these recommendations, and a four-fold increase in type 2 diabetes, with the most profound effects in some minority communities.
“In our Indigenous population in Australia, we’ve seen more than an 80-fold increase in type 2 diabetes over the last half century,” Muecke said.
Despite the steady increase in numbers, type 2 diabetes can be put into remission, a little-known fact amongst doctors and patients alike.
“There are over 100 controlled clinical trials that show an improvement in metabolic health through avoiding added sugars, refined carbs, seed oils and ultra-processed substances. One of these studies reveals over 50% of participants are still in remission after a five-year period,” he said.
“I’ve found a reduction in diabetic macular oedema in over 30 of my patients with type 2 diabetes who’ve embarked on therapeutic carbohydrate reduction.”
Muecke also recommended optometrists ask the GP to request a fasting blood insulin level if they see a patient with retinal vein occlusion. It’s a strong indicator of metabolic dysfunction, and if needed, these patients can subsequently reduce their carbohydrate intake.
“I looked at 45 of my patients who had retinal vein occlusion with macular edoema and who were receiving regular injections of anti-VEGF for at least two years. Over 50% of those patients had pre-diabetes or type 2 diabetes. Of the remaining patients, 60% had insulin resistance with a fasting insulin level of over 5.5mmol/L,” he said.
The bedrock of good clinical practice
Mr Nick Gidas, head of clinical performance at Specsavers, journeyed beyond clinical acumen and into the soft skill of patient communication. He described it as the gateway to making a difference in patients’ lives.
“Communication, like any skill, unless we invest time to develop it, we won’t be able to continually improve our patient outcomes or the experiences we provide our patients,” Gidas said.
He quoted American engineer and science communicator Bill Nye’s philosophy: “’Everyone you will ever meet knows something that you don’t’.
“That’s the mindset you need to have, going into every consultation. What can I find out about you as a primary care practitioner that I can help you with? And what is within our control?”
Gidas emphasised the importance of asking open ended questions and following along closely to formulate tailored treatment options for patients’ lifestyles.
He says that optometrists must listen with the intent to understand what is most important for the patient, if they want to achieve the best possible outcome.
He supports this with a quote from Stephen Covey: “Most people do not listen with the intent to understand; they listen with the intent to reply.”
Gidas added: “What does a day in the life of your eyes look like? So, we’re going to prescribe a solution that hopefully fits their lifestyle puzzle.”
He continued by stating that effective communication will prevent patients leaving the consultation feeling overwhelmed and confused. This entails eliminating jargon from conversations in patient interactions.
“If we’re asking all these fantastic questions to understand how we can best help our patient, we have to be mindful of not using too many words that are familiar to us like ‘distance reading’, because our patients may not relate to them,” Gidas said.
To elevate the personalisation of treatment, he recommended relating the objective back to the patient. That is, what do they want out of this and how does this impact their day-to-day?
He cited the redundancy in relaying potential options to patients, without giving them supportive education and guidance on what best suits their lifestyle requirements.
“We need to be empowering our patients and helping them make informed choices. If we leave them with just the options only and transfer that entire responsibility without some sort of supportive education, then we’re not actually prescribing a solution,” he stated.
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