Dr TIM HENDERSON talks with Insight about the realities of providing tertiary eyecare in the vast Northern Territory via the outreach program which IRIS helps support, the necessity of portable equipment, and challenges securing staffing and funding.
“I grew up in central Africa, so it feels more like home to me than any urban setting ever would,” a voice echoes down the line from Alice Springs.
It’s Dr Tim Henderson, director of ophthalmology at Alice Springs Hospital who also visits dozens of remote communities each year with support from the Indigenous and Remote Eye Health Service (IRIS), which delivers eyecare and eye surgery directly to communities in remote and rural Australia to help address preventable vision loss.
The regional eye service, using equipment secured and placed through the IRIS Taskforce, undertakes regular outreach visits to Indigenous and remote communities to provide access to world-class eye health services. The service, funded through a grant from the Australian Government and coordinated by Vanguard Health, ensures patients receive eyecare and eye surgery closer to home, in their community, and in a timely way. This reduces the impact on the local community and greatly improves the overall patient experience.
Since July 2021, IRIS has supported 199 cataract surgeries; 81 have been completed this year.
“If you were to include the last program where 522 cataract surgeries were performed, the total number would be 721 since February 2020, to date,” Henderson says.
After originally intending to stay for three years, he has now been living in Alice Springs for 22 – 11 of those involved with the IRIS program.
“I trained in the UK, I did my subspecialty training in Adelaide, in cornea and anterior segment. I had brilliant general ophthalmology surgical skills training as well, which is specifically what you need here,” Henderson says.
“And I worked in the UK in the public hospital service, so it didn’t faze me taking on a salaried position, which many Australian-trained ophthalmologists wouldn’t normally consider for a fulltime role.”
He was invited to join the IRIS Taskforce in 2011. In those early days, it was about talking to people on the ground, finding ways to channel the Commonwealth funding to the areas that most needed it, initially focusing on equipment to set the foundations for the service.
“The funding allowed us to ensure all the remote communities got the same basic equipment to make it much easier to provide outreach services. It resulted in 32 different communities getting the basics of a slit lamp table base and two stools.”
Commonwealth funding allowed IRIS to purchase and place 50 slit lamp tables; 32 were located in the NT and the remaining were placed in other areas of need.
For Henderson, having the same platform setup everywhere has meant he only needs to transport the more expensive part of the slit lamp, the optical and illumination system. He can perform laser treatment in remote communities and rely on the stability of the platform for safe portable laser treatment in each location.
“The standard base set-up also allows the visiting optometry services to use the same base set-up and recent extra funding through the Brien Holden Vision Institute has upgraded the slit lamp tops which will continue to work with the IRIS Taskforce supplied tables, hopefully for another 15 years,” he says.
Henderson says spending funding on portable equipment has been incredibly cost-effective. It has allowed the service to achieve the aim of establishing a reliable setup to perform eye specialist outreach effectively.
“A long time ago, I got asked by somebody involved in outreach, ‘Why can’t you just take a small plane and take less equipment?’. To which I responded, ‘You want me to half do my job?’,” Henderson says.
Having portable equipment negates the need for many patients to travel. Henderson isn’t exaggerating when he says patients in remote areas often require a week away from home to travel to and from Alice Springs for a hospital appointment.
“We are quite portable, but we’re also dependent on some high-tech equipment and if you can get small enough portable versions of it, there’s a lot we can do out there,” he says.
“Until people understand logistics, they don’t understand why outreach is such a cost-effective way of providing care. The reality is that most of these patients won’t otherwise get care because there’s so many other competing demands on their time.”
He continues: “Intraocular surgery requires meticulous care and a sterile hospital environment but providing this in central Australia saves hundreds of patients from having to travel interstate or going without the care they deserve.”
When he first arrived in Alice Springs, Henderson recalls feeling privileged to have the opportunity to introduce up-to-date cataract surgery by phacoemulsification.
He says the technical difficulty of some of the surgery has repeatedly reinforced his opinion that the public service should be equipped with the best and most effective equipment to give the greatest chance of an optimal outcome for every patient. This has resulted in timely updates allowing regular surgery and supporting intensive eye surgery weeks prior to COVID.
Treatment in an area the size of Spain
The IRIS Taskforce support has enabled regular visits to 32 different communities annually over the past 11 years, but the introduction of a regular bus service to some communities has reduced that number to 26 for the last few years.
The outreach service goes as far north as Elliott, 760km north of Alice, as far west as Kintore, 450km from Alice Springs or eight hours-plus driving; and to Docker River in the southwest. It also visits Mutitjulu, the community next to Uluru and Finke, which is as far south as it goes; and in northeast it extends to Lake Nash (Alpurrurulam), which is only a two-hour drive from Mount Isa.
“Basically, the regional outreach service that the IRIS Taskforce funding helps support covers a catchment area the size of Spain; one million square kilometres,” Henderson explains.
“It’s lots of discrete communities of 200-400 people, and they all deserve decent eyecare, from youth through to elderly, many of whom have significant problems with managing diabetes and multiple co-morbidities. Trachoma is still a health issue, giving impetus to encouraging children and adults to adopt good hygiene and health care practices.”
Henderson is supported by Aboriginal liaison officer Ms Veronica Stafford, whose position is funded by the Fred Hollows Foundation, orthoptists, eye nurses and a receptionist and outreach co-ordinator when visiting outreach communities. Ophthalmology training registrars also participate on rotation. There are also an increasing number of colleagues who visit for locum weeks to support the service, many are previous registrars or fellows who are established consultants around the country but set time aside to return and share the work.
He does not provide any routine vision screening, if possible. This is performed by a comprehensive optometry outreach program supported by Commonwealth funding through the Visiting Optometry Scheme (VOS) and mainly run through the Brien Holden Vision Institute (BHVI) which means that all remote communities get an optometrist visiting up to three times a year for routine screening.
“They know that they can refer urgent cases to me, so it’s a good dynamic partnership. And that’s why I can afford to say I don’t want to see any ‘normal eyes’ because it’s a waste of my specialist expertise,” Henderson says, adding that he will still see patients who have missed screening when there is time to do so.
“I want to spend more time with less people so that I can perform laser treatment, administer intravitreal injections, and obtain sufficiently informed consent in preparation for surgery. Having an Aboriginal liaison officer makes a massive difference for people to have somebody who can provide cultural brokerage. We also involve family members, and clinic members if they’re available, but having somebody who is familiar with what the discussions are around is really helpful.”
Henderson’s time is predominantly spent performing cataract surgery and treating diabetic retinopathy – but not necessarily always with intravitreal injections.
He says there’s an important role for laser in populations that haven’t got access to regular clinics. Henderson is continually encouraging trainees about how valuable laser is if it’s done at the correct time, in the correct place, and often means people don’t need to keep returning for frequent recurrent injections.
“It can be quicker to administer an injection to treat diabetic retinopathy but if you have patients who aren’t going to be able to keep turning up regularly, you could be setting them up for poorer outcomes. Combining laser and an injection when you first see the patient can work extremely well, the injection produces the prompt response to treatment. By the time it’s wearing off, the laser is starting to cut in and stabilise things further, so you may not need to see them for up to four months, which is much more manageable for people who feel like their vision is fine.
“It’s an important lesson for our training doctors. We have had a number of young patients present this year for the first time with blind level vision due to very advanced end stage diabetic retinopathy.”
He continues: “The complexity of the environment where patients are, means they can’t necessarily make their diabetic eyecare a higher priority. It ends up getting left to become so advanced, it becomes really difficult to try and undo and at least rescue some sight. It’s sad particularly because it’s largely avoidable.”
Henderson performs both focal and pan-retinal photocoagulation for diabetic retinopathy, as well as anti-VEGF injections, but doesn’t have a portable OCT at his disposal.
“I wouldn’t mind one but I’m old enough to know that before OCT, you could diagnose clinically significant macular oedema by examining the patient carefully. Some clinicians can forget that. They ask, ‘Where’s the OCT? Where’s the machine technology?’.”
For Henderson, frequently operating on “unpredictable and technically difficult” complex cataracts has sharpened his surgical skills. If they’ve got a red reflex, it’s a bonus.
“These are patients who’ve resisted surgery for years. And it’s not unusual to have patients on the list with light perception or hand movements vision due to a dense white cataract. Patients can be difficult to track down, often present late and are reticent to proceed with surgery,” he says.
“Several of my colleagues who have helped with surgery weeks have commented on how rarely they see such advanced cataracts despite busy practices.
“Unless you’re used to dealing with complex cataracts, it’s very easy to get caught out, drop the lens and then have to send patients interstate for vitreoretinal rescue. There isn’t a vitreoretinal surgeon next door in the adjoining theatre.
“The stakes are much higher, because if a patient gets a poor outcome, that community will probably not want cataract surgery for another five, 10, 15 years.”
Despite the risks, Henderson says cataract surgery is incredibly rewarding.
“It’s also good to teach registrars about more complicated cases. I quite often say to them, ‘I may not be able to let you do a lot of completely independent surgery, but I hope you’ll see an awful lot of difficult cataract surgery and complications that can occur and hopefully how to get out of most of them’.”
Funding and staffing
Adequate funding and staffing are constant challenges for Henderson in his capacity at Alice Springs Hospital and with the IRIS Taskforce.
It’s a case of supplementing the limited resources that exist through the public hospital system. But public services are already under-resourced and often don’t have the capacity to deal with the workload.
“One of the difficult things is there is no alternative whatsoever for patients to receive eyecare here unless they travel interstate or to a private hospital in Darwin. Everything we do is in the public hospital and clinical status determines priority,” Henderson says.
When it comes to funding, Henderson says politicians typically focus on short-term quantity outcomes, which doesn’t factor in the nuances of providing eyecare to the whole of central Australia.
“Politicians like numbers. They want to know how many cataract operations have been performed, rather than looking at the background. I don’t want to do a cataract surgery blitz then sit on our laurels and say, ‘We can’t do any more operations’.
“I need the baseline level of throughput to be adequate all the time. That needs a stable team of staff to be able to run the service all the time, so that once you’ve got a patient who’s finally ready for surgery, you don’t say, ‘Sorry, we can’t operate until we do the next surgery week’. You have to have the capacity, which means you’ve got to have staff with experience and sufficient staff for backup,” he says.
“That’s been a problem with sufficiently skilled scrub staff but also staff rotating and moving to other roles, because that was the only way they could get promoted. But they take with them all their specialist expertise. It’s been a significant problem in the last year or two. Hopefully we’ll find ways to address that. But having funding for a position which is intended to support specialist skills is really valuable.”
Henderson says the University of Melbourne’s Indigenous Eye Health Unit led by Professor Hugh Taylor has built a solid foundation of statistics and information on the cost-effectiveness of surgical intervention and healthcare in the Indigenous population.
“What is needed is long-term guaranteed IRIS funding for a comprehensive IRIS eye surgery team for the Alice,” he says.
“One huge encouragement in 2022 is the presence of second specialist and colleague Dr Katarina Creese who has been able to make time away from her role in Melbourne to spend a year in Alice Springs as a longterm locum. It is great to be able to share the workload and challenges with an experienced general ophthalmologist.”
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