In the second part of his report into the 51st RANZCO Annual Scientific Conference, Lewis Williams highlights some of the groundbreaking initiatives and research shaping Australian eyecare.
The Council Lecture: An Australian Bionic Eye
Associate Professor Penny Allen, lead researcher on the Bionic Eye Project at CERA who also has associations with the RVEEH and Melbourne’s Austin Hospital, is an experienced vitreoretinal specialist. Her team’s (Bionic Vision Australia [BVA]) main activity is the development of a suprachoroidal (between the sclera and choroid) retinal prosthesis.
The project follows her team’s implantation of the world’s first human bionic eye, a 24-electrode prototype featuring platinum and silicon (but no integrated electronics), in 2012. In 2018 a further four retinitis pigmentosa (RP) patients received a second-generation, fully-implanted 44-channel prosthesis that offered a ‘wider’ field-of-view and a greater dynamic range.
She described the team’s works as being at least a 10-year journey. RP cases are selected because while the photoreceptors have lost their function, functional, residual neuronal elements remain in the retina that are targeted by the prostheses.
The project’s origins can be traced back to Prime Minister Rudd’s Australia 2020 in 2008 when a National Health Strategy/Australian Research Council Research Initiative in bionic vision science and technology was launched. Other bionic eye projects also exist in Australia, including Monash University’s cortical implant, although most are either very early or appear to have been shelved for the time being.
Allen’s original team also included fellow ophthalmologist Dr Mark McCombe, with whom she developed the original surgical technique. The original consortium consisted of the Bionics Institute, CERA, the UNSW, the UMelb, and NICTA following the efforts of Professor Hugh Taylor to form a team with suitable resources to tackle the bionic eye project.
The ‘sharp’ end of their prosthesis, literally, is nanocrystalline diamond electrodes it features. The original UNSW approach proved to be unsuited to human use and was not pursued. Current work involving Professors Robyn Guymer (CERA) and Robert Shepherd (the Director of the Bionics Institute from 2005 to 2017) is taking a two-model approach, suprachoroidal and epiretinal implants. From the outset, Allen and team have also collaborated with Associate Professor Nick Barnes (ANU) researching just how implant-generated visual information should be relayed to patients. The encoding and transmission of visual information to the occipital cortex is still the subject of separate research programmes in several centres around the world.
The suprachoroidal space was attractive to BVA because it is a stable and safe location, provided the eye remains healthy. Some experimental work was done on cats because they are more suited to the task than the traditional rabbit model. Cats fitted with the team’s prosthesis that were delivered with 24/7 retinal stimulation showed no long-term deleterious effects, and the implant was tolerated well. A paper published in PLOS ONE in 2014 presented some early results.
All recent patients reported reliable phosphenes and the implants remained stable and safe over a two-year period. Duration of the surgical procedure to implant the prosthesis has ranged from 204 to 260 minutes.
When the implant patient has not had ‘vision’ for many years, some re-education has been necessary. The patients are able to discriminate light from dark, gross details of their visual environment, such as a shopping centre they are otherwise familiar with, and are able to track or avoid moving people. Once a feature is detected, such as a pylon in a shopping centre, patients will usually move to touch it to confirm what it is. Such behaviour is reliable and reproducible. An Activities of Daily Living (ADL) list is used during assessments, which has now been committed to an app for more reliable and rapid data gathering.
To date, a total of seven patients have been implanted with the 44-channel implant. While there is a significant way to go before retinal implants such as BVA’s will be considered ‘routine’, much of the early research has been successful and the future holds great promise.
RANZCO’s Leadership Development Programme (LDP)
Convened by the RANZCO Leadership Development Committee chair Dr Cathy Green, the session was opened with an address on leadership by RANZCO President Dr Heather Mack.
She defined leadership as leading or commanding a group of people, a country, an organisation, or a profession.
Personal qualities of a good leader were: self-belief, self-awareness, self-management, drive for improvement, and personal integrity.
The aims of a good leader include the empowering of others, demonstrating a good participation style, engendering a feeling of belonging and teamwork, the coaching of subordinates, and the offering of guidance. Effectiveness can depend on the goodwill of all involved.
Mack suggested tangible goals should be written at one- and five-year intervals, and attention should be paid to issues such as work-life balance. Leaders need to promote themselves and inspire followers. Leadership and followership were described as complementary and intertwined. She also noted that great leaders started out as great followers.
Leaders are proactive and encourage positive interdependence through members to facilitate working together. As an example of taking the high ground, Mack gave the medical version as “it’s all about the patient”. Leaders were involved in entities such as the Medical Board of Australia, the Health Complaints Commission, and eyecare teams. After her address, rapid-fire session ensued.
The first speaker was Dr Genevieve Oliver who spoke about encouraging policies and practices that support the health and well-being of RANZCO’s ophthalmologist members. She advised fellows and registrars to talk to their colleagues and not to feel that opening up to someone is a massive personal risk. She claimed that all colleagues have the same exposure, meaning their experiences are familiar to all travelling the same road. Oliver described mental health as a continuum ranging from healthy all the way through to being ill. People pass through a reacting stage followed by an injured phase before finally succumbing and becoming mentally ill.
The very real risk of burnout was itemised as being exhausted emotionally, becoming detached and being cynical, all of which leads to low professional efficiency. She estimated that about half of medical practitioners are affected by burnout and, ironically, many cases of central serous retinopathy (CSR) were stress related. She believes that most practitioners are eager to talk about stress, probably because most are affected by it at some stage of their lives. She gave the physician’s pledge as: “I will attend to my own health, well-being, and abilities.”
She advised those in attendance to manage burnout, anxiety, and avoid imposter syndrome. Another recommendation was to prepare mentally for surgery in the operating theatre. She also suggested that attention be paid to maintaining healthy relationships with those around and to consider the ergonomics of all work environments including the clinic.
From a RANZCO point of view, the college supports those returning to surgery after a break by offering surgical simulators, surgical mentors, suggesting further reading, providing information on where help is available, providing research and advocacy services, as well as the more obvious sources such as congresses, symposia, and CPD sources.
Dr Tanya Karaconji tackled the issues surrounding the transition of ophthalmology trainees to consultants. To study any deficiencies in the Vocational Training Program (VTP), she surveyed current registrars and junior fellows who were fewer than five years out from their fellowship.
In answer to the question on how prepared they were for their respective roles, 33% felt they were somewhat prepared and 38% felt they were prepared adequately. Respondents noted that there was no VTP component that dealt with private practice business aspects, Medicare item numbers, and health fund machinations.
As a response, an all-day Survive & Thrive Workshop was created covering topics such as business, insurance, marketing, billing, practice purchase, staffing, HR management, income and wealth management, asset protection, and business structures. An annual business skills workshop has been proposed, which is intended to be integrated into the VTP as an assessable, but not examinable, inclusion.
Dr Andrea Ang from Perth’s Lions Eye Institute reported on the trialling of a new surgical assessment system in the Western Australian training network. The systems used are referred to as OSATS (objective structured assessment of technical skills) and NOTSS (non-technical skills assessment). She said prime considerations are procedural safety and care of tissue.
OSATS forms are completed and submitted weekly for two months, and usually a total of four to seven forms are then available. A survey based of a modification of the original OSATS form found it to be a valid and easy to use assessment of both professional and technical skills, and users agreed that it was better than the previous assessment system in use before OSATS. Interestingly, registrars felt that weekly submission was too frequent whereas supervisors thought it to be OK. However, senior registrars thought it was a bit like a tick-the-box exercise. A possibility is to require junior registrars to submit forms weekly and more senior staff to submit forms fortnightly. The grading system used is also the subject of clarification by a surgical skills task force. An education process of both registrars and supervisors precedes exposure to the OSATS system.
Royal Melbourne Hospital ophthalmologist Dr Elaine Chong reported on her establishment of a corneal service at RMH from almost nothing. While RMH had an eye department, its corneal service had ceased operating a “long time ago”. The project confronted a lack of equipment, staff, and suitable nurses. RMH also has significant responsibility for Down syndrome cases and keratoconus, and lacked CXL equipment initially.
Surprisingly, RMH is also a referral site for complicated, multidisciplinary surgical cases that can include eye issues. Basic equipment that was needed included anterior segment OCT (AS-OCT), as well as experienced graft and theatre staff. The aim was to include the usual lamellar procedures (DMEK, bbDALK, DSAEK, DALK, etc., as well as PKPs). It was established early that a good training facility was required as well.
Because RMH is located adjacent to the Peter MacCallum Cancer Centre, Chong reported that her new unit also saw a significant number of graft versus host cases. In addition to educating and training ophthalmology registrars, medical doctorates (MDs) were also supervised at RMH as an outpost of the Melbourne Medical School (UMelb).
The session’s final lecture was given by Melbourne ophthalmologist Dr George Kong (RVEEH). His topic was fostering modern clinical audit practices in glaucoma units around Australia. He is the audit lead: glaucoma at the RVEEH.
An audit’s ultimate aim is the improvement of patient care using national and international benchmarks using the best information available about current practice. He reported that audits in specialist areas were often poor. He attributed some of the blame for that to the time-consuming nature of audits, while acknowledging they compete with service delivery.
The RVEEH glaucoma unit has already introduced quarterly audits. The quality and ambition of the projects undertaken, as well as the dedication of those involved, augurs well for ophthalmology’s future in this country. Some success can also be attributed to networking at conferences and the internet, because there is now little excuse for not being aware fully of what peers are engaged in regardless of where they are located.
The Fred Hollows Lecture
Always one of the highlights of each RANZCO Annual Scientific Congress, the 2019 lecture was delivered by ophthalmologist Dr Anasaini Cama from the Fred Hollows Foundation. Hailing from Fiji originally, Cama has spent time in many roles, including at the IAPB, and gained several additional qualifications including a MPH.
Using 2015 global data, she reported that there were at least 36 million blind people, 217 million with at least mild vision impairment (VI), and 253 million with some VI. Given the cultural and other issues at play, it was not surprising to learn that at least 55% of those with vision problems are female. Also unsurprising, 89% of those with impaired vision reside in low or middle-income countries. 2019 data puts those with VI at 2.2 billion, of whom at least 1 billion suffer from avoidable VI.
She described eye health as globally having a lot of inequity and estimated that by 2050 the burden of, and demand for, eyecare will be triple that of today. She stated that the progress made in eyecare over the last 30 years has not kept pace with eyecare needs, meaning that the problem is getting away from those battling to provide eyecare to those who need it. Future challenges include demographic and lifestyle changes already occurring, the difficulty in providing universal health coverage, and trauma and disease prevention, treatment, rehabilitation, and palliative care, especially if those affected are not to suffer financial hardship.
Referring to the Pacific region specifically, there are 21 countries occupying 33% of the earth’s surface but hold just 1% of the world’s population. Despite that data, it has 3x the disease burden of the global average. Complications include strong religious and cultural practices, many communicable diseases, general and health education challenges, and, more recently, climate change. Some Pacific islands are already being affected by rising sea levels. In response, health ministers across the pacific region have already created the Healthy Islands Vision education initiative.
Cama identified the need for strong political leadership, improvement plans with a budget to make them happen, an increase in the current 1:100,000 ophthalmologist to people ratio, and the need for ophthalmic nurses at a ratio better than 1:50,000. Earlier cataract and uncorrected refractive error were the biggest causes of VI, but now DR is an emerging issue highlighting the importance of lifestyle and diet in developing countries. The region is handicapped by the limited availability of information on diabetes and eye health in general, with few trained or knowledgeable in managing DR, in addition to inadequate service provision throughout the region.
A 2009 Fiji health survey revealed that >40% of the population were diabetic and a study by NZ/Australian ophthalmologist Dr Garry Brian found that >60% of those cases were undiagnosed previously. A diabetes-focused eye clinic found that >50% of diabetics had signs of DR, 26% of whom had sight-threatening DR (STDR) and 10% had severe or advanced STDR. At a second-year review of those cases, some 30-50% of them had achieved glycaemic control and with the aid of a laser, most progression of DR had been halted.
Special courses have been held for medical practitioners (12 months) and nurses (6 months) that are focused on DR care and treatment. Ancillary health workers are now joining the training programme to broaden the front combating diabetes and its ocular effects.
Trachoma has also not yet been conquered, so Australia is truly a Pacific nation on that score.
The RANZCO Plenary
This session launched RANZCO’s Reconciliation Action Plan (RAP) and fittingly had Australia’s first indigenous ophthalmologist Dr Kris Rallah Baker teaming up with experienced public health ophthalmologist Dr Ashish Agar as Masters of Ceremony.
After introducing the session, the audience was addressed by local indigenous elder Uncle Allen Madden as a Welcome to Country. He has attended other RANZCO events and is probably most famous for his line; “Where there is a will, there are relatives”.
The keynote speaker was none other than Australia’s famous indigenous athlete and later politician, Ms Nova Peris OAM who delivered a moving and entertaining story of her parents (her mother was a stolen generation woman), herself, sport politics, and her own family. As an Australian Olympian for 13 years she won gold at the 1996 Olympic Games as a member of the women’s hockey team to become the first indigenous Australian, male or female, to win Olympic gold. Later she converted to sprinting and won two gold medals at the 1998 Commonwealth Games. She was also an Australian senator (representing the NT) from 2013 to 2016.
Interestingly, Peris’ athletic prowess was noted early and she was regarded as a future medal prospect at the age of nine. She finished all school years including year 12. She reported experiencing little racial discrimination in the NT, helped by 40% of the territory’s population being Aboriginal. Her original career ambition was to be a PE teacher, but her sporting success meant those plans were deferred.
For a while she was also a NT government member before being offered a senate position by Prime Minister Ms Julia Gillard. Her story in her own words was well received.
Ms Peris was followed by the Fred Hollows Foundation’s Mr Shaun Tatipata, part of RANZCO’s RAP which has been formulated in consultation with Aboriginal people on the basis that self-determination is the appropriate basis of equal health outcomes. The RAP commenced in November 2019 and will continue until November 2021.
The overall plan involves not just eyes in its remit. Although the gap between European and Aboriginal health outcomes has still not been closed, according to Tatipata it has narrowed by 50%. The RAP is based on trust and respect. The in-reach (as opposed to the outreach component) seeks cultural safety and appropriate health outcomes that are free from judgement and discrimination.
Symposium: International Development
International development (ID) has retained an important place in RANZCO’s activities, and many training and eye camp endeavours have been conducted over the years.
Long-term advocate and ‘doer’ Associate Professor Nitin Verma spoke about early team visitation to outposts such as East Timor/Timor-Leste. Those efforts quickly determined that there existed a large need for eye services in many parts of the Asia-Pacific theatre. He was central to the East Timor Eye Programme (ETEP) that used President Xana Gusmão in its fund-raising efforts.
Central to the success of such a programme, other than having the government on side, was having the church on side, as 98% of East Timorese are Catholic. Surprisingly, Verma advised against trying to be a hero with mercy cases because it usually does not work and can adversely affect a programme’s reputation. It should not be conceptualised as a ‘mission’ either. Rather, a 365 day per year on-the-ground approach is required. Simply, intermittent programmes do not work, and local practitioners and staff are required to work from a national headquarters if necessary.
A Master of Medicine level of qualification was recommended, but Verma admitted that suitable candidates were usually difficult to find. A confounding factor is that in some cultures or situations there is very little distinction between a GP and a specialist. This results in practitioners having diminished motivation or interest in bettering their qualifications or gaining specialist status.
He believes that some sub-specialty qualifications need to be fast-tracked because time is important. Succession planning is also required relatively early in any programme. Support staff include nurses, optometrists, opticians, ocular prosthetists, local eye co-ordinators, and technicians, including instrument service people, because machines need to be kept functioning. He advised teams to standardise on the brands and models of instruments so that all team members become familiar with all aspects of the hardware. Any donated, used equipment must be practical, have a good and useful life remaining, and must have spare parts available. To quote Verma: “programmes are not equipment ‘dumps’”. He says the ETEP will be handed over to locals in 2021.
Queensland ophthalmologist and long-time humanitarian Dr Bill Glasson posed the question: “why be involved in international development?”
Although he started at the indigenous end of humanitarian eyecare, he eventually became involved at all levels and locations. He described his main motivation as simply the magnitude of the unmet need in most theatres of operation. He found, and continues to find, the training roles he has filled to be very satisfying, often in a two-way sense, meaning both parties have knowledge to share. He also noted that Australian nurses have been involved in the doing and training of their profession as part of national and international endeavours. He also confirmed that local politicians need to be onside with the programmes as well.
In his experience, the collegiality among those involved is very important and helpful to achieving the aims of each project. He described the pathology encountered, particularly the ocular pathology, as being “extreme”. He identified personal improvement as another benefit of participating in outreach programmes and finds that giving back can lead to a lifetime of joy.
Dr Anthony Hall, a Zimbabwean native and resident before coming to Australia, addressed the question of where RANZCO, which is not a funding agency, fits into the ID plan. He sees RANZCO’s role as driving the improvement of eye health care through education and standards, as well as being a resource of information for fellows. Other organisations with roles to play include IAPB, Vision 2020, CBM, WHO and other, often local, endeavours.
He described ID as having its own language, literature, guidelines, and aims, mostly based on extensive and long-term experience. He also noted the renewed pursuit and importance of child-protection issues, possibly in reference to a scandal involving a UN entity some time ago.
RANZCO has an ID committee and accreditation system, as well as an Asia-Pacific International Development (RAPID) advocacy unit. RANZCO also interacts with the QE II Diamond Jubilee Trust, the Commonwealth Eye Health Consortium, PNG Health Systems Capacity Development, and a PNG train-the-trainer programme. In 2020, PNG’s biggest problem is the number of unoperated cataracts. That has led to the formulation of a plan to perform 30,000 cataract surgeries per year by 2030.
In a brief presentation, Dr John Kennedy, Chairman of the new ANZ Eye Foundation (ANZEF) detailed his organisation, which has subsumed the 2002 – late 2017 Eye Surgeons Foundation (ESF).
ESF fell victim to a combination of declining income and rising operating costs. The new entity is a committee of RANZCO and directly answerable to the organisation. It already has $1 million in donations received mostly from RANZCO fellows, as well as 15% of that total from the public.
Kennedy described ANZEF as a lean, economic organisation, with RANZCO’s CEO and four fellows (Drs John Kennedy, Stephen Best, Clare Fraser, and Eline Whist) forming the ANZEF committee.
Its foci include research, indigenous eye health, rural eye health in Australia, eye health in the Asia-Pacific, and blindness prevention in the ANZ and Asia-Pacific regions. To assist those goals, Kennedy said ANZEF hopes to “engage all fellows”.
The Dame Ida Mann Memorial Lecture:
A regular feature of the Annual Scientific Congress is the Dame Ida Mann (1893-1983) Lecture, given in 2019 by Professor John Marshall, a British medical scientist and world authority on lasers, particularly their use in medicine and the eye.
His presentation was titled Light and the Eye: Chronic Insult or Therapeutic Dream. He commenced by detailing the history of illumination, which consisted of fire until the mid-1800s when electric lighting emerged. Fluorescent lighting followed in the 1940s, up to the current use of LEDs. He attributed the development of the first ophthalmoscope to the English polymath Charles Babbage circa 1847, although at the time it was described by Professor Thomas Wharton Jones as having little value.
It was not until Germany’s Herman von Helmholtz’s independent invention of said ophthalmoscope in 1851 that use of such an instrument became popular and routine. Helmholtz’s demonstration of his instrument to English surgeon, histologist, and anatomist Sir William Bowman (of Bowman’s layer fame) was central to the wider use of ophthalmoscopy.
The use of operating microscopes, slit-lamps, and lasers on or near eyes, commencing in the early to mid-20th century, brought the routine use of high-intensity light sources. This brought concerns of ocular damage, especially retinal damage, to the attention of researchers and users. Later still, the deliberate use of damaging electromagnetic radiation became common, such as in the treatment of tumours, vascular cautery, laser refractive surgery, and FLACS. Very recent developments include Ellex’s 2RT AMD treatment.
Marshall’s involvement with lasers commenced in the mid-1960s while he was a young scientist. Concerns about the military use of lasers, over-exposure to high light levels, eye radiation protection, and the application of excimer lasers to all kinds of surgery have become his forte. Radiation protection and the applications of excimer lasers to ocular surgery are probably the areas for which he is best known. The breadth of the topics and the relevant side stories covered in his lecture added to the audience’s interest in his presentation.
The next RANZCO Annual Scientific Conference, its 52nd, is scheduled to be held in Brisbane’s Convention & Exhibition Centre from 9-13 October 2020.