QUARTER 2, 2020, VOL.23 ISSUE 2 Magazine of the Leaders in Collaborative Eye Care

EYE2EYE 2the magazine of the leaders in collaborative eye care

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IN THIS Member Profile - Gaming the System The Wonderful World Life after the COVID-19 John Grigg pg. 36 of Virtual Meetings pandemic ISSUE: pg. 24 pg. 44 pg. 74 Paired for Performance STELLARIS ELITE ™ + CAPSULE GUARD ® Contents

EYE2EYE the magazine of the leaders in collaborative eye care p.36 p.27 p.41 2 CapsuleGuard® Handpiece

Excellent in all Message from the President...... 7 Eye2Eye is published by The Royal Australian and New Zealand College Censor-in-Chief’s Update...... 9 of Ophthalmologists as information phases of I/A for its members. The views expressed CEO’s Corner...... 11 in the publication are those of the authors and not necessarily of the CEO Journal Update...... 14 College. The inclusion of advertising in this publication does not Branch Musings...... 18 constitute College endorsement of the products or services advertised. Continuing Professional Development...... 20 Publisher: Alex Arancibia Member Profile...... 24 Editor: Jen Miguel Design and layout: Francine Dutton The aptly named CapsuleGuard is the best IA device Feature News...... 26 RANZCO Office “ The Royal Australian and New I have used to date. It provides more degrees of Younger Fellows Educational Travel Scholarships 2019...... 26 Zealand College of Ophthalmologists A.C.N 000 644 404 freedom than any other I/A device: the soft, smooth, Fighting Eye Cancer at Wills Eye Hospital with Dr Carol 94-98 Chalmers Street and Dr Jerry Shields...... 27 Surry Hills NSW 2010 Australia Ph: +61 2 9690 1001 relatively transparent silicon tip obviates metal on Health and Wellbeing...... 30 Fax: +61 2 9690 1321 E-mail: [email protected] capsule contact and three different tip angulations RANZCO Museum...... 33 Website: www.ranzco.edu Built for the next generation. cater for various surgeon proclivities. The optimised Feature Stories...... 35 But ready for this one. aspiration port allows safe, efficient cortical cleanup Gaming the System...... 36 and polishing of both anterior and posterior capsule The View from (somewhere near) the Middle...... 41 From Novice to Expert: The Story of a Zoomed-out I believe that the Stellaris Elite is one of the most and also, removal of epinucleus if required. The dual RANZCO acknowledges the, “ Ophthalmologist...... 43 Aboriginal and Torres Strait

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© 2019 Bausch & Lomb Incorporated. ®/TM denote trademarks of Bausch & Lomb Incorporated and its affiliates. Bausch & Lomb (Australia) Pty Ltd. ABN 88 000 222 408. Level 2, 12 Help Street, Chatswood NSW 2067 Australia. (Ph 1800 251 150) New Zealand Distributor: Toomac Ophthalmic. 32D Poland Road, Glenfield 0627 Auckland New Zealand (Ph 0508 443 5347) STE.0028.AU.19 Contributors Clare Fraser Stephanie Watson Ruth Hadfield Li-Anne Lim

Younger Fellows Educational Travel From Novice to Expert: The Story of Various Articles – Feature & CEO Fighting Eye Cancer at Wills Eye Scholarship 2019 – Feature News a Zoomed-out Ophthalmologist - Journal Update Hospital with Dr Carol and Dr Jerry A/Prof Clare Fraser specialised in Feature Ruth Hadfield, PhD, is a freelance medical writer Shields – Feature neuro-ophthalmology, strabismus and Prof Stephanie Watson is a corneal specialist based in Sydney, Australia. After 10 years as an Dr Li-Anne Lim is an ocular oncologist, cataract visual electrodiagnostics. She is a consultant known for her ground-breaking research academic researcher, she set up her freelance surgeon and general ophthalmologist. She has a Visiting Medical Officer at both Sydney Eye in corneal therapies. She is Chair of ORIA, medical writing practice. Ruth usually takes special interest in managing adult and paediatric Hospital and Liverpool Hospital, and is also Chair-Elect to ARVO’s Advocacy and advantage of working from home by getting out patients with eye cancers and simulating lesions. in private practice in Sydney. Outreach Committee and Expert Advisor to for regular bush and beach walks on weekdays Following her training at Sydney Eye Hospital, the $150M Stem Cell Therapies Mission. when there is usually almost nobody around. she undertook further subspecialty fellowship Recently many people seem to have discovered training at Wills Eye Hospital, Philadelphia, USA. her secret!

Eugene Michael Paul Youn Marc Sarossy Steve Bartnik Rocking the Boat – Feature The Use of Smart Phones in Is Your Practice Protected from The Use of Smart Phones in Dr Eugene Michael, MbChB BPharm, is a third Ophthalmology – Feature Cyberattack? - Feature Ophthalmology – Feature year ophthalmology trainee based in Auckland, Paul Youn, MD, BPharm (Hon), is currently Dr Marc Sarossy is an ophthalmologist and visual Dr Steve Bartnik is a second year ophthalmol- New Zealand. Eugene has a particular interest working as an intern at Sir Charles Gairdner electrophysiologist in Melbourne. He is head of ogy trainee from Perth who has a keen interest in support for those in pre-training or Hospital in Perth, WA. He is very interested in the Ocular Diagnostic Clinic at the RVEEH. He in the role of technology in clinical practice. unaccredited positions and is a member of the the realm of digital health and exploring the has an interest in computing, machine learning Prior to ophthalmology training, he completed Health and Wellbeing Committee as well as the use of technologically advanced tools to fill and cybersecurity. He is an IEEE member and a Masters in Clinical Epidemiology with research Diversity and Inclusion committee. the gaps in patient care. Adjunct Associate Professor at RMIT University. into how telemedicine can increase the access to ophthalmology services for regional patients. When not at work he enjoys watching AFL and running. Rogan Fraser Kiran Sindhu Kris Rallah-Baker Frank Cheok The View from (somewhere near) the What’s it Worth? - In Practice Change in the Midst of a Crisis - Obituary for Graeme Johnson Middle - Feature Dr Kiran Sindhu is involved in comprehen- Feature Dr Francis Poh Gwan Cheok OAM had been Dr Rogan Fraser is a second-year ophthalmology sive general ophthalmology with special Dr Kris Rallah-Baker is a proud Yuggera/Warangu a RANZCO Fellow since 1969. He was the registrar at the Royal Victorian Eye and Ear interests in cataract surgery and paediatric man on his mother’s side and Wiradjuri on his past Chair of the Senior and Retired Fellows Hospital. He was part of the second cohort to ophthalmology. He has a VMO appointment father’s side. He is Australia’s first Indigenous in 2011 to 2015. Outside of ophthalmology, be trained using the structured, virtual reality at Blacktown Mt Druitt Public Hospitals, ophthalmologist, founding member and he is an accomplished musician, specialising augmented microsurgical training program. Westmead Private and Macquarie University current President of the Australian Indigenous in harmonica. He was asked to play at the th He has a penchant for whimsy and antiquated Hospitals. His private surgery is performed at Doctors Association, is Visiting Medical Officer to opening ceremony of the 26 Congress of vernacular. Lakeview Private Hospital in Norwest, NSW. the Sunshine Coast Hospital Health Service and APAO in Sydney 2011. owner of the Sunshine Coast Ophthalmologists at Noosa.

Peter McCluskey Chandrashan Perera Jason Ha

Life after COVID-19 – Food for The Use of Smart Phones in Is your Practice Protected from Thought Ophthalmology – Feature Cyberattack? - Feature Prof Peter McCluskey is currently Professor Dr Chandra Perera is currently doing his oph- Dr Jason Ha is a junior doctor at Alfred Health in of Clinical Ophthalmology and Eye Health, thalmology fellowship at Stanford University, Melbourne and a recent MBBS (Hons) graduate and Director of the Save Sight Institute at The California. He has a strong interest in digital of Monash University. During his medical University of Sydney. He heads the largest health and has implemented a variety of med- studies, he undertook a BMedSci (Hons) at CERA tertiary referral, public sector uveitis service in ical software solutions in hospitals and clinics. investigating the use of hyperspectral imaging Australia at the Sydney Eye Hospital and is a As founder of the Journal of Mobile Technology for retinal disease. He has interests in exploring clinician scientist involved in clinical research, in Medicine, he has a special interest in mHealth. the interface between ophthalmology, global laboratory research and clinical trials. Currently, he is working on AI algorithms to health and technology. solve clinical problems in ophthalmology.

4 Eye2Eye - Contributors Quarter 2 2020 5 Message From The President

HOME VISION SUPPORT PACKS FOR PATIENTS WITH Technology: Transforming Ophthalmology During and MACULAR DISEASE After the COVID-19 Pandemic

The SARS-CoV-2 virus emerged from who could upload visual acuity meas- Wuhan, China in late 2019. Within a few urements, fundus photographs and At times like these, it can be difficult for patients to months, it generated a global pandemic other data to assist in patient care during attend their appointments. But the importance of with over 406,000 deaths (as of 10 June telemedicine consultation. Ultimately, managing their macular disease remains. To support 2020) with hygiene and social distancing patient-generated data such as self-mon- measures the only way to reduce spread. itored IOP may also enable some aspects you in managing these patients, Home Vision Support Ophthalmology training and practice in of care to be delivered remotely in the Packs are now available from Novartis. Australia and New Zealand have been future. significantly disrupted. COVID-19 has Ophthalmologists are innovating to accelerated global trends to work and allow remote administration of their study from home aided by technology, Home Vision Support Packs contain: practices and clinics. Where possible, which will only continue when the epi- administrative staff are working from demic has passed, with technology home. Zoom and other video network- • Snellen Charts to measure visual acuity increasingly used to support work, edu- ing apps have enabled meetings such as cation and wellness activities. • Amsler Grid to monitor central vision multi-disciplinary clinics, hospital senior Ophthalmology is an at-risk profession staff meetings, RANZCO branch commit- during the COVID-19 epidemic, with oph- • Vision Care Journal with instructions on how to tee meetings and practice meetings. We perform the tests, and space to record results thalmologists accounting for three of the 23 reported deaths of healthcare workers can now attend these during the day, via in China. Practice has been disrupted Zoom, which was only previously done in • Measuring tape and adhesive tack for chart set-up the evenings or not at all. by cancellation of elective surgery. Its • Links to further information at Macular Disease slow restoration and prioritisation of Foundation Australia (MDFA) and their website, emergency patients is coupled with the need for social distancing, hygiene and and to seewhatsnext.com.au personal protective measures while prac- ticing. New MBS telemedicine and video “RANZCO would medicine item numbers in Australia have allowed remote care, extending the pio- welcome continuation of neering work of A/Prof Angus Turner in tele- and video-medicine WA. Some independent medical exam- For more information or to iner (medico-legal) assessments are also consultations after the order packs, scan the QR code occurring online. However, ophthalmolo- gists do need to examine and investigate epidemic, although the majority of their patients and this store-and-forward reduces our ability to use telemedicine. RANZCO would welcome continuation of would be more useful tele- and video-medicine consultations after the epidemic, although store-and- for ophthalmic practice forward would be more useful for oph- thalmic practice given our requirement given our requirement for for high quality imaging in patient care. high quality imaging in Reference: 1. Optometry Australia. 2019 Clinical Practice Guide for the diagnosis, Future options may include collaborat- treatment and management of Age-Related Macular Degeneration. ing with other health care professionals patient care.” Novartis Pharmaceuticals Australia Pty Limited ABN 18 004 244 160. 54 Waterloo Road, Macquarie Park NSW 2113. Ph (02) 9805 3555. June 2020. AU-12720. NOBR18790WEE. Ward6 6 Quarter 2 2020 7

NOBR18790W AJO Eye2Eye FPC 297x210 v1_FA.indd 1 5/6/20 5:03 pm Censor-In-Chief’s Update

The education of trainees and ophthalmol- ogists is also rapidly transforming. Although The Acceleration of Online training has been suspended, our staff have been extremely busy working on the online Learning and Teaching LMS. Some networks now deliver considerable teaching via Zoom. Assessment of trainees is RANZCO RAP While the COVID-19 crisis has been the meeting realised all its planned likely to evolve in these circumstances. State hugely disruptive, it has produced some outcomes. branch meetings, SIG meetings and our Annual positive outcomes. From the Education Most of you will have had similarly Congress have been cancelled – the latter for the Team’s perspective, the major ones have good results from virtual meetings over first time since our inception in 1969. However, PROGRESS been an acceleration of online learning the last few months and will understand we have already developed a series of Zoom and recognition that virtual education the potential benefit for the College webinars on Friday lunch times for trainees and Since the launch of the RANZCO Reconciliation committee meetings can be very effec- going forward. While face-to-face meet- Fellows, which have been well received and a Action Plan (RAP) at last year's Congress, RANZCO has tive and efficient. ings will always offer some advantages, means of gaining CPD points. The International commenced implementation and published its first six- many meetings in the future will be Council of Ophthalmology meeting scheduled monthly report. This is available to access on the RANZCO held online. for June 2020 in South Africa has been turned website. We have delivered on our goal to celebrate and The Education Team has been into a virtual meeting. Speakers are on a steep participate in National Reconciliation Week (27 May to supporting the QLD Training Network to learning curve to record their presentation 3 June) by providing opportunities to build and maintain “As terrible as the run regular training sessions online via the online from the Netherlands over the next few relationships between Aboriginal and Torres Strait Islander COVID-19 pandemic Learning Management System (LMS) and weeks. Future international meetings are likely Peoples and other Australians. Zoom. This has included a weekly Friday to be a mix of face-to-face and virtual. RANZCO RANZCO has: has been, it has also training session, a monthly ‘Grand Rounds’ Fellows are likely to be able to deliver their session and a monthly Journal Club. material remotely and avoid the week of travel Î Hosted a virtual screening of ‘Ask us anything: incentivised us to The LMS site has been used to convey and jetlag that has, up to now, accompanied a Aboriginal and Torres Strait Islander People’ for staff. information about assigned readings presentation at an international meeting. Î Utilised social media to promote #InThisTogether to accelerate our progress through discussion forums. Attendance An increased life online does not come raise awareness of NRW. has grown significantly across the trial without cost. There is considerable risk of Î Included #InThisTogether artwork on the website and with online learning period and feedback from trainees and anxiety due to the many health and economic in staff email signatures during NRW. and teaching…” supervisors has been very positive, with unknowns, and isolation of those who have Î Added resources from Reconciliation Australia to the trainees from more remote locations also reduced face-to-face contact. RANZCO is well Cultural Awareness site on the Learning Management able to participate. aware of this and has established a Wellbeing System for Fellows to access. Many of you will be aware of the weekly group of trainees and Fellows, led by Drs Nisha Î Showcased Prof Nitin Verma’s video message On 28 March, the Curriculum webinar series which started on 17 April and Sachdev and John McCoombes as Co-chairs. acknowledging NRW on behalf of the College. Committee was scheduled to have a is expected to run until at least mid-June. The group is planning support activities, RANZCO would like to thank the RANZCO RAP Reference day-long meeting at the Melbourne The presentations have been consistently mainly online, and have already produced Group and Reconciliation Australia for their continued Airport Hotel. Participants were to well attended, with approximately 200 many useful links for everyone to follow. guidance in implementing the RANZCO Reconciliation fly in from all over Australia and New Fellows and trainees attending weekly. Ophthalmologists are coming together to sup- Action Plan. For more information on the RANZCO RAP Zealand, meet for the day and fly home The webinars are recorded and stored on port each other collegially during this time. As and a more detailed report on our activities to date, please again. Such meetings take us away the new VTP Home site on RANZCO’s LMS a small College, it is easier for us to reach out visit the website. from our families and, with up to 25 and Fellows can accrue CPD points for to each other face-to-face and online. people involved, are costly from both a participating in the webinars. Data from the COVID-19 is accelerating the already rapid financial and an environmental point of weekly feedback survey for this initiative rate of change in the world as well as in view. has also been positive. ophthalmology training and practice. The Because of COVID-19, the Curriculum There has been an acceleration of online College is rapidly changing in response and meeting was held on Zoom which learning for trainees in all networks. New facilitating online learning and practice. The minimised the time cost and created Zealand has brought forward the creation next 10 years will be a fascinating journey! no negative financial or environmental of a Friday afternoon national teaching impact. These meetings are interactive program accessible even to trainees in Clinical A/Prof Heather Mack and involve breakout groups to regional centres. This will help standardise President brainstorm components. With some teaching and ensure that every trainee adept work by the College staff, this is able to benefit from the expertise of was achieved quite satisfactorily and consultants from all parts of the country.

8 Eye2Eye - Message From The President Quarter 2 2020 9 CEO’S Corner

The College has a long term goal of in the long term, learning modules will creating a central repository of teach- have a stepwise progression, provide RANZCO’s Digital Rise in the Time of ing resources on the LMS. This will levels of interactivity to participants and include tutorials covering as much of asynchronous expert feedback. The site COVID-19 the curriculum as we can with voice over will also deliver educational webinars for “While face-to-face Powerpoints created by a specialist in that supervisors with topics such as dealing The rapid changes to work as a result of positioning for much greater digital area. The first lecture has been prepared with complex training situations, cultural meetings will always offer the COVID-19 situation have resulted in interactions, especially around learning and will likely be on the LMS at the time safety and communication skills. I would some advantages, many at least one clear winner – technology. and assessments. We have employed this issue of Eye2Eye is published. We will encourage tutors and supervisors to keep There is no doubt that while the use of highly experienced adult educators need to sort out the intellectual property technology within the RANZCO oper- with the right skills and helped develop a watch on this site as it develops: meetings in the future issues for content creators and also have ations and by Fellows in daily practice existing staff capabilities to meet the an expiry on material to ensure it is regu- will be held online.” was always high, it has undergone a expected need. As with all things IT, larly reviewed and updated as necessary. huge upswing in a few short weeks. Even it hasn’t been without the occasional However, I hope it will become a valuable the most recalcitrant laggard has had to delay. However, I would still like to thank resource for trainees and also for Fellows quickly adapt to Zoom-ing, using apps all the staff and Fellows involved for who want to refresh themselves on any and the idea of telehealth consultations. accepting the need for changes made particular subject. RANZCO has been re-developing our and working so well to make it happen. Once we have all this didactic You will be asked to sign into the por- back-end IT system for over two years. We have in place an excellent platform material available online, then trainees tal, so have your RANZCO username and Most Fellows will have experienced which helps develop RANZCO as a will be able to prepare for teaching password handy. the changes through recording CPD leader in the digital delivery of specialist sessions more effectively. Hospital As terrible as the COVID-19 pandemic activities, whether via the portal or the medication, education and training. and network sessions can become less has been, it has also incentivised us new app. For those who have taken the While we may not have managed to turn about delivering information and more to accelerate our progress with online time to explore the portal, you will have Congress into a virtual meeting this year, about using it to analyse case studies learning and teaching, and it has proven seen many other features that are now we have certainly learnt a lot. It is not and problem solve. the value of online meetings. Our world much easier to access. New committee unreasonable to expect that a number of traditionally face-to-face scientific We are also developing improved may never be the same but some of these sites are being rolled out – after having been through a pilot project with the meetings will be virtual in 2021 and resources for trainers in a new ‘Term outcomes will be positive. Board – and will make life easier for beyond. Supervisor and Clinical Tutor Lounge’. anyone on a committee. One area that Learning resources previously developed Dr Justin Mora has undergone a lot of change in a by RANZCO are being repurposed and Censor-in-Chief short time is the Learning Management System (LMS) which now has a wealth of resources across many areas of clinical “Fortunately, before practice, cultural safety, professional development and links to journals. It also COVID-19 was even holds the webinars which have been mentioned, RANZCO running every Friday since mid-April. This was a planned activity brought had been positioning SAVE THE forward by the COVID-19 situation. The success of these has spawned other for much greater digital online educational initiatives such as grand rounds, journal clubs and smaller interactions especially DATE! tutorials. The need for social restrictions around learning and has literally forced members and staff to The 38th World use online learning or have no learning assessments.” Ophthalmology Congress, at all. But the success, while not entirely 25 - 28 February 2022 unexpected, is beyond what I had imagined, with very high number of Much of the recent work has been done happy participants. by teams, including Fellows, all working icowoc.org Fortunately, before COVID-19 was from home. The success of this has also even mentioned, RANZCO had been been beyond expectations and I can see

10 Eye2Eye - Censor-in-Chief ’s Update Quarter 2 2020 11 AVANT Advertorial

Supreme Court, in the recent case of Jambrovic v Day, was that Consent for New and Innovative the doctor should have told his patient that it was his first time Procedures performing a particular surgery. Therefore, a key takeaway for doctors is to be clear with your patients about your experience Venturing into the unknown can bring all sorts of rewards and with a new approach or technique. Be open about the amount of this becoming the norm for committee flying hours of all Fellows in all colleges visual tests and close patient interaction challenges. In a medical context, trialling a new or innovative meetings rather than having people to attend what are usually fairly short required, it will make a difference in procedure can be quite conflicting for a doctor. On the one hand, times you have performed a new procedure. Provide information fly in from across Australia and New meetings, it would be substantial. I medical care generally. It may result in improvements and breakthroughs would not occur without about how prevalent the procedure is and where it is being per- Zealand. The use of video conferencing admit that my own travel schedule was the more rapid advancement of some doing things differently. On the other hand, inherent in ‘doing formed (either in Australia or around the world) and by whom. is by all accounts much better than previously at the upper end of the curve, digital eye scanning technologies and things differently’ are risks that might not be fully realised or The study also found that an explanation of the known risks and phone conferencing. This not only has but it was rare that I took a flight without a different way of treating patients in understood. Patients expect doctors to know all the risks of a an acknowledgement of the unknown risks were important to a positive effect on the overall RANZCO seeing a familiar Fellow’s face in the regional or remote areas. We will keep a new and innovative procedure so they can decide whether or patients. Patients attach significance to this information and budget (as travel was a significant cost), lounge or on a plane. close eye on this. not to proceed. Or do they? therefore you should discuss it with them. If complications arise but also the environment and savings Finally, while I don’t think telehealth Clinical trials of unregistered medicines and devices must be during or post-surgery, you will be in a better position to defend in time. My colleagues at other colleges will become the new norm for ophthal- Dr David Andrews reviewed and monitored by an Ethics Committee. These have your actions if a civil claim or a complaint to a disciplinary body agree, and I think if we tallied up all the mology due to the many complicated CEO clear processes that need to be followed, particularly regarding arose. patient consent. However, many innovations or deviations from Items to discuss with your patient for all consent discussions — the norm fall outside this scope. What occurs when the procedure particularly those involving a new or innovation procedure: is new to a particular doctor but not necessarily the industry? • Your experience and training using the new approach Char et al. surveyed patients and surgeons about the types should be made explicitly clear. This includes the number of of information they would want to know during the consent times you have used a new approach and whether you will process for an innovative surgical procedure (‘the study’). The be supervised or assisted. single most significant piece of information for patients surveyed • The place of the new approach among the options available, was whether the surgeon was performing the procedure for the including the evidence supporting the new approach. first time. In fact, 80% of the patients surveyed said that they • Your rationale for recommending the new approach for this could not decide on whether to consent to the surgery or not patient, compared with other options. without this information. Also, rather than expecting doctors to • Potential risks and complications as well as potential ‘know all the risks’, patients valued an acknowledgement that benefits. there were unknown risks. • Explore with the patient what is important for them in terms So what does this mean for the preoperative, consent discussions of outcomes. What would they be prepared to live with? between an ophthalmologist and their patient? Is there a • Make it clear that long term outcomes and expectations different type of legal test for the consent process for new and may be unknown. innovative procedures? • Discuss any difference in cost to the patient. No. Comprehensively document the discussions you have with your The famous Australian case of Rogers v Whitaker involved an patient in their records. Sending a copy of your letter back to ophthalmologist and set the standard for all doctors when the referring doctor to the patient can be helpful. That way, they they have consent discussions with their patients. A doctor can take the time to consider your advice and it gives them the must provide their patient with sufficient information to make opportunity to ask thoughtful questions. a meaningful decision. This includes information about general risks and material risks. A risk will be considered material if a From the constant discussion, make sure that you are working reasonable person in the patient’s position, if warned of the within your approved scope of practice. You may need to notify risk, would be likely to attach a significance to it. A risk will also your medical defence organisation before you start using a new be considered material if the doctor is or should be reasonably approach to ensure you are properly protected. aware that the particular patient, if warned of the risk, would be More information: likely to attach significance to it. For more information, watch Avant’s webinar Brave New World The two limbs of this standard apply to new and innovative New Technologies and Techniques. SMALL APERTURE OPTICS procedures. While there is no explicit legal obligation to inform Contact [email protected] if you have difficulty patients of the innovation per se, you must decide whether the viewing the webinar. ‘new-ness’ of the procedure would be considered ‘material’ to has influenced the way we’ve been able to see things for your patient. Rocky Ruperto centuries. In photography, a small aperture extends depth From the study, we know that the majority of patients would not Legal and Policy Officer, Avant be able to make a decision without the knowledge of whether of field bringing objects across a range into clear focus. it was a surgeon’s first time conducting a particular procedure. References available upon request. Please email RANZCO. Additionally, the expectation of the medical experts and the NSW If a small aperture can do that, what can it do for vision? 12 www.SmallApertureOptics.com Quarter 2 2020 13 MK-1409 Rev A CEO Journal Update

Online Article Downloads at a Record High Highlights from the CEO Journal

The 2019 publishers report for the 350,000 Victoria Cartwright, Managing AI in Ophthalmology: Emerging issues in ethics RANZCO scientific journal, Clinical and Editor of Clinical and Experimental Experimental Ophthalmology (CEO) 300,000 and regulation was recently released to the Editorial Ophthalmology (CEO), has high- Board. Part of the report focusses on 250,000 lighted three not-to-be-missed May/June Issue | RC Heath Jeffery and M Smith the number of online article downloads technology articles from recent which are the primary method by which 200,000 Artificial intelligence (AI) offers exciting As noted by Drs Stuart Keel and journal issues. possibilities for simplifying and Peter van Wijngaarden in the CEO readers access CEO articles. We are 150,000 automating procedures in medicine. Journal 2019: delighted to report that online article In fact, the first ever autonomous AI “The potential for these systems to downloads soared in 2019 to more than 100,000 diagnostic system to be approved by improve patient access to timely and 322,000, which is a 59% increase on the 50,000 the FDA in any field of medicine was in accurate diagnosis and clinical risk number of online downloads for the ophthalmology. stratification needs to be tempered previous year. 0 “FDA authorized the system for use by by risk controls around privacy and The vast increase in numbers of articles 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 health care providers to detect more than data security, as well as the need for accessed by readers is a reflection of the mild DR and diabetic macular edema, ongoing human input into diagnosis increasing quality of CEO articles in recent Figure 1: Article downloads trend making it the first FDA authorized and clinical decision making that years. autonomous AI diagnostic system in presently lies at the centre of the It is interesting to note the geographical any field of medicine, with the potential doctor-patient relationship and which spread of the readership, particularly when to help prevent vision loss in thousands remains the foundation of health care.” compared with the origin of the articles of people with diabetes annually”, Indeed, there are a growing number published in CEO. As would be expected, Dr Michael Abràmoff of the Department of AI applications and uses stemming Australian and New Zealand research of Ophthalmology and Visual Sciences from ophthalmological deep learning reports comprise the majority (58%) of the at University of Iowa, USA wrote in the inputs (see below). United States articles published in the RANZCO journal, journal Nature. however Australasia only accounts for 12% China of the online article downloads. Deep learning Al Eleven per cent of published CEO Australia inputs applications Uses articles emanate from the USA, however readers in the USA downloaded more India Î Î Î Automation of CEO articles (27%) than any other country Fundus Screening United Kingdom photographs & grading tasks in 2019. This suggests that American of diabetic researchers are reading many of the Î Optical Î Diagnostic Canada retinopathy excellent Australasian research papers coherence pattern identification published in CEO. Japan tomography Î Retinopathy (OCT) of prematurity Î Patterns in Victoria Cartwright Germany Î Visual field (ROP) large data sets Managing Editor, CEO Journal patterns Î Glaucoma Î Simplification South Korea Î Age-related of procedures Brazil macular Î New diagnostic degeneration & prognostic Others information from consolidated Figure 2: Top 10 downloading countries AI in ophthalmology datasets

14 Eye2Eye - CEO Journal Update Quarter 2 2020 15 However, in a Letter to the Editor of the CEO Journal, Drs Rachael Heath Jeffery Machine learning for triaging ophthalmology outpatient referrals and Marcus Smith have outlined some of March Issue | Y Tan, S Bacchi, RJ Casson, D Selva and WO Chan the likely challenges to be faced as the use of AI expands and develops in the field of ophthalmology. A new pilot study conducted at the South “Our results demonstrate that The research team also noted that One challenge is obtaining sufficient Australian Institute of Ophthalmology machine learning, in particular deep further larger studies were required and high quality and expertly labelled images has found that deep machine learning learning, can accurately assist with the future research should focus on data can accurately assist with prioritising and to train AI algorithms. Another is keeping triaging of ophthalmology referrals,” the from multiple centres. up to date with the changing regula- triaging referrals. researchers said. tory environment, with the Therapeutic Dr Yiran Tan and colleagues at Royal “A system could be developed that Read more here: Goods Administration (TGA) in Australia Adelaide Hospital used the text component would flag certain referrals definitely holding public consultations in late 2018 form 208 outpatient ophthalmology refer- requiring a category one prioritisation rals from GPs, optometrists, specialists and and early 2019 to inform medical device (with high specificity and positive emergency departments. regulation amendments. The resulting predictive value).” Amendment Regulations will introduce Patients were triaged into three cate- “Our pilot study is distinct as we new classification rules for Software as a gories: 1) appointment in < four weeks; demonstrated with a relatively small Medical Device (SaMD). 2) appointment in one to three months or sample size that natural language Ruth Hadfield “The regulation of AI is also very 3) appointment in > three months. challenging because of the black box Convolutional neural network (CNN) processing (NLP) can accurately identify References are available upon request. Please problem,” explained Rachael and Marcus. was the best performing model, with urgent referrals from the full unfiltered email RANZCO. “The exact methodology used by an 81% accuracy at separating the most spectrum of clinical ophthalmology algorithm cannot be fully integrated due urgent category one referrals from the referrals instead of just a specific disease to its complexity and the fact that it will other less urgent referrals. process,” the researchers said. continue to make more specific, indi- vidualised predictions and recommen- dations, adapting and becoming more Selective laser trabeculoplasty follow-up using self- complex as more data is incorporated.” The TGA proposes that any SaMD that administered tonometry diagnoses or screens for a condition April Issue | MS Awadalla, A Qassim, M Hassall, TT Nguyen, J Landers and JE Craig that could result in death or a severe deterioration in health will be classified as Class III; any SaMD that diagnoses Promising findings show that patients The researchers reported that all a condition potentially resulting in can successfully use Icare® HOME patients were able to successfully moderate risk to health will be Class IIb. tonometry to monitor eye pressure obtain IOP measurements using the “Ophthalmologists should stay abreast following selective laser trabecu- Icare device. Using the patient self- of developments in AI and its regulation loplasty, facilitating safe follow-up measurements after SLT, a statistically as it is likely to have a significant impact in rural, remote and self-isolation significant reduction in mean IOP of on the field in coming years,” the authors settings. 5.12 mmHg was observed. On the first noted. A tonometry device for use at home day following SLT, self-administered enables IOP monitoring outside the tonometry recorded a mean IOP clinic and also facilitates continuous reduction of 63%. Fluctuations in monitoring. The Icare HOME device IOP were significantly reduced by an uses rebond measuring with a sin- average of 24%, no IOP spikes were gle-use probe and requires no anaes- recorded and no adverse effects were thetic drops. Importantly during the reported. COVID-19 pandemic, the device does It has been reported that greater fluctu- not use an air puff which can create ation in IOP may be associated with glau- micro-aerosols and risk cross-contam- coma progression. Thus, accurate and ination. It takes around 20 minutes for frequent IOP measurements at different most patients to be taught how to use time points are imperative,” explained the device. Dr Mona Awadalla and colleagues from A study published in the April the Department of Ophthalmology at issue of CEO reported on 14 pri- Flinders Medical Centre, Adelaide. mary open-angle glaucoma patients “To our knowledge, this study is the undergoing SLT (mean age 65 years). first to look at the role of Icare HOME Each patient enrolled in the study tonometry on post-SLT follow-up,” was trained to ensure they were able explained Mona. to position the device correctly and While Goldmann applanation tonom- obtain two accurate measurements etry (GAT) is the gold standard for on their own. Patients took four meas- assessing IOP, the usual twice a year urement per day (morning, afternoon, outpatient appointments may not evening and before bedtime) for a adequately capture patients who have week before and a week after SLT. rapidly progressing glaucoma.

16 Eye2Eye - CEO Journal Update Quarter 2 2020 17 Branch Musings

New South Wales Queensland New Zealand

CHAIR: the building. The receptionists open the CHAIR: CHAIR: Diana Farlow windows to the courtyard from their Medicolegal Advisory Stephen Godfrey Peter Hadden VICE CHAIR: office for the paperwork so the waiting Group of NSW seeking VICE CHAIR: HON SECRETARY & TREASURER: 20 Alina Zeldovich room head count is not breaking social NSW Fellows Mark Chiang Kenneth Chan RANZCO HON TREASURER: distancing rules. HON SECRETARY: Nisha Sachdev The Branch had its first virtual meeting Alison Chiu It has been a busy few months for the BRISBANE21 COUNTRY VICE CHAIR: on Wednesday 1 April via Zoom. It Under the Chairmanship HON TREASURER: NZ Branch, dominated of course by the 19-23 November 2021 Neale Mulligan worked really well and we ran to time. of Dr Michael Delaney, the Oben Candemir coronavirus. I still feel we have achieved We welcomed two observers: Dr Alok Medicolegal Advisory Group quite a lot especially compared to other The editorial brief from the Sharma from Wagga, on the Work Force of NSW consists of Fellows who The second quarter issue of Eye2Eye has specialties in New Zealand, such as make themselves available Local & International Communications Team at the RANZCO Committee, and Dr Parth Shah, Sydney a much different landscape from the orthopaedics. We have engaged with for expert opinions in cases ODOB and NZAO to develop guidelines for Head Office for this article was paediatric ophthalmologist. summer edition. We now find ourselves Invited Speakers technology and isolation and how of medical litigation, workers with teleconferenced journal clubs and optometry during this time, the College The items discussed were: compensation and motor vehi- has published triage guidelines which we I, personally, and the Branch, were registrar training. We ‘Zoom’ in for state Dame Ida Mann • No increase this year on the NSW cle accident impairment assess- have modified for the NZ situation and coping. I feel very fortunate to be an branch meetings and the surgical side of Memorial Lecture RANZCO membership fee, ment. The Chairmanship will we worked with the Ministry to develop ophthalmologist. I have been going to ophthalmic practice is curtailed as with all Prof Alex Hewitt • Branch donation of $100,000 to transition to Clinical Prof Frank guidelines for Level 3 while other groups work three to four days a week so I leave areas of medical practice. ORIA, Martin at the NSW Branch AGM are struggling. We have also set up a Sir Norman Gregg the house and interact with staff and All this results in a very short report this • Cataract surgery simulators and how this year. Dr Michael Delaney subcommittee to look at how we can use Lecture patients. Of course, I’m seeing fewer quarter. The most significant negative is best to obtain two more for NSW. will provide ongoing support telehealth and produce guidelines in this Prof Graham Barrett patients. A couple of new patients with the cancellation of the Annual Congress as well as continue his routine regard and they have released an app that Fred Hollows urgent problems commented that it Dr Alina Zeldovich, Vice Chair, in Brisbane this October 2020. There has medicolegal work and clinical allows for contact tracing within practices. Lecture was weird being treated for a serious organised for Lyndall Humphries, Senior been a massive amount of preparation practice. We have been made aware that the Private Dr Catherine Green problem by a doctor whose face they Employment Lawyer and Jessica Rankin, which has been stalled. We thank the have never seen because it was hidden Workplace Relations Team Leader from For worker’s compensation Hospitals Association of New Zealand has Council Lecture and motor vehicle impairment organisational committee of Drs David been lobbying for extra funding from behind a mask. NSW AMA to join the teleconference Gunn, Katie Chen and Abhishek Sharma Dr Clare Fraser I’ve made use of telephone consul- assessments, some basic famil- the New Zealand government and have to discuss the impact of the COVID- for their hard work. Hopefully this just adds Neuro- tations. Patients really appreciate this iarisation of processes will need lobbied the Ministry of Health to consider 19 pandemic and issues such as work to the Congress 2021 in Brisbane. ophthalmology service, especially the elderly, many of to take place, including obtain- day stay eye surgery centres that are not health and safety, employee obligations, There has also been severe exam Update Lecture whom have had strict instructions from ing knowledge of the American part of this organisation in any funding business continuity and business upheaval and we find ourselves zooming Dr Lynn K Gordon MD family not to leave their homes but are downturn. Both were working from Medical Association’s Guides deal. in for RACE examination meetings. All in all, Cataract Update concerned about the vision risks by not to Impairment Assessment Outside coronavirus, immediately home. it’s a surreal time and we can only hope for Lecture attending their routine appointments. The Branch will trial a Virtual Journal Edition IV. Following that, prior to the lockdown, David Andrews, rapid resolution. Mr David Lockington For those that really need to be seen, Club, initially with committee members. If an application to the State Philip Polkinghorne and I met with Unfortunately, Queensland has once I have been able to reassure them that popular and successful, it will be opened Insurance Regulatory Authority ODOB in Wellington and we also got Retina Update (SIRA) is required for accredita- again farewelled one of its most senior the practices where I work are following to NSW Fellows. some newspaper exposure regarding Lecture tion as an Authorised Health Fellows. Dr Brian Wilson, a towering figure inequities in access to DHB-funded eye strict infection control measures. This Lastly, following up on the newly Dr Anita Agarwal MD Practitioner. in Queensland ophthalmology, passed care around the country. Unfortunately, alleviates a great deal of anxiety. I’ve also named Medicolegal Advisory Group of Glaucoma Update Further information can away in March 2020. Brian was a Churchill we had to cancel our branch meeting this been in contact with a number of GPs by NSW, Dr Michael Delaney, current Chair, Lecture be obtained by contacting Fellow and OAM recipient. He was a mentor year, but will have it in the same location phone. The conversations have strength- will be handing over the reins to Clinical Dr Pradeep Ramulu Dr Michael Delaney. If you have to a generation of Queensland Fellows and – Christchurch – next year and Nelson the ened professional relationships and it’s Prof Frank Martin at the NSW Branch MD the appropriate expertise and leaves a massive legacy to the Australian year after that. We shall have an online been interesting to learn how they are AGM. Michael will provide ongoing Refractive Update are interested to apply, please College of Ophthalmology. Once again, we AGM. coping. One GP group practice located in support for the group and continue his Lecture email [email protected]. farewell him with gratitude. I’m sure too, that like everyone else, we a small city terrace house with rear lane routine medicolegal practice and clinical Dr Damien Gatinel MD The hope is that the virus will be stopped shall be looking forward to getting back to access and a courtyard maintains social practice. Please refer to the EOI notice on Closing date: 7 September 2020 sooner rather than later. Our collegiate life as normal! distancing by performing minor proce- the right and in the bi-weekly RANZCO hope is that we are able to report a lot bet- For all Congress details visit dures like vaccinations and blood collec- e-news. Dr Peter Hadden tion outside in the courtyard (weather ter situation in the third quarter of Eye2Eye. www.ranzco2021.com permitting). This frees up room inside Dr Diana Farlow Dr Stephen Godfrey

18 Eye2Eye - Branch Musings Quarter 2 2020 19 Continuing Professional Development

Mandatory Notification Requirements for Concerns about registered practitioners that you need RANZCO Fellows and Trainees in Australia to make a mandatory notification Your role Significant departure Concerns that need to be reported Intoxication while Impairment from accepted Sexual misconduct and their definitions practising professional There are four concerns that you are required to consider when making a mandatory noti- standards fication to APHRA: Practising while Significantly departing Have engaged in, are Practising with an Impairment: A physical or mental intoxicated by alcohol from professional engaging in or might impairment placing impairment, disability, condition or disorder Treating practitioner* or drugs, placing the standards placing the engage in sexual the public at risk of (including substance abuse or dependence) public at substantial public at substantial misconduct connected substantial harm. that detrimentally affects or is likely to risk of harm. risk of harm. to their practice. detrimentally affect the person’s capacity to Practising with an Significantly departing practice the profession. Non-treating Practising while Engaged in sexual impairment placing from professional Intoxication while practising: Under the practitioner or intoxicated by alcohol misconduct connected the public at risk of standards placing the influence of alcohol or drugs. ‘Drugs’ include employer or drugs. to their practice. substantial harm. public at risk of harm. illicit drugs, prescribed and over-the-counter medicines. *Exempt in WA Professional standards: Practice and pro- fessional behaviour based on the standards practitioner. As a medical practitioner, you • form the belief while providing reporting depending on the circumstance. for that profession. Refer to documents such have a professional and ethical obligation advice about legal proceedings or the You may also want to consider other as the RANZCO Code of Conduct and the to protect and promote public health preparation of legal advice; factors such as the frequency of the Medical Board of Australia’s Good medical and safety, so you may consider whether event when reporting about practising practice: A code of conduct for doctors in • are exercising functions as a member to make a voluntary notification about a Australia to judge whether there has been of a quality assurance committee, while intoxicated and the extent of self- concern where the mandatory notification council or other similar body approved reflection when reporting about significant a significant departure from accepted requirements do not apply to you. Any or authorised under legislation which departure from professional standards. You practice and professional behaviour. individual or organisation can make a prevents disclosure of the information. must report past, current and future risk of Sexual misconduct: Sexual misconduct in voluntary notification about a registered sexual misconduct that is connected to the connection with the practice of the practi- health practitioner or student’s health, Reporting thresholds Notification is the term used when you Under the National Law, the practitioner’s practice. notify the Australian Health Practitioner requirements and the threshold of your tioner’s health profession and with people conduct or performance. To make a mandatory notification, you under the practitioner’s care or linked to Regulation Agency (AHPRA) about a concern for mandatory notification You do not have to make a mandatory generally need to form a reasonable belief Refer to the guidelines at the practitioner’s practice of their health concern that a health practitioner may varies depending on: notification if you reasonably believe some- which means you need direct knowledge AHPRA for decision flow- be putting public safety at risk. By law, profession. It includes: one else has already made a notification. If • your role as a treating or non-treating of the incident or behaviour that led to your charts and specific examples. registered health practitioners, employ- • sexual activity with a current patient or you practise in Western Australia and are concern. The notification cannot be based practitioner; and the treating practitioner, you are exempt ers and education providers must make client, whether or not consent is given; on rumour, suspicion, gossip or speculation. If you are unsure about a specific • whether you are notifying about a from mandatory notification requirements. a mandatory notification in some limited • making sexual remarks; Most importantly, if you are the treating circumstance, you are advised to seek health practitioner, which includes There are several other circumstances circumstances. On 1 March 2020, the • touching patients or clients in a sexual practitioner, the threshold for reporting a advice from your professional indemnity RANZCO Fellows and trainees, or a where you are exempt from mandatory requirements to make a mandatory noti- way; concern about impairment, intoxication insurance provider or a legal advisor. fication changed. AHPRA hopes these student who is registered as a student • touching a patient in an intimate area notification requirements as a treating or and practice outside of professional changes support health practitioners with their respective national board. without a clinical indication, whether or non-treating practitioner where you: standards has been raised to ‘substantial RANZCO CPD Team seek help about their health without If you are an employer, you must notify not consent is given; and • form the belief from a disclosure in risk of harm’ to the public. fearing a mandatory notification. about health practitioners but are not • engaging in sexual behaviour in front of a the course of a legal proceeding or The Mandatory Notifications guidelines In this article, we explain what this required to do so for students. patient or client. the provision of legal advice arising require you to make your own judgement means for you as a medical practitioner These guidelines do not affect other Refer to the table on the next page for your from an insurance policy, where you on the level of risk of harm. You need to or an employer. Separate requirements legal mandatory reporting requirements, mandatory notification requirements based are employed or engaged by the consider factors including but not limited apply for education providers. e.g. child abuse. on your relationship with the registered health professional indemnity insurer; to practice context, oversight and incident

20 Eye2Eye - Continuing Professional Development Quarter 2 2020 21 RANZCO CPD ACTIVITIES RANZCO The following activities and resources are available through the RANZCO Learning Management System (LMS) for you to acquire CPD points. Completing a reflection of any reported activity attracts an additional 5 CPD points.

ACTIVITY DESCRIPTION CPD POINTS

DIARY Webinar Ten-week webinar series targeted for trainees but is open to all 1 point P members. You can participate in the live webinars or view the Category 1, Level 1 series recorded versions. Complete the webinar evalua- C D tion form to claim your points. Points will be entered in the CPD Diary by College staff. CPD APP Clinical The RANZCO Clinical Audit Tool (RCAT) provides a simple platform 30 points Audit to manage your clinical audits. Category 1, Level 2 You can also participate in Fight Retinal Blindness! Audit and Benefits to downloading the ANZSRS Retinal Surgery Audits. CPD App: If you do not have current patients who meet the eligibility for audit due to the COVID-19 pandemic, you can do a retrospective • A great and convenient way to enter audit. Go to screencast.com for a video on how to add information CPD activities and points on RCAT about patients you have previously seen. • Includes searchable options to find CPD activities Office Involves the retrospective audit of a patient’s medical record. There 10 points Record are 27 ORR Excel templates, each of which pertains to an ophthalmic Category 1, Level 2 • Auto-populates your points and CPD diagnosis with a specific definition and time frame requirement. categories when you select a CPD Review You can claim up to 30 activity (ORR) points in a CPD year. • Tracks your CPD activities and points Surgical audit is a systematic critical analysis of surgical performance 30 points in real time Surgical Audit and outcomes. Templates are available for 10 procedures. Category 1, Level 2 • Allows you to enter CPD activity offline and will automatically sync QUEEN’S to your online CPD Diary once Workforce A 25-minute survey that focusses on issues relevant to ophthalmic 1 point connected to internet BIRTHDAY Survey – practice, seeking to understand the current state of ophthalmology Category 2, Level 1 in Australia and in New Zealand and thereby enabling RANZCO to Fellows only advocate for members on a range of policy issues. Download the RANZCO CPD 2020 HONOURS App on your mobile now! Learning Category 3, Level 1 A big congratulations to two of our Modules • Cultural competency 3 points Fellows who were awarded the Medal and • Ophthalmology-focussed cultural awareness modules (videos 2 points of the Order of Australia in the Queen’s Resources may be slow to load) Birthday Honours granted on 7 June 2020: • Intercultural learning modules online 2 points • Communication and consent issues with Aboriginal Patients 2 points - CICM iPhone Android Dr Harold Paul Spiro • Social and professional responsibilities 1 point for the service to paediatric • Operating with respect 1 point ophthalmology • Telehealth module 2 points Fellows may log into the • RANZCO Leadership Development Program – self-directed 1 point/hour Dr Arthur Michael Briner projects and resources app using your RANZCO for service to the Jewish community username & password and ophthalmology (same with RANZCO portal). For a more detailed list with links, please scan this code using your mobile phone’s camera app:

22 Eye2Eye - Continuing Professional Development Quarter 2 2020 23 Member Profile

networks of people from across the I’ve also been inspired by my wife, John Grigg country and health departments is how Q: Have you achieved balance in Prof Robyn Jamieson. She’s Professor of we’re going to achieve this. your life? Genomic Medicine, head of a university The challenge with inherited retinal A: I enjoy travel, travel photography, department and runs a lab. I’ve observed diseases is there are about 260 different cooking and gardening. It’s more gar- the outcomes that come from support We caught up with RANZCO genes and so each one would require dening than travel at present. providing a useful perspective. its own specific therapy. The RANZCO I’ve always worked in teams and there’s Fellow Prof John Grigg via Zoom I fit clinical work during the day, one Guidelines for Inherited Retinal Diseases and a half days of private practice and been excellent women in those. In our and talked to him about his various (IRD) went live on the website on 7 May. two hospital clinics a week, and six oper- work, there are many opportunities and or interests and endeavours, the I chaired that committee and Prof Robyn ating sessions a month. requirements to contribute to managing Jamieson is the Chair of the genetic future of paediatric ophthalmology I try to achieve balance by trying to or advancing the endeavour. All of us side. We had great contributions from get home by 7PM. I take the dog for a have different talents and strengths. To treatment and his commitment to Australia and New Zealand ophthalmol- walk and then we share the cooking in address challenges may require multiple gender equality. ogists and geneticists. That will provide our household. On weekends, we try to viewpoints as well as many contributors. the template for how we should manage have one day off to do some exercise In a relatively small specialty such as people with inherited retinal disease. and go out. ophthalmology, the demands remain the It’s a really huge achievement for us as same but the responders are fewer. To a College and for people who look after Q: When did the commitment to advance, we need all hands on deck to inherited retinal disease. gender equality start? contribute. This means not excluding any Read more on the RANZCO Guidelines group. When these conditions exist, the them for the different things I do. It’s It started subconsciously for as long You have so many interests for Assessment and Management of A: outcomes are greatly improved. Q: an eclectic group of things and some Patients with IRD here: as I can remember. including paediatric ophthalmology, people can’t pitch and hole me as to glaucoma and inherited eye diseases. what my interest might be. My goal How do you manage to keep abreast is that when you’ve got somebody of developments in all these fields? sitting there with a complex eye A: You can think of these interests disease and they’re losing their vision, as sort of vertical, encompassing all the question you ask is “Why?”, and Can you talk about the people age groups. The interest started with that’s how I’ve put together the skills Q: who you look up to as mentors? paediatric ophthalmology and then I to try and help unravel that. eventually gained interest with fields Q: What do you think the future A: I was lucky with the mentors across all ages. I’ve been lucky with holds in terms of treatments for that I had. I was a Professorial Senior “To advance, we need the training I’ve had and the people kids with genetic eye disease? How Registrar at the Sydney Eye Hospital, I’ve worked with who worked that do you think we’ll get there? and there were four people who really all hands on deck to way as well. I think in Australia we’re served as my mentors. One of them was really lucky because in the surgical A: Looking at the effects of genetic Prof Frank Bilson who was a paediatric contribute. This means perspective, people in paediatric oph- eye diseases on children before school ophthalmologist in glaucoma and thalmology have really high standards through to retirement, you would was also my influence around the not excluding any group. because they still do adult cataract see that the child who has vision electrophysiology service, which was When these conditions surgery. Because paediatric surgery is impairment may not be fully blind but important for developing the phenotypes more complicated than adult surgery, you’ll find that in their 40’s and 50’s, for inherited retinal disease. There’s Prof exist, the outcomes are you can apply the skills and knowl- that’s when they lose all their sight — Frank Martin, Prof Ravi Thomas and then edge to cataract, glaucoma and other they lose their jobs, they can’t drive Dr Kathy McClellan who had a particular greatly improved.” inherited eye diseases. I find my inter- and it’s having a devastating impact interest in corneal and was exceptional est in paediatrics and glaucoma to on their lives. That’s the hard-to-beat in external eye diseases. She understood be an overlapping thing. And know- argument that will be used to justify the importance of having really strong ing that most of it is inherited, that’s why we need to treat these people. fundamentals in clinical observation. where the interest in inherited eye It’s a complex process. There’s a whole Prof Peter McCluskey has also been disease comes from. series of steps. We’ve got to help a very good friend and mentor in lead- I’ve taken advantage of people as make sure that we have good quality ership and we’ve worked very closely they have come along to learn from eye care so working with the College, together. Prof John Grigg and his wife Prof Robyn Jamieson

24 Eye2Eye - Member Profile Quarter 2 2020 25 Feature News

Younger Fellows Educational Travel Scholarship 2019 Fighting Eye Cancer at Wills Eye Hospital supported by RANZCO and Johnson and Johnson Vision with Dr Carol and Dr Jerry Shields A/Prof Clare Fraser reports back The North American Neuro- OSA and vice versa. Finally, I outlined the Travelling Scholarship 2018 Update It was at the best International Society every pearl, skerrick, tip and trick. From on her experience at the North Ophthalmology Annual Meeting is evidence that treating patients with OSA – Dr Li-Anne Lim talks about her of Ocular Oncology conference counselling a choroidal melanoma the key conference in the world of does mitigate the risk of NAION. ever held in Sydney 2017 that my patient for plaque treatment to doing American Neuro-Ophthalmology neuro-ophthalmology. While typically, In addition to the ‘Hot Topics’ session, I ocular oncology journey at the journey towards a career as an ocular a fine needle aspiration biopsy of an Annual Meeting at Amelia Island, the meeting attracts over 800 regis- was the co-organiser for the International Wills Eye Hospital in Philadelphia oncologist would begin. Fortunately, intraocular tumour or marking a four- Florida in March. trants, the numbers were lower this year Relations Committee (IRC) symposium under the mentorship of Dr Carol right on my very own doorstep, I was month-old baby’s eye for intra-arterial as a result of COVID-19 travel restrictions. for NANOS. Over 30% of NANOS attend- introduced to the “all-stars” of ocular chemotherapy to treat retinoblastoma, Despite this, the conference was still a ees are not from North America so as the and Jerry Shields. oncology by our very own local hero, there was no shortage of interesting fabulous experience and a great way Vice Chair of the IRC, I felt it was impor- Dr Michael Giblin, and was inspired cases and never a dull moment. to network with my mentors and col- tant that our international attendees to join this team of superheroes, This plethora of pathology was leagues from fellowships, and to make have a chance to speak in their area of Drs Carol and Jerry Shields, who our stomping ground to engage in new friends. expertise and provide some insight into were fighting eye cancer at Wills Eye clinically relevant research, with the On the first day of the conference, the how certain conditions differ outside of Hospital, Philadelphia, USA. opportunity to formulate our own ‘Hot Topics’ session was probably one of the USA. The session was well-attended As an unfunded fellowship, the questions which we aimed to answer the most well-attended. This year, the with talks on vaccine-related optic neu- generosity of the RANZCO Travelling through research that we saw through organisers had scheduled an update ritis, the various food-borne illnesses that Scholarship turned an aspiration from infancy to publication. I was on the potential trigger factors for can affect the eye and brain, and a dis- into reality, catapulting my husband mentored and shaped into a scientific non-arteritic anterior ischaemic optic cussion on the risks of long haul flights. and 18-month-old son on a trans- writer as I worked with my colleagues neuropathy (NAION). I was invited to give To top off an already great conference, Atlantic adventure to the home of to supervise medical students writing A/Prof Clare Fraser representing Australian a short update on the potential role of Dr Jenny Hepschke won the award for the best cheese steak, cream cheese, case reports and publish on large series of ophthalmology at the NANOS banquet obstructive sleep apnea (OSA) in NAION. the Best Presentation by a Trainee, for her American football team – the Eagles, retinoblastoma, Coats’ disease, choroidal presentation on our visual snow research Amish bakeries and ocular oncology melanoma and vitreoretinal lymphoma. I first became interested in the role of Li-Anne with Drs Jerry and Carol Shields OSA while on my fellowship at Emory project. and pathology. Philadelphia is The most fulfilling achievement of all Eye Centre in Atlanta, USA. Since return- I would like to thank Johnson & America’s home of firsts: the first was finding meaningful answers to our ing to Australia, I have continued with Johnson Vision, as well as RANZCO, for hospital, library, medical school and clinical questions that would later shape my work exploring the link between OSA their support. At the NANOS banquet, theatre; and so it was that I was to my own thinking and practice of ocular and vascular changes in the eye. The lack those who were given grants to attend become a part of Wills Eye Hospital, oncology. of oxygen caused by airway obstruction the meeting were announced and rec- “America’s First, World’s Best”. Learning from Carol and Jerry, I truly at night may be one of the only treatable ognised onstage by the President of “It is only by doing the In the city of brotherly love, on the came to appreciate the art of medicine causes of NAION. I demonstrated in my NANOS, Dr Andy Lee. And yes, someone cold and icy spring morning of March and the importance of attention to talk that there was a reasonable patho- did hand me an Australian flag as I went basic things well that 2018 at 6:30 am, I walked down detail, efficient patient care, and the physiological link between what hap- onstage – so I was very proud to repre- Walnut Street in the dark to enter the need to have well-sharpened coloured pens to the body with OSA and NAION. sent Australian ophthalmology! fancy modern advances hallowed walls of Wills Eye Hospital pencils. Although I was fortunate to I also showed the literature that confirms A/Prof Clare Fraser Level 14 to begin a wild and wooly become well-versed in the utilities the increased risk of NAION in those with FRANZCO, NSW in technology and ride, as an Ocular Oncology Fellow of multimodal imaging and modern at Shields and Shields. Along with therapeutics including chemotherapy, therapeutics can enhance fellows from Mexico, China, Utah and plaque brachytherapy and intra-arterial our ability to care for Minnesota, our days were filled seeing chemotherapy that now dominate the some 30,000 new patients from ocular oncology work space, I came patients with life and sight across the United States and abroad to learn the surprisingly simple truth: with lumps, bumps and simulating That at the end of the day, nothing threatening tumours” lesions. Days turned to weeks as can replace an accurate history and we traversed the clinics, operating indirect examination documented on room, the chart room collecting data a coloured retinal drawing. It is only by L-R: Drs Julie Falardeau, Clare Fraser, Howard Pomeranz, Anthony Arnold, Nancy Newman, and early morning clinical rounds, doing the basic things well that fancy Susie Mollan and Valeria Biousse learning, observing and soaking up modern advances in technology and

26 Eye2Eye - Feature News Quarter 2 2020 27 Softgels vs Tablet Shields Fellows Formulations therapeutics can enhance our ability As Philadelphia became our home and fight eye cancer. For that, I am truly to care for patients with life and sight away from home, we enjoyed upsized grateful. threatening tumours. North American culinary delights, freez- Dr Li-Anne Lim Living in the historic city of Philadelphia, ing “Noreaster” snowstorms in spring, down the road from Liberty Bell and and scenic walking trails across the city FRANZCO, NSW Independence Hall where America first that ended with a sprint up the iconic BIOAVAILABILITY PATIENT COMPLIANCE began, I also had the privilege of meeting Museum of Art’s staircase – of course, There has been some a few of the very people who carved exactly like Sylvester Stallone in the discussion as to the • The bioavailability of • Studies and analysis has and moulded ocular oncology into an movie “Rocky”. In addition, I was able to formulations between shown that only between independent speciality of its own. That attend and present at ophthalmology very year, Jerry was honoured for his meetings both global and local. I met the benefits of tablet tablets and capsules has 1% and 18% of patients contribution to ophthalmology in his own alumni of the other Wills Eye Oncology been compared. are fully compliant with 2 issue of the journal Retina, while this year, Fellows at the 9th Wills Eye Intraocular per day dosages ²&³. formulations vs • Zinc absorption between Carol was named the Number One Most Tumour Symposium where we “oohed” Influential Ophthalmologist in the World and “ahhed” over cases describing the softgels when treating tablets and softgels • Labeling on the 2 per on the power list. It was pure luxury and good, bad, ugly and outlandish. Our was shown to be largely day products directing really downright indulgent to be able to own homegrown Dr Michael Giblin, who macular health. similar with bioavailability patients to take 1 per day amble next door to discuss the pathology was Jerry’s very first Fellow some 30 being slightly improved in is confusing. of a case with the one and only Dr Ralph years ago, also visited me and together the softgel form¹. Eagle. To top it all off, I had the pleasure of we attended the American Academy • Prescribing a 2 per day dining with the now late Dr Luther Bracy, Meeting in Chicago as well as a fantas- • Lutein and Zeaxanthin product will likely result who together with Jerry, perfected the tic up close magic show at a magic club were given in tablet form, in the patient receiving technique of plaque brachytherapy, as complete with a secret door behind a well as Dr Anna Meadows who pioneered laundromat façade. January brought the all other ingredients a non-therapeutic 50% chemotherapy for retinoblastoma. yearly Atlantic Coast Retina Meeting in including zinc were dose. In my time spent not being awestruck Boston amongst the likes of Dr Yannuzi provided as softgels in by the achievements of those in my midst, and Dr Freund. Needless to say, present- recent clinical studies. I was able to ponder my thoughts along- ing my “interesting case” in such com- side the statue of the “Thinker”, walk the pany was nail-biting! • Once a Day Macutec has halls of the Philadelphia Museum of Art At the end of the day, it was my hus- a significant benefit over and enjoy the bright lights of New York City band and mother who looked after my the two per day tablet just a short bus ride away. Weekends away 18-month-old son day in and out. They Li-Anne with son Gabriel in Philadelphia were spent learning about the Amish way did the real hard work. I just got to look products. of life in nearby Lancaster, enjoying the at interesting tumours and cases all day www.macutec.com.au Jersey Shore and visiting the honourable long alongside experts in the field, make Mr Donald J. Trump in Washington, D.C. amazing friends from across the globe

¹ Bioavailability of micronutrients from softgel capsules and tablets: a pilot study Molecular Vision 2014; 20: 1228-1242. ² Stiltec in-house 28 Eye2Eye - Feature News data based on patient usage follow up. ³ Ng WT, Goggin M., Clinical & Experimental Ophthalmology 2006 Jan-Feb;34(1):9-14Quarter 2 2020 29 © Stiltec Pty Ltd 2018. Phone 1800 622 883 Health and Wellbeing

Health and Technology in Isolation

We asked some RANZCO Fellows Diana Semmonds Andrew Chang on what their go-to technology What: An E bike! What: Kmart Air fryer has been in this time of isolation to Why: I have been riding a road bike for Why: Ensures peace in a time of chaos. combat cabin fever, promote good a few years now – just at weekends if I How: Child 1 is a KFC aficionado, child get the chance. 2 is philosophically opposed to eating health and mental wellbeing. Once a year, I do a bicycle ride for a chicken and loves tofu. The air fryer week with a group in Europe. Prior to enables a roster system, alternating this, I try and increase my bicycling fried chicken and fried tofu. Safe and miles but I never reach the level and accessible care for all stakeholders and fitness of my companions. Over the almost guilt-free meals. last few years I have refused to ride the mountains as I get left behind and, on occasions, lost. How: I am now able to ride the hills and when my legs or chest gives in, I turn the engine on for a few minutes “The air fryer is jet and power up the steepest bits then settle back into my own pedalling. This black, sleek with an technology has now become cool. inspiring engine note.”

“The idea of an E bike brought thoughts of ‘failure’, ‘old people’ and ‘not cool’. However, my rides were becoming limited so I decided to ride an E bike but to not turn on the engine unless e s s e n t i a l .”

30 Eye2Eye - Health and Wellbeing Quarter 2 2020 31 Nisha Sachdev RANZCO What: Zoom What: HouseParty Why: To continue my exercise journey “My running coach has Why: To have a virtual hour party with in isolation. For my mental wellbeing, continued her strength friends all over the world. Museum and to maintain my current fitness and How: It’s an app that allows you to to keep fit. workouts virtually. “host” a party. If you “lock” the door, How: My running coach now organises then no one can enter! If you, however, a Zoom "catch up and workout". She Normally, we catch up keep your “door” open, then any of your sends us an email on the day to let us friends can come to your house to join know what equipment we need, which in Kiribilli (under the the party! Spontaneously! usually is a yoga mat, water, tennis/cricket bridge!) and do an hour It’s a fun way of keeping in contact with ball, foam roller resistance bands and everyone. I did different things with weights (which can be wine bottles of strength work in a each of my groups of friends! Played or a 5kg basmati rice bag in my case!). trivia, “happy hour” drinks, birthday Forging Links with She instructs us on what to do by beautiful location in celebrations – the list was endless! demonstrating the workouts live and India corrects us as we go along. It allows Sydney!” And, yes, it is a sign of the “times” but it us to connect with the all crew as we was still so much fun connecting with "normally" do on Monday nights. It's everyone. At the invitation of the All India been great to see everyone, motivating Ophthalmology Society (AIOS), I us all and keeping us accountable. attended the national AIOS Congress in Delhi with 15,000 delegates! Following “I have lived all over the Congress, several presentations were given by myself and Kirsten the world and this was Campbell, Assistant Curator, on devel- the best opportunity for oping an online museum to project the work of the College and preserve its her- me to catch up with my itage. Fortunately, the Delhi air was clear Presentation of Aboriginal artwork to Prof Natarajan, AIOS President, from RANZCO and all travel was smooth, arriving home friends in the UK, NZ, just before the COVID-19 crisis struck. Canada and around The AIOS Museum in Delhi, while small, has unusual artefacts on display Australia!” including a carbon arc photocoagulator - pre-Xenon and an early vitrectomy device. Travelling to Chennai, we lectured at the Elliot Museum situated in the The Practice Managers Advisory Government Eye Hospital founded a year after Moorfields in 1819. Group talks about their health Elliot was an ophthalmologist in the Health Indian Medical service who, in 1913, and wellbeing initiatives in their developed the glaucoma operation by In Practice respective practices. trephination. He was a polymath and superintendent of the hospital with interests ranging from magic to tropical medicine. He was an expert conjurer who became Chair of the Occult Committee of Government Eye Hospital Chennai (Madras) the Magic Circle on returning to London. “We do a practice run once a year, Jetty to Jetty, where staff can choose to walk or run (3k, 5k or 10k). After the The long-term plan of the RANZCO run, we hold a BBQ together. We offer flexible working arrangements and healthy lunches provided every day.” Museum is to develop links with other Peggy Ekeledo-Smith ophthalmic museums in the USA and UK Moreton Eye Group, QLD on the internet.

“We provide flu vaccinations and encourage wellbeing by having quarterly team conversations to ensure they are doing well. We have just established return from sick leave wellness catch ups to check in with how people are doing post sick leave. Generous training and professional development support is provided for our teams which includes attending the annual RANZCO events for some.” Deb Boyd Auckland Eye, NZ

Carbon arc photocoagulator Elliot trephines

32 Eye2Eye - Health and Wellbeing Quarter 2 2020 33 70 Years Ago – Zeiss Xenon Photocoagulator

Meyer Schwickerath in Essen, Germany produced by electrical discharge in Diabetic Retinopathy Study, so initial developed the Photocoagulator (PC) a high pressure Xenon chamber. The protocols had not been established. with Zeiss in 1950. beam delivery was enabled through a Focal macular burns migrated in time, Preceded by the unreliable carbon long tube to a direct ophthalmoscope making results variable. arc machine, the Xenon PC produced head which swiveled. The tube could The burns were quite painful, limiting an intense beam of light which focused be moved in a limited fashion to treat the treatments. Adjusting the patient’s on the retina. It was used to treat the recumbent patient on a trolley. position to allow visualisation was limited retinal tears, diabetic retinopathy and Cumbersome to use, with considerable by the adjustment of the delivery head. retinopathy of prematurity. An adaptor difficulty to locate and treat peripheral allowed treatment of surface lesions. lesions, it produced large intense burns Treating infants with ROP required Dr Graeme Chester in Perth recalls that enlarged over time. Proliferative general anaesthesia with an assistant using the machine in the 1970’s at the diabetic retinopathy presented new rotating the eye to visualise the periphery. Royal Perth Hospital. Termed ‘Jumbo’, challenges as any vitreous blood Nevertheless, Graeme acknowledges whether affectionately or not, the large absorbed the light with heat being patients with useful vision decades after device delivered focused Xenon light produced. Treatments preceded the being treated as infants.

Gaming the System The View from (somewhere near) the Middle From Novice to Expert: The Story of a Zoomed-out Ophthalmologist Meyer Schwickerath Zeiss Xenon Photocoagulator Retinal burns produced by Xenon Photocoagulator The Wonderful World of Virtual Meetings Major Upgrade for the RANZCO Museum Website – Collections Viewing The Use of Smart Phones in Ophthalmology

The installation of iMu software Rocking the Boat has allowed a much improved display and search function of the artefacts Is Your Practice Protected from Cyberattack? in the Museum. This is viewed via the Collection tab on the RANZCO Museum The Journey Towards AI-assisted Telehealth for website (https://museum.ranzco.edu). Diabetic Retinopathy Screening in New Zealand The unfortunate cancellation of the RANZCO Congress in October has allowed for a lot of work to be done on developing presentations covering the history of the photocoagulator and Elliot’s trephination for glaucoma. The presentations and posters from 2019’s 50th Congress are now on the Museum website.

Dr David Kaufman Curator, RANZCO Museum New collections page from the RANZCO Museum website Feature MUSEUM Stories

34 Eye2Eye - RANZCO Museum Quarter 2 2020 35 Feature Stories

RANZCO Fellows Reap Benefits from Gaming

How virtual reality, simulation that are important in cognitive control. and gaming can enhance an Larger grey matter volumes were also observed in action video game players in ophthalmologist’s skills. the right hippocampus, right dorsolateral prefrontal cortex and bilateral cerebellum. Gaming impacts the brain – it improves motor control, enhances brain plasticity Gaming was also associated with neural and cognitive performance, and alters brain plasticity in regions of the brain used for structure and function. Research shows navigation and visual attention. that gamers make better surgeons and RANZCO Fellows who are interested in the next generation of ophthalmologists gaming have appreciated these benefits are harnessing the power of gaming to firsthand. Dr Amy Pai started playing improve their surgical skills. video games as a child but really got There is growing evidence that into gaming at university when she got commercially available video games a Playstation 2 as a birthday gift from improve cognitive function. Choi et al friends. (2020) published a systematic review “I enjoy playing games after work to of 28 studies on the topic in the journal help me relax and destress,” said Amy. Behavioral and Brain Functions and con- “I think gaming has helped improve cluded that video games “were found to my dexterity, hand-eye coordination, be positively associated with cognitive visual attention and concentration, and function (e.g. attention, problem solving potentially, reaction time,” she said. skills)”. Similar benefits have also been There are five genres of video games: observed by ophthalmologist Dr Matt traditional games such as card and Ball who is an avid PS4 virtual reality F1® board games, simulation games such (Formula 1) gamer. as sports or driving, strategy video “Driving 320km/hr in an F1 car really games, action video games such as first sharpens the concentration,” said Matt. person shooting, and fantasy games. “There are a lot of similarities between GAMING Choi and colleagues at the Department F1 and surgery. You have to use both of Psychiatry, Eunpyeong St Mary’s hands and both feet, so in that sense, it Hospital in Seoul, Korea found that is similar to cataract surgery. Posture is different genres conferred different also very important – you need to relax improvements in cognitive function, your shoulders and keep your back with action video games giving the straight which translates to surgery as widest range of cognitive benefits. well,” he said. THE Overall, gaming was positively asso- Matt has also been inspired by ciated with six different cognitive two books The Core: Better Life, Better functions: attention, working memory, Performance and Exponential which is visuospatial function, probabilistic about the training philosophy of Dr Aki learning, language and problem-solving Hintsa, McLaren physician and F1 coach. skills. Moreover, many different studies In his lifetime, Aki helped at least 11 F1 observed specific structural changes drivers win Grand Prix titles by focussing SYSTEM training on physical fitness and mental in the brain. For example, action video games were associated with greater wellbeing. Many of the principles of plasticity of white matter networks in training F1 drivers and athletes can also regions such as the prefrontal cortex be applied to training surgeons.

36 Eye2Eye - Feature Stories Quarter 2 2020 37 Aki’s training philosophy, established While most of the publications focus video game usage have superior visu- when he was working in Africa with elite on general surgical skills, in particular ospatial ability. Younger surgeons seem to High-tech Hands-on Training Using VR Simulators: Ethiopian long-distance runners, is based laparoscopic skills, there are some that acquire skills in laparoscopic surgery more on the premise that optimal performance specifically investigated ophthalmology easily than older colleagues and increased Evidence Update requires a healthy, balanced life. training. video game usage in this population is “Within ophthalmology, regular one possible explanation.” Dr Rahul Chakrabarti shares I am privileged to have been involved in A 2020 study by John Ferris’ Group of video game play enhanced baseline “It is important to emphasize that man- the development and implementation ophthalmology trainees in the United microsurgical performance measured his expertise and updates us on ual surgical technique is just one of the of the new microsurgical skills program Kingdom published in the British Journal “Many surgeons on a surgical simulator,” said Rahul. competencies that it takes to become a the evidence for this developing for ophthalmology registrars in Victoria of Ophthalmology, showed significantly There is even more evidence for the good surgeon and clinical outcomes are technology. since 2018. Along with Director of improved outcomes following exposure participate in sport benefits of gaming in the area of general strongly influenced by interpersonal com- Training, Dr Jacqueline Beltz, a micro- to VR simulation in cataract surgery. A surgery. or yoga to help their munication skills and good judgment,” total of 17,831 cataract operations were “In one study, general surgery faculty surgical wet and dry lab curriculum was wrote Jeremy. performed by 265 trainee surgeons, and residents who systematically played developed that incorporates virtual performance – all of Dr Sarah Gentry, from the School of of whom some had access to an EyeSi video games for five weeks were found reality cataract surgery simulation in Public Health, Imperial College London, simulator and others did not. The these types of activities to perform better on laparoscopic simula- addition to traditional animal and dry has made similar conclusions in a recently researchers reported a 50% reduction tions. In addition, those who played video lab models for developing ophthalmic published systematic review of 30 clinical in capsulorrhexis complications and translate to improved games for six weeks performed better surgical skills. trials of serious gaming published in the a 38% reduction in posterior capsular on a laparoscopic simulator than those The motor skill component of ophthal- motor skills.” Journal of Medical Internet Research. rupture rate when trainees had received who trained on the simulator itself for six mic surgery involves hand-eye-foot coor- “Results from our review show that EyeSi simulator training. Similar findings According to the Hintsa High weeks,” said Rahul. dination dexterity and three-dimensional serious gaming/gamification in pre- and were reported in a US-based study of Performance Institute: “Inspired, Dr Hintsa “There have been studies to show that spatial awareness. Traditional Halstedian post-registration health professions simulator training which also noted drew a circle and on the outer layer, he those who play Nintendo Wii for a few approaches for teaching have shifted education could result in increased significantly shorter surgery times (by placed the following six elements: physical hours for three days before using laparo- knowledge, skills, and satisfaction when towards simulation as it offers a platform 6.7 minutes; P = 0.0001) in those trainees activity, nutrition, recovery, biomechanics, scopic simulators perform better in the for safe, deliberate practice. Virtual real- mental energy and general health. Then in non-dominant hand on the simulator compared to traditional education,” who used a simulator compared to noted Sarah. ity (VR) for cataract surgery is not new, those who did not. This has implications the middle of the circle, he wrote the word compared to those who did not,” he said. and the EyeSi® (VRmagic, Mannheim, “core”. It represents identity, goals and So with all this evidence supporting not only for the patient at hand, but Rahul also highlighted a 2007 study Germany) simulators have been used in control. This model would come to define by Dr James Rosser, Jr and colleagues at gaming, should we all be taking up this also for the health economic benefits of training programs extensively through- the entire Hintsa philosophy.” the Department of Surgery in Beth Israel new hobby? Rahul notes: managing the complication itself, and out UK, Canada and US over the past “Many surgeons participate in sport Medical Center and New York University “I think it’s pertinent to remember that the costs associated with further surgery decade. There is clear evidence of bene- or yoga to help their performance – all Medical Centre. In this study, trainee sur- gaming is ultimately a form of entertain- and follow-up appointments, etc. of these types of activities translate to geons were asked about their video game ment. There is no specific one game or fits from studies of simulator training and There is a great deal of further evidence improved motor skills. Surgeons should usage and tested on video game ability. console that has been shown to improve outcomes include reduced phacoemul- for the benefits of VR simulator training in treat themselves like athletes and gaming They then performed a series of standard- surgical skills for consultants (or non-train- sification times, lower phaco energy and the academic literature, including a num- is just another way that we can maintain ised laparoscopic drills and suturing on ees). There is limited evidence to suggest it fewer intra-operative complications. ber of recent systematic reviews. Lee et al. and build on our skill set,” said Matt. porcine bowel. Surgeons who had played actually improves patient outcomes in live In addition to evidence of the benefits video games three hours per week made surgery, but perhaps indirectly through of gaming on motor skills and cognitive 37% fewer errors, were 27% faster and performance on a simulator.” function, there is also a body of research scored 42% better overall than trainees “By the time one is a consultant, “There is clear evidence dedicated to gaming and surgical skills. who had no video game exposure. bimanual dexterity and motor skills are RANZCO Fellow Dr Rahul Chakrabarti, established and it doesn’t take long for of benefits from based at The Royal Victorian Eye and Ear those aspects to be regained. It may be Hospital (RVEEH), recently conducted the mind skills aspects that a surgeon studies of simulator a comprehensive literature review on “Surgeons should treat is looking to excel or refine in order to training and outcomes gaming in surgical and ophthalmology maintain or progress to becoming an training. themselves like athletes expert. In that sense, video gaming may include reduced A total of 39 papers on video gaming not be the highest yield. In fact, greater and surgery were identified in his review, and gaming is just benefit may come from peer-to-peer phacoemulsification covering the most recent five years of coaching, discussing cases especially published literature. another way that we can complicated ones with other consultants times, lower phaco “This is an emerging area in terms of maintain and build on and objectively self-reflecting,” said Rahul. energy and fewer intra- surgical training and publication interest,” “So I wouldn’t be necessarily recom- said Rahul. our skill set.” mending starting gaming or challenging operative complications.” “Video gaming is often practiced as a their teenager in Mario Kart!” recreational activity, but also offers photo- Another of the studies Rahul reviewed Ruth Hadfield realistic simulation of various scenarios was authored by Dr Jeremy Lynch, that require motor, visual and cognitive Department of Surgery at the Royal Sussex References available upon request. Please email RANZCO. coordination. These attributes are highly County Hospital. Writing in the Journal of desirable particularly in microsurgical Surgical Education he notes: specialties such as ophthalmology. Used “…there is a need to search for factors judiciously, video gaming holds the that improve surgical technique outside potential for a beneficial effect on surgical of the operating theatre. There is some training,” he said. evidence that those with extensive prior

38 Eye2Eye - Feature Stories Quarter 2 2020 39 (2020) included 53 studies of VR tools in a Even experienced surgeons may ben- systematic review published in the journal efit from using a VR simulation platform The View from (somewhere near) Eye. The authors concluded that: from time to time. This is a platform that “Virtual reality simulators were the most I will occasionally go back to prior to live the Middle widely evaluated and the Eyesi Surgical cataract surgery if there has been a gap Simulator in particular. For cataract surgery, of several weeks. For example, last year I Dr Rogan Fraser talks about his evidence to support all aspects of content completed a strabismus fellowship and validity has been reported. Critical data naturally had limited opportunity for cat- perspective on virtual reality support the collateral effects of using the aract surgery. training. Eyesi with training being shown to result The benefits for me at a personal level in improved operating room performance are both in the actual motor skill aspect but and lower complications.” also in the realism of surgical planning (for The GenEye faculty, an initiative of the example, a case with a small pupil or white Eye and Ear Hospital, delivers a four-tiered cataract) and adjusting fluidic parameters. course with basic and advanced modules These specific scenarios, as an example, and complication training. In Melbourne, can be simulated on the VR platform. It we are privileged to have two EyeSi offers immense benefit for safe, deliberate “Change is inevitable but virtual reality cataract surgery simulators. practice, and objective feedback. The simulator itself combines software neither good nor bad in built into an interface with an operating Ruth Hadfield (Interviewer) Listen to “GENEYE and of itself .” microscope, foot-pedals, and a patient References available upon request. Please email Philosophy” here head. Trainees receive objective feedback RANZCO. from the training software machine and have to demonstrate both proficiency and consistency at each level before being allowed to progress to the next level. We are now into our third year of registrars who have completed the VR cataract simulation In the beginning there was light. So This is complemented by numerous as part of their transition to live surgery. much light. And too much magnification. small group tutorials from experienced No, now not enough magnification. And surgeons, combined with various why is everything out of focus? Hang on, simulation activities. These tutorials are you left-handed? Okay, start at the covered some tasks that could be readily end. Or, start at the beginning and when taught using the EyeSi platform, such you get to the end…stop. Actually, STOP as capsulorrhexis and hydrodissection, NOW. in addition to critical topics that are Change is inevitable but neither good not part of the VR training, such as nor bad in and of itself. George Bernard suturing, wound construction, selection Shaw said: ‘Progress is impossible with- of viscoelastic, trauma surgery and post- out change.’ He also said: ‘There is no operative care. These latter skills are love sincerer than the love of food’, honed using wet and dry models. which is less relevant to the topic at Of the EyeSi itself, I hear you ask: hand. One significant change to the way Is it like a video game? Well to some ophthalmology registrars are training extent, yes. Is it fun? Sometimes. Is it has come with the implementation of frustrating? Almost exclusively for a virtual reality (VR) as a surgical training period there. Does it make you a better tool. surgeon? It is now reasonably clear that The RANZCO Victorian training network trainees learning on this platform have introduced a structured VR simulator a lower complication rate once they training program for cataract surgery using transition to live surgery (Ferris, 2020). the EyeSi® Surgical platform (VR Magic, In our network, a survey of trainees Mannheim, Germany) as a compulsory from the first two ‘VR-trained’ cohorts module at the start of 2018. Since then found that capsulorrhexis was viewed it has been iterated and continues to be as one of the easier steps when starting a core part of the first three months of cataract surgery. And while informal, the training for first years and has also been consensus opinion that I have gathered integrated into the training curriculum of in conversation with supervising SMALL APERTURE OPTICS second and third year registrars. surgeons is that they feel these groups It is worth noting that the Victorian have started at an advantage. program does not only rely on VR But what do I actually think about the has influenced the way we’ve been able to see things for simulation, with wet and dry model whole experience? centuries. In astronomy, small aperture corrects optical eyes still being used. Broadly, the It does start out feeling like a video structure of the program has two game and while this, to me, did not aberrations allowing objects in distant space to be visualized. parts. The sequential completion of seem to prohibit the development tasks within the EyeSi platform is one. of skills to begin with, I found that a If a small aperture can do that, what can it do for vision? 40 www.SmallApertureOptics.com Quarter 2 2020 41 MK-1406 Rev A change of mindset somewhere along the way was needed to get the most out From Novice to Expert: The Story of a of the training. It seemed reasonable to treat it like a game when all I was doing Zoomed-out Ophthalmologist was using my forceps to move small red triangles into a sphere. So, when I Prof Stephanie Watson talks Over the past two months, I have table, out of view of the camera, to give ruptured my first posterior capsule, it about how COVID-19 sped up the supervised my research group via Zoom, you ‘fill and bounce’. But if you try to reach felt like I had ‘lost a life’ but could simply recruited two excellent candidates for our this level of Zoom expertise, you will end restart the game and carry on. Then evolution of her Zoom skills. Corneal Fellow positions at the Sydney up looking tilted due to your uneven book I remembered my supervisor saying Eye Hospital, been part of a staff meeting pile, with a sore neck from looking down, something like “I want you to take this I have been an on and off Zoom user for at the Save Sight Institute, contributed and a headache from the glare of the light seriously. Especially your mistakes. This the last few years – a so-called ‘novice’. to a RANZCO committee meeting, hired and the white paper! is the time to make them, but they Last year, I chaired an ORIA board meeting an employee, attended a conference and Until the day we meet again in person, shouldn’t be made in vain.” This is the via Zoom with over 10 people. I felt like also had regular social catch ups. During I know with much more than a hunch, benefit of supervision and structure, and my Zoom skills had already dramatically this process, I have learnt the basics: how that our College will still form a great I think this was the stick. But the carrot increased, as I was then able to turn my to schedule a meeting and mute/unmute bunch on Zoom and that’s the way we was there too. Merit-based transition to screen into what looked like The Brady (important when you are working from will move vision care forward. live surgery. Bunch theme song – clearly the produc- home with home schooling). I have also ers had travelled into the future and seen upped my skills by now knowing how to Prof Stephanie Watson Ultimately, the bar to pass was high. FRANZCO, NSW Firstly, there was regular assessment from a Zoom meeting. At that stage I had not choose an appropriate virtual background supervisors, the director of training and envisaged that Zoom would become an (handy for when you have not tidied the self-assessment. Then, timely completion increasing part of my everyday life; that I bookshelf behind you), posting ‘reactions’ of five cataract cases with consecutive was on my way to becoming an ‘expert’. I and touching up my appearance. scores of at least 80% in total and for guess it was a bit like The Brady Bunch – I have also found Tom Ford’s ‘Guide to you end up getting drawn to something “At that stage I had not each of the five domains (capsulorrhexis, Looking Hot on Zoom’ where Tom sug- that you do not necessarily want to end up hydrodissection, sculpting and cracking, gests that you put your computer on a envisaged that Zoom spending time on and find that you can- stack of books so the camera is slightly irrigation/aspiration, and insertion and not stop. I started with The Brady Bunch higher than your head – at about the top rotation of a toric IOL). And here, the lens would become an TV series but have now moved on to ‘The of your head, and then point it down to capsule had a proclivity for charging off Brady Brides’, ‘A Very Brady Christmas’ and your eyes. He then suggests you take a increasing part of my towards the equator. The nucleus was as ‘Getting Davy Jones’ – the 37th Greatest tall lamp and set it next to the computer strong as an ox, and the zonules as weak everyday life.” Episode of all time according to TV Guide’s on the side of your face that you feel is as a kitten just born. To some, the training Top 100. Now with Zoom, my use was the best to provide some ‘flattering light’. came easier than to others. But alas, not increasing and I was gaining new skills! Then put a piece of white cloth on your a one passed first go. Nor second, third or fourth. But we got better and we all passed in good time. but even in those discrepancies it acts that. Virtual reality training is something as a form of elaborative rehearsal, that I would hope and recommend for whereby concepts – in lieu of precise all trainees. actions – are solidified in one’s mind. “…it is not without The perception of depth, heft and size Drs Rogan Fraser, Nick Enright and are readily appreciable. The patient’s Tiffany Lo some idiosyncratic eye moves and the red reflex with it FRANZCO, VIC as our (initially) heavy hands pushed discrepancies, but even and pulled. A millimetre’s real estate in those discrepancies becomes invaluable as you learn the virtue of steering well clear of the it acts as a form of corneal endothelium. The training program encourages a steady hand but elaborative rehearsal, also purposeful actions. And punishes the contrary. whereby concepts – in I had experienced poor outcomes lieu of precise actions on many (simulated) eyes before I had even been handed my first keratome – are solidified in one’s by a scrub nurse. This is significant, or at least it was for me. I had a feeling for the mind.” mechanics of getting it right and some of those mechanics of getting it wrong. This training program and the experience I believe that the EyeSi platform is I gained through performing virtual immersive, receptive and representative cataract surgery, gave me the of real cataract surgery. To be sure, it is not confidence I do not think I would have without some idiosyncratic discrepancies, had otherwise. Our patients deserve Artwork by Jen Miguel

42 Eye2Eye - Feature Stories Quarter 2 2020 43 The Wonderful World The Use of Smart Phones in of Virtual Meetings Ophthalmology If combatting “Zoom fatigue” is now on your list of skills to master, it means you have suffered the fate of many In this article, we discuss the uses others. You join a meeting and after a few minutes, you decide you can absolutely do two things at once. After and benefits smart phones offer to all, you spend most of your professional and personal different fields in ophthalmology life multitasking, so why is this any different? You check as well as its limitations. your emails, read the meeting notes, notice the shelf behind the monitor is askew… or if you’ve joined through your mobile, take a wander around the house to find that cup of tea you made 30 minutes ago and never touched.

The mute button Angles 1 You forget to turn it off and everyone else in the meeting 2 Sorry but your computer or mobile phone’s camera is not suddenly becomes overly familiar with the chaos that your friend. Before the meeting, you only had one chin. Now surrounds you or is noticing how you are clearly typing away that you’ve joined the call, you somehow have seven of them. on the computer. Everyone can see, in great detail, how often you shave, pluck, manicure and otherwise care for your skin and hair. They can You forget it’s on and are chatting away to no one. The host also see your house or office, and all the stuff you have, or don’t is madly screaming “Your mute button is on!” while everyone have. else frantically waves their hands. Once you finally switch it on, your embarrassment forces you to cut short the point you were To fix this, just google “bad Zoom angles” and you’ll feel better making. knowing how many other people get it wrong! D-EYE Smartphone (left) and iExaminer (right) – Photos retrieved from the official company website. There’s no easy fix for this aside from consciously muting The experts seem to agree on three things: yourself as soon as you’ve said hi to everyone. If you want to • Lighting – softly does it. make a comment, raise your actual (or virtual) hand first and • Camera angle – have the camera at a height that it can be then be ready to unmute when the host calls on you. angled just slightly down at you. Think about the camera as being right at your hairline and have it pointed down With improved data storage capability have been performed to screen for DR at your eyes. and faster processors, the use of using smartphones. In 2015, a study • Let Zoom fix it – Zoom actually has a feature built in smartphones and applications are was performed on 120 patients with specifically for the purpose of making you look better. In diabetes mellitus (DM) to assess the the Zoom desktop app, there’s a “touch up my appearance” increasingly becoming more popular option located in the camera settings. amongst physicians. The number of users reliability and accuracy of smartphone is rapidly increasing, with more than one ophthalmoscope (Andrea Russo, billion users across the globe. A variety Morescalchi, Costagliola, Delcassi, & Sorry, I missed that Yadda, yadda, yadd… of devices are currently available for Semeraro, 2015). After dilation, the participants underwent smartphone 3 Staying focussed is hard, especially when you’re not face-to- 4 If you find you’re hosting a lot of virtual meetings, you need to smartphone ophthalmoscopy, two face with people. That comes with a level of accountability to find a way to keep your participants engaged. of which are FDA-approved, namely ophthalmoscopy with the D-Eye device, stay in the room. Fix this by getting out of your comfort zone: the D-EYE and the iExaminer (Bifolck, followed by a fundus examination at the On a video call, the only way to show we’re paying attention • In a virtual meeting, looking into the camera is the Fink, Pedersen & Gregory, 2018). slit lamp to grade DR. Both techniques is to look at the camera. But, in real life, how often do you equivalent of looking into someone’s eyes. It may feel While the D-EYE attaches directly resulted in the same grading in 85% stand within three feet of a colleague and stare at their face? unnatural but it means you’re directly addressing the of subjects, showing good agreement participants. to a smartphone, the iExaminer is Probably never. an attachment for the Welch Allyn in the grading of DR between slit- • Participants can’t read your lips and facial expressions with lamp biomicroscopy and smartphone The best ways to stay present are: the same clarity as a face-to-face meeting so it’s important PanOptic ophthalmoscope (Bifolck et • Close any tabs or programs that might distract you. ophthalmoscopy. Numerous other to speak clearly and a little louder than you’re probably al., 2018). • Hide yourself from view (in Zoom, right click your video to comfortable with. studies have been published since, display the menu, then choose ‘Hide Myself’). • Be mindful of how long and how often you speak, which Smartphones in Diabetic all with >90% sensitivity, and around • Find a softly lit space that you’re comfortable in and that’s can be hard if everyone else is on mute. 80-90% specificity (Kim et al., 2018; relatively free of distractions. Retinopathy (DR) • Check around the room for waving hands, in the same way Rajalakshmi, Subashini, Anjana & • Prepare for the meeting the same way you always would: you would for a face-to-face meeting. If you have multiple The monitoring and diagnosis of DR are come armed with a drink, etc. and arrive on time. Mohan, 2018; Ting et al., 2017). Overall, hands waving, set out the order in which each person will challenging in resource poor areas due • Determine why you’re on the call, either to contribute smartphone ophthalmoscopes are speak, reminding them to unmute first! something or to gain something. Setting the goal at the to the lack of trained personnel and the useful tools in the grading of DR. In • Utilise the chat window. You can post the agenda or links, start of the meeting will at least ensure you keep enough prohibitive cost of imaging equipment. addition to this, implementing an note topics that need to be addressed offline, etc. Do this focus to achieve your goals. Thus, the ubiquitous diffusion of the sparingly though – you’re not as good at multitasking as AI-based grading algorithm alongside you think you are. smartphones, in addition to their validated smartphone-based fundus portability and recording capabilities, images could be an effective alternative You know all of these and you still zone allows for this technology to be to direct ophthalmoscopy for identifying out? Apologise and hope the minutes utilised in DR screening, especially in DR in the future. Not only does it are accurate! remote locations with limited access offer a high sensitivity and specificity to clinical facilities. Several studies for detection of DR, it is more easily

44 Eye2Eye - Feature Stories Quarter 2 2020 45 accessed, and the increased portability fundus examination. Fifty-two consecutive and lack regulatory oversight by clinical allows a mobility that the traditional patients who presented to a hospital with or governing bodies. As previously Rocking the Boat fundus examination with a slit-lamp an acute hypertension (i.e. systolic blood mentioned, there are currently only biomicroscope fails to provide. pressure > 180 mmHg and/or diastolic two devices that are FDA-approved Smartphones in Optic blood pressure > 100 mmHg) underwent for smartphone ophthalmoscopy: the a mydriatic funduscopic examination by D-EYE and the iExaminer, both of which Dr Eugene Michael discusses Nerve/Glaucoma a trained medical student using both a are only available on the iPhone iOS Although most glaucoma types conventional direct ophthalmoscope and platform (Bifolck et al., 2018). A possible the importance of ‘speaking out’ progress slowly, scientists suspect D-EYE digital ophthalmoscope. Of these, no obstacle in the inclusion of more than in helping RANZCO trainees that more than 50% of patients are relevant abnormalities of the funduscopic one mobile platform is the variation navigate through a sea of unaware of the diagnosis until it reaches examination were detected by traditional of form factor between smartphones, advanced stages due to the disease ophthalmoscopy. However, abnormal meaning that devices for a specific emotions. being generally asymptomatic early examination findings were detected model of phone or platform may not fit on. A growing body of literature has using the D-EYE digital ophthalmoscope another. Therefore, addressing this issue demonstrated the potential use of in 17 and 19 patients by the medical would be a vital component in increasing smartphone-based fundus photography student and ophthalmologist, respectively screening and enhancing the safety of (SBFP) in improving case detection (Muiesan et al., 2017). It is well known that patients. Also, the existing concerns and minimising glaucoma-related direct ophthalmoscopy is a difficult skill regarding limited high-quality research blinding in the long run. A study was with the majority of clinicians struggling in smartphone ophthalmoscopy should performed in 2016 which compared the to use the device. This was evidenced in guide the planning of studies that accuracy of vertical cup-to-disc ratio this study with none of the trained medical address methodological deficiencies (VCDR) obtained with undilated fundus students able to identify pathology using in previous studies. This will ultimately biomicroscopy (90D fundus lens), with the direct ophthalmoscope. However, enable smartphone technology to be SBFP (D-Eye) in 110 patients. In brief, it by using the smartphone adapter, they accepted as an important adjunct to the was found that clinical grading of VCDR were able to identify the majority of cases delivery of healthcare globally in future. between the slit-lamp biomicroscopy with pathology, clearly demonstrating its Smartphones are a useful addition to and smartphone ophthalmoscopy ease of use. Replacing or supplementing the ophthalmic examination. Currently, For many doctors, one of the proudest ment to the system itself. At their worse, techniques showed a substantial direct ophthalmoscopes with smartphone there is a significant amount of evidence moments in their academic career is they have the potential to foment unmit- agreement, achieving a high specificity adapters such as this may allow non- that supports their use in diabetes, graduation from medical school. It is the igated bullying and sexual harassment, at value of 99% (CI 0.94-1) grading VCDR of ophthalmologists in the emergency hypertension, glaucoma and as a teach- “Trainees will need culmination of years of discipline, hard the expense of those in lower positions 0.9 (Russo et al., 2016). More recently, the department to rapidly identify urgent ing tool. Their portability, accessibility support and guidance work and enduring some of the many of power. (The National Academies of impact of pupil dilation on image quality ocular pathology to help facilitate early and low cost make them an excellent challenges encountered in our hospitals. Science, Engineering and Medicine). in VCDR with SBFP was further evaluated treatment and more accurate triage. accessory to ophthalmic diagnostic on when to ‘rock the As they set sail, undergraduates are In medical education, the practice of by Wintergerst et al. (2018). In this study, tools. Although a variety of challenges exposed to clinical medicine, absorbing ‘pimping’ is viewed as a rite of passage. 54 eyes (27 patients) with glaucoma remain in their wider spread adoption, boat’ in stormy waters the workplace culture, understanding A trainee is asked a series of questions or suspected to have glaucoma, were with the steady publishing of literature complex practices in a hierarchical scrutinizing their medical knowledge, in imaged with both conventional fundus citing the positive impacts that is seen and how to achieve system and engaging with an array front of patients and their peers, often in photography (CFP) and SBFP (D-Eye with their use, they are likely to gain ‘smooth sailing’ during of personalities. Yet for some, not all an interrogative and unrelenting manner. adapter) monoscopically. The findings “Smartphones are popularity in remote locations with poor experiences in the workforce are smooth The social cues of a trainee’s discomfort of this study were that the mean VCDR a useful addition access to healthcare. times of relative sailing. Humiliation, belittlement and are overlooked in the pursuit of on CFP and on SBFP was 0.76 (SD ± verbal abuse are extensively reported in educational ideology. While some thrive Paul Youn, Dr Steve Bartnik and 0.14) and 0.73 (SD ± 0.13), respectively calmness.” medical undergraduate surveys as a source in this type of learning environment, to the ophthalmic Dr Chandrashan Perera (Wintergerst, Brinkmann, Holz, & Finger, of training dissatisfaction (Wilkinson). others become overwhelmed and feel as 2018). These findings further support examination. Their References available upon request. Please email As a result, universities, medical training though they are drowning in a wave of existing data showing that glaucoma RANZCO. institutions and training boards have emotions, questioning their self-worth screening using SBFP is promising. portability, accessibility implemented specific strategies on and intellectual competency. The ‘Socratic Use of Smartphones in and low cost make them bullying, harassment and discrimination. Dialogue’ method of education and its While these policies are well-intended, differentiation from ‘pimping’ is a grey area Hypertensive Retinopathy an excellent accessory to a criticism of a ‘report per incidence’ and those with previous bad experiences, Despite the widespread availability strategy is that it focusses on punitive re-live each encounter like they’re once of direct ophthalmoscopes, several ophthalmic diagnostic or accusatory measures as opposed to again ‘walking the plank’. ‘Pimping’ limitations of the direct ophthalmoscope addressing what is quintessentially a continues to be a popular method of have restricted its use in the emergency t o o l s .” systemic issue. The policies neglect the education, despite a lack of evidence to department (ED) to identify ocular fact that certain individuals in positions of suggest it is of superior benefit in training changes in an acute hypertensive seniority, would otherwise, under normal performance (Scott). patient. These limitations include a long circumstances, behave quite differently if As doctors navigate through their period of learning and no image storage Limitations it weren’t for challenges they must also training, there is pressure to gain rapport capability. In 2017, a prospective study Although the use of smartphones can manage on a daily basis. from senior doctors and a reluctance to was conducted to evaluate the feasibility potentially replace more conventional, The medical system is inherently hier- challenge a perceived authority figure, of the ocular fundus photography with a expensive devices in the future, several archical. While hierarchies optimise out- due to the reliance on them for career D-EYE digital ophthalmoscope in an ED limitations of the smartphone imaging comes for efficiency, leadership and the advancement (Crowe). This creates a setting to better capture the diagnosis must be considered. Firstly, many management of a complex system, they vulnerability for those, particularly not of hypertensive retinopathy, and to smartphone devices and applications also yield downsides which may be del- on training programs, who will often go also compare it with a traditional ocular do not have an adequate evidence base eterious to individuals and pose a detri- to considerable measures to appease

46 Eye2Eye - Feature Stories Quarter 2 2020 47 their senior colleagues, such as sacrificing personal time to attend outstanding clinical or research duties. Is Your Practice Protected from This, in turn, makes them particularly susceptible Steps you could take if you are to burn out, emotional fatigue and declining levels Cyberattack? of empathy (Neumann). Those that swim with the ocean current and possess attributes of agreeability, having an interpersonal issue deference or obsequiousness are more likely to be with a colleague at work viewed favourably. Drs Marc Sarossy and Jason Ha Are my backups able to It is suggested that a tidal change in the cultural paradigm is required to empower those at a junior discusses the importance of stop ransomware? level to have the confidence to ‘speak-up’ when gross building cyber-resilience. The malware can get onto the system in Based on the Decision Tree diagrammed by the inequities occur. Where behavior directed towards All of us know someone or some a myriad of seemingly innocuous ways, another is unequivocally inappropriate, there are clear Royal Australasian College of Physicians (RACP), including USB drives, emails, file attach- here are some steps you could take if you are company that has been the victim of a guidelines in dealing with these issues. The difficulty cyberattack. Toll, which delivers many ments including PDF and office doc- arises when micro-aggressions or passive aggression having an interpersonal issue at work with a uments or via insecure remote access colleague: of our surgical supplies such as IOLs, occur and how to identify or raise this. There are also has been targeted twice, and even large protocols. situations in which a trainee may not appreciate • Define the problem – Is it violence, sexual institutions are not immune. One of the reasons ransomware is so their contribution to an undesirable interaction and harassment, bullying, discriminations, Ransomware is one particular insidi- successful is that it targets well-known understand the need for calmness and conciliation. impacting on patient safety? ous cyberattack where your computer backup protocols, including batch files One proposal is that feedback is made bi-directional • If it is, review your workplace policies and systems may be infiltrated and impor- that write copies of data to network and to promote open dialogue without fear of reproach. consider reporting the behavior. tant files are encrypted in a way that share or portable drive locations. The Moreover, if a trainee is perceived as questioning a • Get advice. renders them unusable. A large ransom malware encrypts or destroys those senior’s behaviour towards them or their clinical decision- must be paid via cryptocurrency in order backup files too. • Internal advice: Consider seeking advice CHECKLIST making, this can be achieved without being constructed to decrypt the files and use your systems Current ophthalmological electronic through a trusted senior colleague, mentor, again, with no guarantee that this will 3-2-1 backup rule: Keep as mutinous (Srivastava). Enabling those at a junior level HR department or medical administration. records and imaging software are to freely express their concerns and contribute to patient be successful. Exfiltration of confidential inadequate to deal with increasingly at least three backups of • External advice: Consider seeking  care can foster an inclusive and supportive environment, documents is also possible and can clever ransomware and much of the your data on at least two independent advice (i.e. industrial constitute a risk to you or your patients. with benefits to the wider workplace (Plan-Smith). data are not encrypted, which imposes different storage media, organisation, legal representative, Cyberattacks are increasingly As we set forth for the horizon, it is incumbent on all onerous reporting requirements on the independent organisation). aimed at businesses and enterprises. with one of them located of us medical educators to improve the status quo. For practice in the event of an attack. If the problem is not any of the highlighted: Ophthalmology is at particularly sig- offsite. example, practicing self-reflection of our teaching style If your practice becomes the victim nificant risk of these cyberattacks and and how we interact with juniors, colleagues and other • Assess the problem’s impact – Is the problem of a cyberattack, its effects can be dev- Secure your email – having a significant impact on your learning your own practice may be more vulner-  minimise your risk of staff. Asking trainees how they feel about ‘pimping’ able than you might think. Electronic astating. Patient records and frequently or wellbeing? phishing or spoofing. can allow them to voice whether they find it a useful or medical records software, imaging used systems can be rendered unusable, • Evaluate the severity of the problem – Do negative learning experience. The underlying cause of databases, email systems and shared all resulting in significant downtime, Ensure your software is you think the problem is of a serious nature? workplace harassment and bullying are systemic issues files – all frequently used in ophthal- costs in data recovery and unnecessary  up-to-date and important and subsequent systemic-approached initiatives are • If it is, review your workplace policies and mology practices – are all at risk of stress for you. security patches are applied. consider reporting the behavior. imperative in addressing this. It is worth asking your cyberattack. Many attacks are now What can you do to improve workplace or department how to access these resources. • Get advice. targeted attacks (spearphishing) with Consider the use of third- party mail filtering services. Similarly, dialogue should be actioned between senior • Internal advice: Consider seeking advice the attackers having previously done your cyber-resilience?  staff and others within the workplace that specifically through a trusted senior colleague, mentor, research on the target. Many practices For now, the best way to improve your Consider the use of discuss these issues on a regular basis. This form of HR department or medical administration. publish “About Us” information and cyber-resilience is to work with your  virtualisation where awareness-raising is in itself an incredibly powerful this can be cross referenced to other • External advice: Consider seeking IT provider to review cybersecurity possible. publicly available information to craft catalyst for change. independent advice (i.e. industrial standards with respect to resistance to a plausible but malicious email. Ultimately, any progress should not fundamentally organisation, legal representative, cyberattack, encryption of key data and Segment your network undermine the incredible amount of goodwill, mentorship independent organisation). How significant are the disaster recovery plan. Ultimately on a different subnet and and time invested by senior medical educators, which for  If you are unsure on the nature of the problem, what is required is greater collaboration domain, and write backups the majority is conducive to a healthy and cooperative cyberattacks? think it through: between practices, professional there. Consider having learning environment. Trainees will need support and We performed a study of the unwanted organisations and hardware vendors servers on the segmented guidance on when to ‘rock the boat’ in stormy waters and • How bad is it? traffic encountered by the firewall of to ensure products are designed with a suburban eye clinic over a 24-hour network too, if feasible. how to achieve ‘smooth sailing’ during times of relative • How often does it happen? adequate security. calmness. period. 15,126 intrusion attempts • How does it affect you personally? For more information about guide- Secure remote access with were logged, 53% of which originated VPN – don’t rely on RDP *Trainees refers to both undergraduate and postgraduate level, • How does it affect your performance? from the Russian Federation (perhaps lines and our research, please visit  with those in formal training programs and in preparative training • How many people have been affected? unsurprisingly!). http://cybersecurity.sarossy.com. security. roles Well known ports and vulnerabilities Use multi-factor Dr Marc Sarossy, FRANZCO VIC Dr Eugene Michael were targeted: Telnet (1,818 attempts), authentication. and Dr Jason Ha  FRANZCO, NZ SSH (349), remote access RDP (162) and A more detailed look at the RACP VPN systems (SoftEther 124 and PPTP Invest in a good next With acknowledgement to Dr Nicholas Toalster for his Decision Tree can be found here: 40). Forty-four per cent of all attempted  generation firewall that contribution to the article. intrusions probed all four IP addresses in has been professionally References available upon request. Please email RANZCO. the range. configured.

48 Eye2Eye - Feature Stories Quarter 2 2020 49 The Journey Towards AI-assisted Telehealth for Diabetic Retinopathy Screening in New Zealand

We spoke to Dr David Squirrell, an By 2040, it is estimated that 224 million same time protecting our eye clinics from THEIA performed well with high ophthalmologist and researcher people worldwide will have some form being overwhelmed with multiple false accuracy (98%), sensitivity (95.53%), of diabetic retinopathy. Diabetes is the positives. specificity (82.02%) and negative pre- based in Auckland, New Zealand leading cause of blindness in adults of “We wanted to read all the normal dictive value (99.8%). and co-founder of Toku Eyes, working age. images quickly so we could focus our “The negative predictive value was about his team’s journey towards In New Zealand, although there has resources on the small number of very important because we needed been a diabetic eye screening program patients with significant disease,” he said. to know that if the machine said the an AI-assisted diabetic retinopathy for the past 12 years, around 40% of image was non-referable, then we screening. diabetic patients are still not being THEIA – mobile diabetic could be very confident that this screened for diabetic retinopathy. retinopathy screening AI patient did not have disease which “This means that patients with In stark contrast to the weeks taken by the was going to be missed,” said David. diabetes are losing sight unnecessarily traditional screening program, the newly The system is also suitable for which has both a human and societal developed THEIA system identifies the deployment into rural areas as it lets Figure 1: A good quality image (left) is normalised with Gaussian filters (centre) and then passed cost,” explained Dr David Squirrell. the operator know when a suitable through the AI (right). The AI attention map shows areas where associations are being made – in this 6% of patients who need to be referred image has been obtained, so no high case, new vessels at the disc and some at the periphery (Image courtesy of Dr David Squirrell, Toku How can AI improve diabetic for further investigation within seconds. level expertise is required. Eyes). The AI system helps by providing rapid retinopathy screening? THEIA was given a training data set triage of ‘normal’ images and increasing “There are two main factors that lead to of 165,000 images that were represent- the productivity and cost-effectiveness of • 165,000 images from 39,554 individuals the lack of completeness of screening: ative of people with diabetes in New the clinician reading the referred images. TRAINING • Labelled with DR and maculopathy grades human factors – it is difficult to train or Zealand (Figure 1). Good quality images “We had an old system which was taking SET (0-5), ethnicity, age, gender get trained personnel to read the images, were processed and AI attention maps six weeks to find that 5-6% of patients and geographic factors – it is difficult for show where associations are being those patients located in rural areas to who needed to be sent in and now we made (Figure 1). access screening,” said David. have a system which finds that 6% in 10 “We introduced a traffic light system Although New Zealand is a small country, seconds,” said David. with red, the highest level, indicating it is divided up into 20 different health “Essentially by integrating an AI sys- that referral is required, amber may VALIDATION • 62,000 images from 21,284 individuals board areas resulting in an inevitable lack tem within our diabetic eye screening need referral and green does not need SET of consistency and standardisation. As in programs, we’ve enabled them to work referral,” said David. many countries, there is a divide between smarter and harder. The vast majority of David noted that many stakeholders urban and rural populations in New patients with diabetes who we screen were consulted throughout the process. Zealand, with many rural people facing have no or minimal disease so we spend a He also highlighted the ethical concerns • Image input & QA more difficult access to healthcare services. lot of time looking at normal images. Only with approval from national and local THEIA • Image enhancement The traditional diabetic screening a very small percentage of images actually bodies required to proceed. DEVELOPMENT • Diabetic retinopathy classification process is lengthy with multiple steps. In have significant disease which needs eye The team have been very successful New Zealand, four images are required clinic review.” in obtaining funding for their research per screening episode and the time “The AI transforms the fundus camera from a broad range of sources, having from screening to reporting back to the into a smart diagnostic platform and it received in 2019 a Graeme Mack Award • Healthy patient can take up to six weeks. can use any existing camera system,” Diabetic Retinopathy from Diabetes THEIA Seeing a need to improve both the • May need referral said David. New Zealand and a Science for OUTPUT • Referable DR efficiency and the coverage of screening, Technological Innovation – National the team at Toku Eyes set out to improve Science Challenges grant, and in 2018, productivity and find an automated and an award from the NZ Ministry of scalable solution. Business, Innovation & Employment networks. Numerous labelled images alise to my patients? Is it trained on the are required to train the machine and AI “We identified a need to develop a (MBIE) Endeavour Smart Ideas Fund. patients you intend to use it on? Does bespoke system for New Zealand so we “Essentially by is only as good as the data it is trained the data set have an inherent bias? Does commenced our journey to develop THEIA What elements make a on. Important factors include the size of it add value? Is it ethical and is the data – our aim was to develop an accurate integrating an AI system the dataset, whether it is trained on the secure?” explained David. diabetic retinopathy AI. Essential criteria good healthcare AI? types of patients it will be used on and were that it must conduct autonomous within our diabetic eye Grouped within the term AI, there are generalisable, and whether the data is image quality assessment. It must be able different types of learning (Figure 2). biased in any way (e.g. race, age, gender, to accept images from multiple camera screening programs, In machine learning, the features of smoking status, etc.) (see box on next systems and data from multiple different we’ve enabled them an image that you want the machine page). graders,” said David. or computer to identify must be care- “For those of us who are clinicians “Our vision was to create a unified, to work smarter and fully defined. In comparison, in deep that are not so familiar with AI, I would automated, scalable system that would learning (which is a subset of machine encourage you just to continue to look allow our diabetic eye screening pro- h a r d e r.” learning), the machine itself learns at it like you would any other medical grams to work smarter and faster, to what features are within an image data. What’s the original data set? Is the deliver results very quickly and at the that defines it using artificial neural data set sufficiently big that I can gener-

50 Eye2Eye - Feature Stories Quarter 2 2020 51 When asked whether there were any Special Interest misconceptions about AI, David Artificial Intelligence emphasised that AI won’t replace oph- Programs with the ability to learn thalmologists but will instead allow and reason like humans them to work faster and smarter. Groups “AI is starting to have quite a major impact on ophthalmology – in many ways it is surprising it hasn’t had more Machine Learning impact yet because of the power of AI,” Algorithms with the ability to learn said David. without being explicitly programmed “I like to think of AI as a clinical assis- tant tool.” He echoed the sentiments of Noel Sharkey, Professor of Robotics & AI at Deep Learning Sheffield University, who said: ANZCS Ocular Oncology Subset of machine learning in which artificial neural networks The Australian and New Zealand Cornea virtually presented the Douglas Coster Update adapt and learn from vast Society (ANZCS) and the RANZCO Cornea Medal Lecture on infectious keratitis Although the COVID-19 pandemic has pre- amounts of data Special Interest Group have merged. as he was unable to attend due to “Decisions about people Membership is free and open to all travel restrictions. The in-person John sented significant interruptions and chal- ophthalmologists, eye bank scientists, Blandford Lecture by Prof Colin Green lenges, numerous opportunities relevant Figure 2: Different types of learning should be made by ophthalmic researchers or others with an was about the journey from laboratory to ocular oncology have also emerged. For people; AI should be interest in cornea. If you would like to join, bench to bedside. example: please contact [email protected]. Currently, we are working on strategies • The necessary triaging and The ANZCS committee has been to progress corneal transplantation rationalisation of ocular oncology considered a tool to and look after our patients during and finalized as below. I would like to thank consultations have prompted a after the pandemic. We look forward assist human decision- A/Prof Richard Mills, Prof Geoff Crawford, widespread review of clinic booking to progressing according to our Dr Andrew Apel, Prof Stephanie Watson, protocols. This may result in efficiency recently identified values of excellence, making, not the A/Prof Mark Daniell, Dr Andrea Ang, gains persisting well beyond the innovation, collaboration and diversity Prof Nigel Morlet, Dr Raymond Loh and pandemic. replacement.” Prof Gerard Sutton who have all recently over the next few years. stepped down from the committee. • Telehealth consultations – while Dr Jacqueline Beltz suboptimal in many respects – are ANZCS had a successful meeting Chair, ANZCS combined with the Eye Bank Association particularly valuable to many ocular oncology patients accustomed to David also noted that this sentiment is of Australia and New Zealand in Auckland travelling long distances for in-person AI voiced in a Māori proverb: on 28-29 February. This was the last consultations. He aha te mea nui o te ao. He chance many of us had to travel prior to tāngata, he tāngata, he tāngata COVID-19 restrictions and the meeting • In the context of widespread What is the most important thing in was enjoyed by all. Prof Fung-Rong Hu cancellation of conferences, on 25 April, the world? It is people, it is people, it the All India Ophthalmology Society is people. (AIOS) convened the first international webinar on ocular oncology. A faculty Read more in the recent PloS One ANZCS Executive: of distinguished international speakers article by Dr Squirrell and his team: What makes a good Chair produced highly informative and Jacqueline Beltz timely presentations with relatively few hiccups! healthcare AI system? Secretary/Treasurer/QLD Peter Beckingsale • The increased reliance on technology, including electronic data storage Young Fellow and communication in patient 9 Trained and tested on local conditions Nick Toalster 9 Trained on data that are Ruth Hadfield care, clinical trials and continuing Eye Bank Rep professional development, highlights representative of the people who will References are available upon request. Please Graeme Pollock use it email RANZCO. the importance of systematic data VIC collection. Ocular oncologists in 9 Camera, operator and systems Elaine Chong Australia and New Zealand face agnostic WA significant challenges here, including 9 Fully automated process Steve Wiffen dispersed populations, scarce resources and diverse administrative and funding 9 Should not use ‘black box’ data SA structures. Data collection and clinical processing Aanchal Gupta audit will be the principal focus and 9 Aligns with data sovereignty laws of NSW the country priority of the Ocular Oncology over John Males the next couple of years. 9 Maintains data security NZ Charles McGhee (Dipika Patel) Dr Daniel McKay Chair, Ocular Oncology

52 Eye2Eye - Feature Stories Quarter 2 2020 53 RANZCO Affiliates

Australian Society of Ophthalmologists Update ANZEF Update

believe my boss still uses an OCT? He have graduated within the last two an eye injury in the home and think it Technology and doesn’t even use an MGA (molecular years are entitled to a 50% discount Getting Ready for might be the basis of a good story, get in genetic amplifier).” I do hope that they on membership. Trainees receive touch via [email protected]. Politics – Bedfellows are also saying, “Just as well the ASO complimentary membership. For further JulEye As always, your Foundation is work- If you would like to went into battle with the government information please visit https://asoeye. This JulEye, your Foundation is working ing hard to increase public awareness for Eternity financially support your to get a rebate for the Phaco Vaporiser. org. hard to raise public awareness of simple of ophthalmology and to raise funds. Foundation, please make a As I tuned into my first Zoom telecon- Otherwise, we’d be stuck with that old prevention measures to common The Foundation is a keen supporter tax-deductible donation via ference, I was proudly waxing lyrical phacoemulsifier the bosses talk about.” Dr Peter Sumich household eye injuries. With more and of ophthalmic research, with a total of bank EFT as follows: to my children about the miracles of The current COVID-19 medical President, ASO more people staying indoors and tackling $178,020 raised and donated to ORIA. technology. They were thoroughly emergency will pass, but I fear that the DIY projects and complex recipes, eye Capacity building in our region through BSB: 062016 unimpressed. To them it was not much economic legacy of indebted governments injuries are on the rise. The Australian and educational grants have also enabled the Account #: 11614360 of a miracle! That is the thing about new will remain for the lifetime of the current New Zealand Eye Foundation (ANZEF) Pacific Oculoplastics Fellowship in the Ref: ANZEF/ Your Name will be campaigning to increase the technology – it is only miraculous if you reader. With excessive training of medical Solomon Islands to proceed. Immediately email public’s knowledge of simple prevention have a memory of the past. practitioners currently underway, it We look forward to working with you [email protected] afterwards Our current crop of registrars will not may not be a seller’s market in 20 years. measures. ANZEF is also seeking to raise throughout 2020 and beyond. In the so we can contact you with a know of a time before anti-VEGF, OCT Governments and private insurers will public awareness of ophthalmology – meantime, please keep looking out for receipt. and microsensor-controlled phacoemul- look to reduce medical expertise to a largely in the context of the role of the the JulEye publicity and contact us with sification. Just as surgeons of my gener- cheapened commoditised product and ophthalmologist when injuries do occur. your feedback via [email protected]. ation gave little grace to talented extra- technology companies will advance We will be working hard to get your capsular cataract surgery, the modern artificial intelligence to supreme levels. stories into the mainstream media. If you John Kennedy generations will not be interested in my Will the art and science of medicine be have treated a patient who has suffered Chair, ANZEF technical difficulties with early phaco lost to the economics of a minimally viable technology. Does a modern fighter pilot product at the cheapest labour cost? really understand the talent of the origi- The ASO exists to ensure that clinicians The Australian and New Zealand Eye Foundation nal test pilots? will always have a seat at the table of wants all Australians and New Zealanders to focus on Post occlusion surge and chamber discussion. This means that we must preventing avoidable eye injuries this JulEye. instability are historic references the know where and when the discussion is registrars will never know – which is happening – which is of course the art LOOK OUT Did you know about 30% of all eye injuries occur in the a good thing of course! However, it of politics. We want ophthalmologists domestic setting? DIY, car repairs and gardening have been shown to be a common cause of eye injury especially does leave my feelings hurt that I had to have at their disposal the best amongst males. Nearly all of these eye injuries can be to battle through such difficulties with technology of the day and an economic FOR YOUR prevented by taking the simple precaution of wearing nobody giving me credit, except for my framework within which it is affordable suitable eye protection. peer buddies at the RANZCO Congress. to patients and ophthalmologists. Every year at RANZCO, watch as old pals Technology will change but the tensions Suitable eye protection is that which is: break off into private dinners and relive between cost-cutting governments and Î designed for the particular task at hand, their glory days, “Geez we were great frontier clinicians will never go away. Î correctly fits the wearer, and registrars weren’t we?” The ongoing role of ASO is to work Î complies with the relevant AS/NZS standards for that The thing about technology is that with governments of today and those activity. it is a cruel mistress which marches of tomorrow to maximise the input of EYES forward without room for hurt feelings. ophthalmologists on the front lines. Find out more You adapt or become outdated. A newer I would like to see more younger THIS thing comes along and you are obsolete ophthalmologists join ASO. The platform ANZEF is the charitable wing of The Royal Australian overnight, which is why it is so important we lay today will help you and your and New Zealand College of Ophthalmologists to keep investing in your technology patients afford your MGA and Phaco ABN 80 000 644 404 base and pushing your personal comfort Vaporiser in 20 years’ time! 94-98 Chalmers Street Surry Hills NSW 2010 zone and skills to remain current. The ASO is Australia’s peak medico- Website: www.ranzco.edu Email: [email protected] In 20 years’ time, today’s registrars political ophthalmic body, fighting for Australian and New Zealand will fully understand the cycle of life. the rights of patients in both public Eye Foundation Their registrars will be saying, “Can you and private health sectors. Fellows who

54 Eye2Eye - RANZCO Affiliates Quarter 2 2020 55 CERA Update MDFA Update How COVID-19 is Changing the Future of Eye Care MDFA’s Online Campaign Supporting IVI Patients During COVID-19

The rapid uptake of telehealth As the COVID-19 pandemic has spurred “After COVID-19, face-to-face consulta- In any other year, Macular Disease campaign. Ita is held in high regard by technology, and mental wellness with services to stop the spread of Australia’s health care practitioners tion will become increasingly challenging,’’ Foundation Australia (MDFA) would the macular disease community and low vision. to replace many routine face-to-face says Mingguang. avail of this edition of Eye2Eye to share the feedback was almost instantaneous, The webinar format allows MDFA to coronavirus is adding impetus to appointments with phone or video “Artificial intelligence integrated with Macula Month campaign activities. This with a doubling in calls to the National continue to reach out and provide edu- research to develop innovative consultations, telehealth has moved into automation and robotic technology will annual campaign, with a goal of urging Helpline days after the release of the cation remotely to a wider audience new ways of diagnosing and moni- the mainstream. enable us to develop a virtual clinic as a Australians in higher risk groups to book community service announcement. across Australia. Importantly, the tech- CERA researchers are leading major new model of care. in for an eye examination, has been a Her calm reassurance has gone a long nology provides more opportunities for toring patients with eye disease. staple of the eye health calendar over way to address the concerns held by projects to develop innovative new “We are working hard to not only make people living with or caring for someone recent years. many wAMD and DMO patients. We are diagnostic tools that can be used in AI more accurate, but also faster, easier with macular disease to access profes- The impact of COVID-19 meant grateful to Ita for her continued support the home or outside of traditional eye to use and less dependent on operators sional advice in an online environment that our planned Macula Month 2020 in awareness campaigns aimed at saving from the comfort of their own home clinic settings. They predict the shift and physicians.” campaign had to be ‘put on ice’ for a later sight. while in isolation. to telehealth services will continue In a separate project, Mingguang, date–which involved innovative use of MDFA also implemented an ambitious Many of the seminars are co-hosted to gather pace after the COVID-19 supported by the Google Impact technology–and instead, Macula Month phone support outreach program, with by experts such as retinal specialists, pandemic has ended. Challenge, has led the development of focused on very different messages. education officers using our extensive psychologists and nutritionists. This pro- AI bridging the eye health an app which enables people to measure In early April, ophthalmologists around database to make hundreds of calls vides for a more interactive forum where gap their visual acuity at home. Australia reported an increase in the num- to ‘check in’ on at-risk members of the participants can ask questions directly The app, which calibrates distance ber of cancellations for intravitreal injec- macular disease community. All of MDFA Prof Mingguang He is leading research to subject matter experts. All webinars using face recognition technology, has tion appointments due to fear and con- have been working remotely from home are recorded and available on the MDFA trialling the use of an artificial intelligence an accuracy level similar to tests taken in fusion around Coronavirus regulations. In thanks to our recent investment in inte- website for those unable to attend live. tool to identify people at early risk of grated technology. clinical settings. some clinics, up to one–third of patients The success of the webinar series will blinding eye diseases including diabetic were missing appointments, citing fears ensure the program will continue after retinopathy, glaucoma, age-related of breaching public health COVID-19 COVID-19 regulations have been lifted. macular degeneration and cataract. restrictions. This was despite RANZCO’s If you are an eye health professional After taking a photo of the back of government-endorsed COVID-19 Triage “MDFA also implemented and would like to participate in a webi- the patient’s eye, the AI system scans Guidelines categorising eye injections nar or suggest a relevant topic, please for signs of disease and prints out a and laser as urgent and essential. an ambitious phone contact MDFA’s education team at report identifying if the patient should This issue prompted us to focus [email protected]. be referred to a specialist for further our Macula Month messaging on the support outreach If you would like to invite your patients assessment and treatment. importance of maintaining sight saving program, with education to register for webinars, they can do so at “Vision impairment and blindness injections and laser treatments during www.mdfoundation.com.au/educa- Professor Mingguang He are major public health problems in COVID-19. MDFA made representa- officers using our tions to the Federal, State and Territory tion-sessions. All MDFA services are free Australia, with up to 50 per cent of major to the general public. eye diseases remaining undiagnosed,’’ Health Ministers to ask that government extensive database to messaging emphasise the importance says Mingguang. Dee Hopkins of urgent and essential treatment for make hundreds of calls “Artificial intelligence has the potential CEO, Macular Disease Foundation chronic health conditions including eye to close the gap in eye care by enabling to ‘check in’ on at-risk Australia screening programs to be introduced in health. We also rolled out a national inte- “Vision impairment and remote and regional areas that are cur- members of the macular grated media campaign featuring MDFA rently missing out on eye care services.’’ National Research Adviser, Prof Paul blindness are major The AI tool’s algorithm has been disease community” Mitchell and MDFA Medical Committee developed over five years using more public health problems Chair, A/Prof Alex Hunyor who spoke on than 200,000 images of the back of the the importance of attending scheduled in Australia, with up eye and has been found to be highly appointments during the pandemic. Community webinar series to 50 per cent of major accurate. They reassured patients on additional It is now being trialled in real world sanitisation protocols set in place to min- The community response to switch eye diseases remaining setting, including remote Indigenous imise the risk of disease transmission. education seminars from traditional communities in the APY Lands in Central A second wave of the media cam- face-to-face forums to a webinar format undiagnosed” Australia in a collaboration with the paign featured long time MDFA Patron, has been very positive and has attracted Nganampa Health Council and The Fred Ita Buttrose AC OBE making a direct strong registration numbers. Hollows Foundation. appeal to older, more vulnerable The webinars have allowed MDFA to The next step will be to compare Australians through a community ser- focus on specific topics of interest to the AI tool against current telehealth vice announcement. the macular disease community and models and measure accuracy, cost The messages, broadcast extensively people living with macular conditions effectiveness, ease of use, and patient by mainstream media, were supported such as nutrition for optimal eye health, and clinician acceptance. by a complementary, multi-stream digital safety in the home, low vision aids and

56 Eye2Eye - RANZCO Affiliates Quarter 2 2020 57 ORIA Update Ophthalmology New Zealand Update

Supporting the Future of Ophthalmology through Artificial COVID-19 has been said to be the most website (www.ophathlmologynz.co.nz) A greater outcome from this egalitarian challenge seen in the last 100 include: meeting was the strength of our Intelligence years as the challenges that are being • A resource package, including links to ophthalmologists, brought together by faced do not discriminate by country the various NZ bodies for assistance ONZ, to communicate across the nation, of origin – it is on every continent in in employment, subsidies, tax and across the private and public spectrum, ORIA support enabled Dr Stuart Keel, diabetic retinopathy cases in Australia the need for expert manual interpretation the planet. Of the 251 countries recog- health advice and policies. working together to ensure patients’ working with RANZCO Fellow Dr Angus go undiagnosed. of the photographs presents a barrier nised by the World Health Organization urgent needs were met in the safest Turner and Prof Mingguang He, to harness “Identification of eye diseases through to its wider use. The development of (WHO), 212 are reporting COVID-19 • COVID-19 workplace policies, in clinical settings possible in our new the power of AI for eye disease screening a screening program is an important an automated system of interpretation infections (as of 12 May 2020). Each of patient flow and infection control. COVID-19 world. in primary care. The ORIA Research Impact step towards the protection of visual solves this problem, and its integration these countries have their own envi- In order to increase communication The ONZ Board also took the time, Report published in 2019 highlighted function in the Australian population,” with an affordable and portable retinal ronment, regulatory system and more nationally, ONZ created a dedicated pri- while locked down in their homes, to research such as Stuart’s. explains Stuart. “Given that GPs are the camera offers great potential to increase importantly, health system. This is why vate Facebook group for ophthalmolo- attend to a Strategic Planning Session, Prof Stephanie Watson, Chair of the cornerstone of primary care and 85% the uptake of eye disease screening Ophthalmology New Zealand (ONZ) gists to exchange information and best which has clarified our vision, mission ORIA, commented that “Ophthalmic of the Australian population visit a GP within GP settings,” said Stuart. went into action during March through practice resources. and goals. research is highly valued by patients, service at least once every 12 months, to May, as New Zealand announced In addition to the resources, on 21 the profession, and the public. Research they should have a central role to play Prof Stephanie Watson a unique Level 4 Alert System on 21 April, ONZ convened a special COVID-19 such as Dr Keel’s has the potential to save in the opportunistic screening and Chair, ORIA March. New Zealand quickly moved to Update Meeting in conjunction with the sight by diagnosing conditions such identification of eye diseases.” full lockdown on 26 March, where all NZ Branch of RANZCO. This online meet- as diabetic retinopathy while they can For this ORIA funded project, an inno- non-essential business closed and all ing was attended by 87 ophthalmologist still be treated.” Research also provides vative screening system was developed New Zealanders (with the exception of members, non-members and RANZCO evidence so that better decisions can be to combine retinal photography with AI essential services) were asked to stay in executive and staff, in a discussion which made on how to treat patients, how to grading in a portable system. The aim of the “bubbles” of their own homes. Only centred around surgical options upon educate the profession, and to develop the technology was to facilitate detec- urgent and emergency medical care was moving from Level 4 to Level 3 and policy to influence stakeholders, such as tion of diabetic retinopathy, glaucoma, permitted, and all elective surgery was beyond. the government, and inform the public. age-related macular degeneration and cancelled. The outcome of this meeting was a For example, ORIA’s contribution to the cataract, in an opportunistic primary During this time, ONZ’s work has been coordinated agreement on surgery post MBS review. care setting. A rural general practitioner to assist our ophthalmologists with Level 4, a greater understanding of DHB There was an urgent need to fund is currently being trained to use the advice and resources on how to attend and private workflow requirements, and this project, as up to 500,000 adults in system. to their patients and workflow in these how providers could assist in the National Australia have vision impairment or “Delays in diagnosis of common eye challenging times. An important func- blindness with around 80% of vision diseases dramatically increase the burden tion has also been to ensure that we Response. Further resources from this Reference available upon request. Please email loss avoidable through early detection, of vision loss in the Australian community O RIA created forums where ophthalmologists meeting include the RANZCO Statement RANZCO. prevention and treatment strategies. and health care system. Although retinal could work with the Ministry of Health on Level Changes and the ONZ An estimated 50% of glaucoma and photography can increase early diagnosis, ADVANCING EYE RESEARCH and each other. Guidelines on Elective Surgery post- Resources that have been compiled and Level 3 (available to members on the ONZ made available to our members on our website: www.ophthalmologynz.co.nz). KeepSight Update: 2020 Australian of the Year Dr James Muecke Lends Support to KeepSight

The KeepSight team recently caught up with Australian of the Year and Chairman of Sight for All, Dr James Muecke to discuss diabetes and eye health. James has devoted much of his career to fighting blindness around the world and is lending his support to KeepSight, Australia’s diabetes eye check reminder program. The program is run by Diabetes Australia, in partnership with Vision 2020 Australia and is supported by the Australian Department of Health, Centre for Eye Research Australia (CERA) and Oculo, as well as Specsavers, Mylan, Novartis and Bayer. The eye care sector is being urged to register as KeepSight providers and then sign up their patients for regular reminders. L-R: Ms Judith Abbot (CEO, Vision2020), Dr Kate Taylor (CEO, Oculo), Dr James Muecke, A/Prof Peter van Wijngaarden (Deputy Director, CERA) and Prof Greg Johnson (CEO, Diabetes Australia).

58 Eye2Eye - RANZCO Affiliates Quarter 2 2020 59 Save Sight Institute Update Optogenetics for Vision Restoration

“I’ve been told nothing can be done” is it similarly reattains its light sensitive of Physiology at the University of present, we are completing pre-clinical a phrase we commonly hear from our state through a simple process of Sydney, we have demonstrated that trials. The ultimate aim is to complete patients with inherited retinal degen- spontaneous relaxation. Third, it AAV gene therapy leads to a significant the requisite steps to conduct a Phase eration (IRD). As ophthalmologists, we shows preferential sensitivity to long production of bReaChES in retina I trial of optogenetic gene therapy in know that this isn’t true. Many things wavelength light, which is both less (Figure 1). In turn, this expression results Australia. can be “done” to assist people in living damaging to the retina and better in novel light sensitivity of normally A/Prof Matthew Simunovic with conditions that are considered transmitted by the optics of the eye, light insensitive retinal ganglion cells “untreatable”. But what about active than short wavelength light. The (Figure 2). Importantly, responses Save Sight Institute interventions for IRD? Luxturna (vore- treatment itself is delivered using a occur at light levels equivalent to tigene neparvovec) gene therapy has “conventional” gene therapy approach bright indoor lighting and with been approved by the US Federal Drugs – the genetic sequence for bReaChES is receptive field sizes similar to those Administration and the European incorporated into an adeno-associated achieved through photoreceptor- Medicines Agency for patients with viral (AAV) vector. The vector, in turn, mediated stimulation (Figure 3). As RPE65-associated retinal degeneration. delivers its genetic payload to retinal a consequence, this is anticipated to The impressive results of the pivotal cells which results in stable and support adequate levels of visual acuity trials of this drug should not be down- sustained protein production. Together and light sensitivity without the need Figure 1: Human surgical retinal explant in tissue culture exposed to an adeno-associated played, nor should the importance of with our colleagues in the Department for stimulus enhancing goggles. At virus carrying the sequence for bReaChEs demonstrating co-localisation of Hoechst IRD as the leading cause of blindness staining (blue) and bReaChEs expression in the retinal ganglion cell layer. in people of working age. Nevertheless, luxturna gene therapy is suitable for perhaps only one in 300,000 people and more than 250-causative genes have been identified in association with IRD. This is further compounded by the fact that around 30% of patients presenting to specialised clinics never receive a firm genetic diagnosis. Clearly, there is a need for causative gene-independent approaches for vision restoration in IRD. Optogenetics, which was originally developed in the early 2000s to study and control neu- ral circuits in the brain, is just such an approach. In many respects, it repre- sents a biological alternative to the electronic retinal prosthesis. Regardless of the genetic cause, the final common pathway to vision loss in IRD is the loss of cone and rod function. However, the second order (e.g. bipolar) and third order (i.e. retinal ganglion) cells per- sist. It is these cells that are targeted by optogenetics, which renders them light sensitive, thereby restoring vision. This is achieved through the introduction of light sensitive proteins or opsins. At the Save Sight Institute, we have been studying the effects of a new opsin, bReaChES, on the retina. bReaChES is a modified channelrhodopsin – a class of light sensitive protein found in unicellular green algae which is particularly promising for vision restoration. First, bReaChES not only acts as a “light- Figure 2: Light-evoked responses from a retinal ganglion cell in a wholemount retina detector”, but it is also simultaneously following intravitreal injection of AAV2-CaMKIIα-bReaChes-eYFP. Responses were evoked Figure 3: Receptive field characteristics to light stimuli from patch-clamp recordings from two individual retinal ganglion cells expressing capable of activating nerve cells without by flickering yellow light (565 nm) at (a) 1 Hz, b) 3 Hz, c) 5 Hz, d) 10 Hz and e) 30 Hz) following bReaChES. These demonstrate intrinsic light-sensitivity and responses over retinal areas ranging from 75-300 microns. The x-axis and a series of complex reactions. Second, bleaching of the photoreceptor response. y-axis represent distance in microns and the heat map represents the peak spike frequency (left column; spikes)

60 Eye2Eye - RANZCO Affiliates Quarter 2 2020 61 Policy and Advocacy Matters

during this crisis. That adoption has been assist us and work collaboratively to build Change in the Midst of a Crisis driven by past experience, including on our experience to date. With careful the more recent SARS, and an acute “Our Indigenous rural public health policy, effective messaging awareness of the significant morbidity and Dr Kris Rallah-Baker delves into We live in interesting, though not society. The threat of false messaging and and the utilisation of appropriate unpredicted, times. The COVID-19 crisis misinformation through social media has mortality incurred due to the worse social and remote communities technologies, there is no reason we the Aboriginal Health Sector’s determinants and disease burden suffered has challenged our systems and forced been confronted with nimble responses have remained free of cannot continue to protect all Australians. response to COVID-19 via the novel approaches to the business of doing from medical experts and government by Aboriginal and Torres Strait Islander We all need to take something from our creative use of media and the business across the whole of society. In advisory units utilising those same Peoples. Technology has been utilised to COVID-19.” experience during this crisis and just the context of patient care, we have been platforms in real time. facilitate messaging with the production like Chicken Little, realise the sky has dissemination of public health of parodies, crisis webcasts, information not fallen in. With judicious application, forced to re-think the structure of our In ophthalmology, although critical We are indeed “The Lucky Country” sessions supported by web-based technology has helped protect us. messages to remote and diverse traditional Western medical paradigms care delivery, including the administra- and we all hope our current success in and the delivery of care. Telehealth item conference, facilitated by the Australian communities and language. tion of intravitreal injections, has had controlling COVID-19 will continue. If, numbers for phone consultations have to remain an in-person event, review Indigenous Doctors Association (AIDA) and Dr Kris Rallah-Baker however, as ophthalmologists we are groups. been opened across specialties and appointments for stable conditions and related peak bodies, as well as the utilisation FRANZCO, QLD required to return to restricted and online virtual meetings have flourished. some post-op reviews have been able to of numerous social media platforms. Our Social distancing has been enhanced be undertaken via telephone consulta- Indigenous rural and remote communities urgent face-to-face care only, we will and often enabled with the assistance tion. In Western Australia, where the dis- have remained free of COVID-19. need to remember where technology can of technology. The untapped reserves tances are vast, telehealth services have within our IT systems have performed been utilised in ophthalmology for quite seamlessly and demonstrated that if a period now and lessons can certainly need is the mother of invention, then in be learnt from that experience in the this, crisis has been the mother of change. current climate. It may be time that we In Australia, we are lucky – we have re-consider our traditional emphasis on done well in controlling the virus and bringing our often elderly and infirmed “The untapped reserves have successfully flattened our curve, to patients in to see us in person when an date. That effort has not been without trial alternative may be available, particularly within our IT systems and personal sacrifice, but in the absence in the case of routine review, building have performed of current technology, much of what has on our history of ophthalmology being been achieved would simply not have a quick adopter of new and proven seamlessly and been possible. We had the technology technologies. That is not to discount the present and operational. Consequently, inherent value of person-to-person con- demonstrated that if virtual meetings, consultations and sultations but simply to suggest that we interactions have placed us in a very reserve our resistance to new tools in the need is the mother of different position than our forebears who area of tele- and virtual health which may invention, then in this, endured the Spanish Flu. emerge to enhance our armoury availa- Public messaging, particularly to ble in the pursuit of best patient care. crisis has been the remote and diverse communities and Mainstream Australia has done very language groups, has been enabled with well in adopting and adapting to change mother of change.” the widespread and rapid dissemination in the health care system in response of official and unofficial messaging. to COVID-19 and in no small means our Ranging from government apps to Indigenous population has been even local onscreen guides, we have utilised quicker in that adoption. The online MJA information technology to rapidly spread published on 29 April 2020 included an the latest public health message. As the article titled “First Nations people leading crisis has evolved and our knowledge of the way in COVID-19 pandemic planning, the virus improves, our infotech systems response and management”, which have informed the public on a real outlines the prior experience and drivers time basis of those updates. Infotech behind Australia’s First Nations speed in also allowed the rapid translation of responding to the onslaught of COVID-19. the English language to cater for our It is ironic that the world’s oldest cultures language-diverse communities and have been most adept at adopting adapted messaging to remain relevant new technologies to communicate and and targeted to other diverse groups in interface with the health care system

62 Eye2Eye - Policy and Advocacy Matters Quarter 2 2020 63 RANZCO Blue Light and Digital In Screens Position Statement Practice

At the beginning of the year, RANZCO released an evidence- based position statement on the effects of blue light and digital screens on vision. We dive through some key aspects of the statement here.

The harmful effects of blue light from mobile phones, tablets and Top Tips to Maintain Social Distancing and Boost computers is a controversial issue. Given the mandate of RANZCO’s public health committee to improve public awareness by providing Hygiene in your Practice accurate, up-to-date information about health risks, RANZCO has responded with an evidence-based position statement. Over the past 1. Space all waiting room chairs 1.5m 5. Encourage all patient carers to wait in year, there has been an influx of media articles on the health impacts of apart and place easy visual sym- the car or outside to minimise bod- blue light and digital screens – some based on misinformation. To reach During this time, to ensure state bols on the floor for where patients ies in the practice. Encourage them a position that reflects expert consensus, the public health committee should wait upon arrival/departure at to stick to appointment times with led a collaborative process, with careful consideration given to external health guidelines are followed reception. minimal waits to ensure time within stakeholder feedback. and social distancing measures 2. Upon entry to the practice, have the practice is also minimised. For In Summary are maintained within practices, a dedicated patient screener to elderly/frail/multiple carers, call for ensure screening criteria are met and them to come into the practice when No evidence exists to suggest that normal environmental exposure strict but easy guidelines for all temperatures taken. the doctor is ready to see them. to blue light, including digital screen technology, causes measurable team members and patients are 3. Install automatic hand sanitisers with 6. Have your protocols and screening damage to eyesight (unlike UV light, which has a number of potential World Health Organization’s (WHO) criteria visible on your website harmful effects as highlighted in a separate RANZCO UV Eye Protection required. Here are some top tips “How to hand rub” posters. and include the link in your SMS Position Statement). Filtering out the blue light from screens is not to maintain social distancing and reminders, inbox auto replies and necessary for general use. However, there may be a benefit to reducing 4. Provide training on hand washing/ boost hygiene in your practice in phone answering message. screen time in the evening or using night time settings on screens PPE/COVID19 to all (the DHS has a in the few hours before bedtime to reduce interruption to circadian General health effects of exposure the midst of COVID-19. module everyone can complete and 7. Install shields on slit lamps, reception rhythms. General measures to reduce symptoms of eyestrain include to light from digital screens send a certificate). desks and lasers. taking regular breaks and focussing on distance objects from time to time as well as ensuring spectacles, if worn, are appropriate for the task. • Night time exposure to blue light from The RANZCO position statement recommends consulting a health care screens can affect circadian rhythms professional if symptoms of eyestrain persist. (the biological clock) and suppress Ideas to Boost Staff Morale During COVID-19 melatonin. Key conclusions around the risks associated with normal environmental exposure to blue light include the following: • Blue light in the range of 470-490 nm is more effective in phase-shifting the • Make sure communication occurs • Ensure all staff are involved in extra Sources of blue light: Although people often associate blue light with human circadian clock compared to to ensure everyone is onboard and cleaning to the point it almost becomes computers and phones, the largest source of blue light is sunlight. monochromatic light of 555 nm. initiatives are rolled out collectively. a competition and the team are Other sources include fluorescent light, compact fluorescent light It is also important to ensure Schedule regular Zoom/check in times motivated to finish work together. bulbs and LED light. • Exposure to light-emitting e-readers at everyone in the practice is bedtime may negatively affect sleep. with all teams to consult and gain • For team members working from In-built protection from blue light: A small amount of UV light gets supported. Here are our top feedback when creating new policies/ home, ensure that the WHS checklist through the visible spectrum of the human eye (short wavelength blue ideas to boost staff morale during procedures so everyone has ownership is completed – the AAPM provides a light to long wavelength red light) and some infrared will travel through COVID-19. of the process. This also allows for template. clear ocular media to the retina. The macular pigments (zeaxanthin, everyone to see each other’s faces and • Don’t forget to maintain birthday lutein, and meso-zeaxanthin) protect the retina by absorbing 40% Protecting against digital eye reconnect with the team. recognition, celebrate work of the high energy (short wavelength). strain • Ensure staff feel safe. If they feel safe, anniversaries and other gratitude Evidence of impact of blue light: While there is some experimental there will be a positive mindset all events. • Regular breaks when reading and using animal data indicating a correlation between blue light exposure and around and work capacity will be • Check in with each staff member digital devices can be helpful to reduce reduced cell viability, these findings cannot be generalised to human heightened. informally and on a one-on-one basis symptoms of dryness of the ocular light exposure due to the nature of the exposure in the experimental • Point all staff in the direction of to see how they’re travelling in the new surface. settings being very different to normal environmental exposure. resources for their personal wellbeing, normal of COVID-19. What is the risk to the eye of exposure to digital screens? Researchers • While blue-light blocking (amber) e.g. HeadSpace and DownDog are RANZCO Practice Managers Advisory have measured output from some of these devices to inform risk to the spectacles can impede the capacity offering free services to healthcare Group eye and found that computer screens and smart phones have a very of bright light to supress melatonin workers. low level blue light radiance being about <0.5% of the luminance production, there is little evidence to • Consider some fancy dress/brightly- If you have any specific questions, level that the International Commission on Non-Ionizing Radiation show they improve visual performance coloured scrubs/themed days to divert Protection consider safe. or conserve macular health. please post them on the Discussion attention from the doom and gloom of Board in the RANZCO Practice Dr Jane Khan COVID-19. Manager’s Lounge here: Chair, RANZCO Public Health Committee

64 Eye2Eye - Policy and Advocacy Matters Quarter 2 2020 65 Valuation based on net tangible assets and intangible assets (Goodwill) using average profit of $400K. Goodwill (intangible asset) can be valued at 3.5x Superprofit. Superprofit is the average annual profit of $400K (450K + 400K +350K divided by 3) minus a rate of return of 20% on the net tangible assets ($140K) which gives a figure of $372K. Then 3.5x the Superprofit gives an estimated value for the intangible assets (“Goodwill”) of $1,302,000. Net tangible Assets $140,000 Then a valuation based on the What are the general Worked example total of the tangible ($140K) principles? Let’s explore the factors used in each and intangible ($1,302K) assets will give a final figure of of the valuation methods using a “real” What’s it There are a few ways to value a business $1,442,000. practice. and we’ll explore the three that are most relevant to medical practices: Vista Central is an established practice with an annual turnover of $2 million. It 1. Percentage of annual revenue Worth? employs staff and is responsible for pay- Medical practices make money ment of all fixed and variable expenses. Thus, Vista Central is valued at between based on revenue from doctors’ bill- The annual ophthalmologists’ billings $1.350 and $1.458 million. ings. On average, a medical practice (which includes principals and locums) Dr Kiran Sindhu maps will make 40-60%, with larger med- A grain of salt Business Vocabulary ical practices being at the higher is $3 million. And over the past three out the importance of end of the scale. To calculate the years, the profits were: I cannot overemphasise the estimation Annual revenue is the total turnover or income of a practice. worth of the practice, you need to Last year - $450,000 character of valuation. Although we’re Average profit is the annual profit averaged over a given number of business valuation for understand the current billing pat- Two years ago - $400,000 using financial principles, business years. terns and revenue. Once you know Three years ago - $350,000 valuation is not an exact science. Ultimately, the value of a practice really Weighted average profit is annual profit averaged over a given num- that, and based on the size of the Fellows and trainees. It has net tangible assets of $140,000. depends on future (therefore uncertain) ber of years but giving more weight to more recent profit results. This practice, multiply the billings reve- This is all the information we need to value potential and circumstances and values method either reflects favourably on a practice with growing profits nue by between 40% and 60%. You spent a decade studying medicine the practice. are ultimately set by what the market is but penalises a business that is losing market share with dropping 2. Multiple of profit and almost the same amount of time 1. Percentage of annual revenue is willing to pay. profits. For example, ophthalmology prac- building up your practice. What is it based on billings of $3 million mul- I don’t profess to be an expert on this Tangible assets is an umbrella term that covers non-fixed current tices usually provide a 3 to 3.5 times worth? This is a question that many tiplied by 45% resulting in a practice matter but merely provide some back- assets like cash holdings and trade debtors plus fixed current assets established Fellows will ask as they multiple on profit. Once you know valuation of $1.350 million. ground in understanding the concepts like plant and equipment and trademarks. start to consider retirement, succession the average profit of a practice, of the different ways businesses are 2. Multiple of profit shows the average Intangible assets include things like ‘goodwill’ and there are a few planning and life after ophthalmology. multiple it by 3 or 3.5. valued. profit is $400,000 and this is multi- ways to quantify them into a value, with one being a 3.5x multiple of Business valuation is also important 3. Net Total Assets It goes without saying that one should plied by 3.5 resulting in a practice the superprofit. for newly graduated Fellows who are This principle takes into account seek their own accounting, financial and considering joining an established practice. valuation of $1.400 million. Using a Superprofit is the maintainable profit that is generated over and both tangible and intangible assets legal advice where appropriate when Understanding the value of a business is weighted average profit method, the above the industry average or normal profit and is calculated as to arrive at a figure. Average profit such major business decisions need to basic due diligence in assessing whether profit will be 416.7K (450 x 3 added to follows: (or weighted average profit) is used be made. the buy-in* price is reasonable and makes as a baseline for calculating the 400 x 2 added to 350 x 1 with the total Average (weighted if applicable) Profit minus fair return (20%) on a viable business case. Superprofit which in turn is used to divided by 6) which when multiplied *Buying-in will be discussed in a future article as there are numerous factors, including net tangible assets. Prior to understanding how to value estimate a value for the Goodwill by 3.5 results in a practice valuation or Average maintainable profit minus normal profit of $1.458 million. This increased val- non-financial ones, that will need to be a business it is important to know a few (intangible assets) as per the for- considered. Total assets are the combined worth of tangible and intangible assets. basic business accounting terms. mula outlined under the definition uation using the weighted average of Superprofit. method reflects a business showing a Dr Kiran Sindhu Liabilities include things like outstanding loans, GST payable, What is business valuation? employee PAYG and payroll tax liabilities and employee leave There are many ways to value good- future growth trajectory. FRANZCO, NSW entitlements. Business valuation is a process and a will and these include: 3. Total of net tangible assets and Net assets are the total assets less the total liabilities. set of procedures used to estimate the • Superprofit method–only this intangible assets (Goodwill using the Return on investment (ROI) is calculated by understanding what economic value of a business or part of method will be discussed, multiple of superprofit calculation money was made less what money was spent in reference to the a business. People use valuation to deter- • Average profit method, method) resulting in a practice valua- investment. mine the price they are willing to pay to • Capitalisation method, tion of $1.442 million as calculated in buy, or buy-into, a business. • Annuity method. the next column.

66 Eye2Eye - In Practice Quarter 2 2020 67 Obituaries

Royal Charter was approved and now knowing everyone – an annual ‘family’ Or you can cherish his memory and let it live FRANZCO, after amalgamation of the reunion. on Dr Graeme Warwick Johnson Australian and New Zealand Colleges. The Accompanying Persons Committee You can cry and close your mind, be empty 1 January 1934 – 11 February 2020 Graeme, with the help of Margaret met weekly to organise the programs on and turn your back Wilson, ran the College from the Medical the sixth-floor cafe in David Jones. As Pam Or you could do what he would want, Eye Service from 1969 to 1975 – just the said, “It was fun, very enjoyable and we smile, open your eyes, love and go on. “You are judged by what you do while two of them initially, with little help. knew everybody”. They called him Gradie A musical tribute was played to honour passing through.” They were very dedicated. Graeme had Graeme and Pam, with a wide circle of He was a gentleman – articulate, intelligent, Graeme and to also serve as a comfort to Graeme Warwick Johnson was born in to give up half to one day a week from and well dressed (unless he was working friends, participated in a variety of activities Leeton and was educated in Artarmon his practice to read and answer all corre- those left behind. on his Triumph). He was always well which included walking, golfing, skiing, and Primary School and The Shore School. He spondence by hand in the days before mannered; a man of principle, voracious enjoying wine and good food. They walked Graeme is Going Home graduated with a Bachelor of Medicine emails and faxes – a monumental task. reader, sensitive and caring about other all over Australia and New Zealand with It’s not far just close by and Surgery at the University of Sydney It was made more difficult when the people, which reflected on his care of his Club Ped. They organised annual ski trips Through an open door and moved on to do his residency at President came from another state. The patients. He was a ‘Gentle Man’, a ‘Good at Arlberg Ski Lodge where Charlotte Pass Work all done care laid by the Lewisham and Royal North Shore load was eased with the appointment of was a highlight. Graeme even conquered Man’, a ‘Compassionate Man’ and a ‘Good Going to fear no more. Hospitals. He did his ophthalmic train- Jim Fair, first Executive Secretary in 1973 the dreaded ‘funnel web’ in Thredbo and Friend’. Mother’s there expecting me ing as an ophthalmic registrar at St and Graeme continued on as Secretary was quoted as saying, “We came, we saw, With varied interests (included home- Father’s waiting too. Vincent’s Hospital Darlinghurst from until 1975 when Dr Michael Steiner took we conquered”. made gourmet pies) and a wide circle All the folks gathered there 1962 to 1963 and obtained his Doctor over. Graeme had to run his practice in Their son Tony’s death was a devastating of friends, he was a man of many parts. All the friends I knew of Osteopathic Medicine in Sydney. His Manly, Macquarie Street and sessions blow to the family. The loves of his life were his family and at the Medical Eye Service, including All the friends I knew overseas training and further studies were The last years more especially tough his Triumph Renown, which we all saw at running the Glaucoma Clinic at the done at the Moorfields Eye Hospital in as Graeme’s condition deteriorated. Pam I’m just going home. London, specialising in glaucoma under various stages of restoration and which Medical Eye Service and the VMO at St and Graeme have faced this with courage, Imagine Graeme being greeted by and Sir Stephen Miller at High Holborn. He occupied a permanent space in his garage Vincent’s Hospital. resilience, compassion and humour. Pam reunited with his mother, father and his obtained his Fellowship at the Royal all his practising life. Restoring the Triumph Graeme maintained his involvement was a tower of strength as she cared for beloved Tony. College of Surgeons in Edinburgh and was was his labour of love. It was a lifetime’s with the Medical Eye Service through Graeme, with love and devotion, and with Graeme was survived by his wife appointed as VMO at St Vincent’s Hospital. work and when completed, he joined the Ophthalmic Association Limited and, the help and support from Meg, Mandy, Pam, daughters Megan and Mandy, and Graeme returned to Sydney in 1967 and the pre-1954 Triumph Club and attended as Chair in 1988, transferred the building Rubi and family and friends. grandchildren Lili, Jack and Ollie, and the set up practice in Manly with a session numerous rallies in Victoria and New South in Commonwealth Street to the College Graeme is now at peace – free from pain each week in Macquarie Street and at the Wales. He also completed a panel beating which was eventually sold to fund the extended family. He will be fondly remem- and suffering, at peace where the angels Medical Eye Service. Subsequently, he and chrome plating course. Some of us purchase of the building which houses bered and missed by all his family, friends, learn to fly. became a Fellow of RANZCO. were privileged to have been driven around our College today in Chalmers Street. colleagues and patients. In 1968, he married Pam Armstrong and Melbourne after it was restored before it As Chair of the Ophthalmic The reflection below was read at Graeme’s Dr Frank Cheok OAM a young family followed: Tony, Megan and was eventually sold when his health deteri- Association, Graeme also donated funeral: FRANZCO, NSW “…a man of principle, Mandy. They also fostered and educated orated. As Pam said, “It was a labour of love approximately $1M accrued from the He is Gone David Robertson. and he loved the journey.” Association’s investments to fund the voracious reader, Graeme practised in Manly until 2000 In the early days, he drove a Fiat 500 new Chair of Ophthalmology at the You can shed tears that he is gone when Dr Simon Irvine took over. He named Didimus – small enough to park University of NSW. Or you can smile because he has lived sensitive and caring continued to work with Simon until between two parked cars at right angles in Graeme was also active in the Archives You can close your eyes and pray that he will his retirement in 2010. Simon writes, the old driveway at St Vincent’s. Committee with Neville Banks. come back about other people, Or you can open your eyes and see that he “Graeme was a very good ophthalmol- Contribution to the College of Graeme always had tremendous which reflected on his ogist and a great colleague and teacher. support from Pam especially during has left [He was] a kind spirit and astute clinician; Ophthalmology some difficult times in the early years Your heart can be empty because you cannot care of his patients.” kind, gentle, always working with the Graeme’s contribution to the College has with a young family. The Annual see him best interest of his patients at heart. The been enormous. Congresses had an organising commit- Or you can be full of the love that you shared best workmate anyone could wish for.” He succeeded Dr David Swan tee which did all the work to make the You can turn your back on tomorrow and live In Macquarie Street, he was loved by who was Secretary to the then OSA Congress successful. There were no yesterday staff and patients alike. He used to look (Ophthalmological Society of Australia) conference organisers then. It was all Or you can be happy for tomorrow because forward to coming in from Manly and one as the first Secretary of the newly formed hands-on deck with the ladies filling the of yesterday of the secretaries, Narelle, would buy him College of Ophthalmology in 1969. We satchel with name tags, lists, manning You can remember him and only that he is a pie for lunch. were MACO then, then FRACO when the the registration desks, greeting all and gone

68 Eye2Eye - Obituaries Quarter 2 2020 69 part of South Australia. They were based Dr William Thomas Hudson Scales at Armata and spread to Ernabella North and Indulkana and Coober Pedy South. 22 February 1918 – 2 April 2020 Following this, Bill took over the eye care of the Aboriginal people in the far west of the Bill was born in England near Salisbury, 1978, he became a Fellow of the College. state. He used to visit about twice a year Wiltshire and emigrated to Sydney in During the Grafton years, he also had and later, up to four visits. Accompanied 1919 where the family lived at Epping. a branch practice at Coffs Harbour and by general practitioner, Dr Richard Jolly, He attended the local public school and was a Senior Honorary Specialist at both they travelled to Yalata, Coonibba and then Sydney Grammar School, where Grafton Base Hospital and Coffs Harbour Koonalda and, by Richard’s twin engine he gained the Wigram Allen prize for Hospital. Cessna, to Maralinga and thence to Oak Honours Mathematics in his final year Valley. Bill also did further visits to the in 1935. He also became the leader of areas they had already surveyed when no the Rifle Shooting Team and excelled one else was available. In recognition of in that sport both at school and later at Bill’s work in this area, he received an Order University, where he received his Blue in “In recognition of Bill’s of Australia Award in 2007. 1939. work in this area, he Bill had to retire at the end of 1982 In 1935, Bill was enrolled in Medicine 1 from both hospitals as his 65th birthday at Sydney University and graduated MB received an Order of approached but, not being ready to fully BS with Honours in 1940. retire, did locum work. This took him all In 1941, he became a Junior Resident Australia Award in over Australia, with some time in the at Sydney Hospital and in November Northern Territory at Darwin and Alice Dr Bill Scales performing remote ophthalmology that year, joined the RAAF as a Squadron 2007. Springs as well as all the eastern states. Medical Officer. During WW2, Bill served He finally stopped all ophthalmology in operational areas at Darwin, as well as In April 1974, they left the Clarence in 1995 at age 77 and found other inter- Dutch New Guinea, Borneo and Labuan, Valley and Bill took up a position as the ests. One major occupation post-retire- finishing the war as a Squadron Leader. Consultant Specialist in Ophthalmology ment was serving as a consultant on the He was at Labuan when the atomic for the Department of Veteran Affairs Pensions Committee for Adelaide Legacy, bombs were dropped at Hiroshima and in South Australia and the Senior taking the appeal cases for War Widows Nagasaki and was repatriate to Sydney in Ophthalmologist at the Repatriation to the Veterans Review Board, where Bill’s November 1945. Hospital in Daw Park, Adelaide. This medical expertise and knowledge of DVA Bill then became a surgical regis- appointment carried with it a position being of particular help. trar at Sydney Hospital for six months at the newly formed Medical School at At age 97, Bill and Pat returned to the before starting post–graduate training Flinders University. Bill also had an honor- Clarence Valley, to Yamba, to spend their in ophthalmology at the Sydney Eye ary position at the Children’s Hospital, final years. This was a very special time, Hospital. He received his Diploma in where he conducted outpatient clinics. with two of their four daughters retired Ophthalmology from Sydney University In conjunction with Dr Donald there and a community who welcomed in 1948 and with his wife, Patricia, went to Perriam, he developed the Department back their beloved Doctor Bill and his Lismore in northern NSW as an assistant of Ophthalmology and Bill serviced the beautiful wife. For Bill particularly, the to Dr T Boyd Law for 12 months. He was first outpatient clinic at the new school. pleasure he gained from reconnecting He was a Senior Clinical Lecturer at an Honorary Ophthalmologist to both with patients he had treated as children, Lismore Base Hospital and St Vincent’s Flinders and held that post until the full and nurses with whom he worked at Private Hospital in Lismore. time Professor, Dr Douglas Coster, was Grafton Base Hospital, made this final In 1949, Bill moved the family to Grafton appointed from England. move a real homecoming. and took up a deceased ophthalmic prac- In 1976, Bill joined with Prof Fred Bill was a wonderful husband and tice, where he practiced for 25 years. Hollows in the original Trachoma and Eye father, and a genuinely good man who will Bill was a member of the Ophthalmic Health Program. This consisted in, as near be fondly remembered by many. Society of Australia and when it became as possible, a complete survey of the eye the Royal College of Ophthalmology for health of the Aboriginal and white popu- Deb Thomson Australia, he became a member. Finally in lation in the remote areas of the northern Dr Bill’s eldest daughter

70 Eye2Eye - Obituaries Quarter 2 2020 71 Classifieds

Positions Vacant Paediatric/General Fifth year registrar position - Fellowship in Medical and Equipment for Sale Practices for Sale or Ophthalmologist Sunshine Coast, QLD Surgical Retina - Sir Charles Full-time Pediatric — Newcastle A new fifth year registrar position has Gairdner Hospital - Perth, WA Lease Ophthalmologist Paediatric/General Ophthalmologist been established on the Sunshine Items for Sale The Department of Ophthalmology Wanted – Full time ophthalmologist required two days a week to join or Coast. This post will a provide com- • Zeiss Visulas Yag He Ne Laser Sunshine Coast Practice For prehensive ophthalmology clinical for large private practice in Newcastle, locum in a busy general/paediatric within Sir Charles Gairdner Hospital, • Heidelberg HRT-3 experience with high surgical volume. Sale a seaside town two hours north of practice that sees most of the paedi- based in Perth, Western Australia, offers • Heidelberg HRT-3 on electric table It will feature significant subspecialty Well established and equipped prac- Sydney. atric patients in Newcastle, NSW (90 a Vitreoretinal Fellowship with accredi- with ACER Laptop. exposure in the areas of oculoplastics, tice in Noosaville at the Sunshine The population drainage is one million. minutes from Sydney CBD). tation by both the Royal Australian • Tomey Biometer AL 100 paediatrics and medical retinal. Coast, Queensland. There is no paediatric ophthalmologist We are fully equipped with OCT, FFA, College of Surgeons & RANZCO. Current model in excellent condi- For full details on this position visit Consulting two to three days per week. currently working in the area. Pentacam, IPL, optical biometry, SLT/ The next Fellowship position is due to tion, hardly used www.ranzco.edu/classifieds Longstanding referral base. This position would be for a full time YAG/Argon lasers, portable slit lamp commence in January 2021 with dura- All items located in Croydon, Victoria. E: [email protected] Well appointed modern rooms. paediatric ophthalmologist working in and auto refractor. This is an area of tion of 12 months. P: 0419 887 888 both private and public, and a hospital P: 0418 194 433 need (DWS). P: +61 8 9457 4718 E: [email protected] appointment would also be guaran- Private Practice E: : [email protected] P: 0416 221 022 teed with both private and public oper- E: [email protected] E: [email protected] Ophthalmology Zeiss CIRRUS 4000 HD-OCT ating theatre lists. Ophthalmic Practice For Sale Opportunity— Townsville Ophthalmologist In excellent condition. Regualrly main- P: +61 2 4929 5969 Vitreo Retinal Surgeon tained and serviced under a Zeiss - Towoomba, QLD E: [email protected] Seeking an ophthalmologist to work — Melbourne Wanted urgently - VR surgeon to join Optime Contract. Comes with table. Six room strata title suite in nine suite and ultimately take over busy Newcastle in a long established Townsville, Modern (paperless) clinic within 7km double story building built in 1983 General Ophthalmologist P: +61 2 4721 5899 based practice. Queensland practice with an older north of Melbourne CBD. Equipment located in Toowoomba CBD, including — Newcastle general ophthalmologist. E: [email protected] two locked undercover car parks. Great lifestyle and great professional includes Zeiss cirrus HDT 5000 OCT, General ophthalmologist with interest Only ophthalmic practice in the CBD opportunity. Strong possibility of public The practice is located in a modern, Zeiss Visucam 524 photo-Angiography, Original B and L Keratometer in glaucoma/medical retina to join and and walking distance from a dozen hospital appointment with Hunter New custom built premises with up to date HVF, Lenstar, topography etc. ultimately take over busy Newcastle $500 optometry shops. England Health Service with fee for ser- equipment. An adult patient clinic, predominantly based practice. Evoke Dx electrophysiology machine vice payment. cataract glaucoma and retina. An Two fully equipped consulting rooms, P: +61 2 4929 5969 E: [email protected] (still in the box so brand new) cost minor ops room (with basic operating P: +61 2 4929 5969 opportunity to grow your own subspe- E: [email protected] P: +61 7 4779 8008 $70,000, all offers considered. Good for microscope) & instrument room. E: [email protected] cialty practice with support. Full/Part time glaucoma suspects and neuro-ophthal- 532 laser, Tango SLT/YAG kaser, two Associate or Locum Position Ophthalmologist - South Flexible sessions and remuneration mology patients. Ophthalmologist — Hobart Octopus computerised perimeters & Available — NSW Coast, NSW options. automatic refractor. This position is offered on a full or part P: 0438 011 963 Opportunity to step into a busy and P: 0418 708 878 500K ono walk in - walk out. time basis. Busy Hunter Valley practice requires E: [email protected] FRANZCO accredited associate or long-established country practice in E: [email protected] P: +61 7 4632 9987 Our facilities include fully computerised Nowra. Extensive cataract, glaucoma part time locum for our Singleton and Items for sale: E: [email protected] equipment such as OCT, Fluorescein and medical retina work. Would suit a Muswellbrook clinics. Days are flexible. Glaucoma Sub-Specialist • Zeiss Cirrus OCT-4000 angiography, SLT, Yag & Argon lasers general ophthalmologist, full-time or A private surgery list will be available –Canberra • Zeiss Visucam 500 Fundus Camera and fundus photography. flexible part-time, with or without a for the right applicant. and Angiography You will be working with a team of sub-specialty focus. Great opportunity for an enthusiastic • Zeiss IOL Master 700 ophthalmologists with support staff Our practice features a solid client • Modern premises with six consulting ophthalmologist in Canberra, particularly • Zeiss FORUM-GO - with Glaucoma including optometry. We specialise in base, fully equipped consulting rooms rooms suited to a glaucoma subspecialist. For a full list of classifieds featuring the latest ophthalmic equip- workplace please scan the QR code. cataract surgery, diabetic & glaucoma • Testing rooms and procedure room Could include a good mix of general ment, fully trained and knowledgable • Ellex YAG TANGO II - for capsul- management and general ophthalmol- • YAG/SLT and retinal lasers, OCT, IOL ophthalmology with high volume ophthalmic technicians and adminis- tomy and SLT ogy. We have a high surgical volume. Master, FFA, VF, wide-field imaging, cataract surgery and intravitreal anti-VEGF trative staff. E: [email protected] We are offering an attractive salary A/B-scan. therapy. package or percentage–based associ- Sub–specialty training in medical ret- • 5 minute drive from public and This would be a full time position and ateship. Early Equity is available for the ina would be an advantage but is not private hospitals suitable candidate. mandatory. • Close to beaches, private schools would not be suitable for fly in fly out practice. C: Dr Gordon Wise C: Jami Street and the Southern Highlands P: 0419 379 214 P: +61 2 6572 2522 P: 0412 149 910 P: 0418 211 463 E: [email protected]. E: [email protected] E: [email protected] E: [email protected]

72 Eye2Eye - Classifieds Quarter 2 2020 73 NEW1

Food for Thought ciclosporin 900 microgram/mL Life After the COVID-19 Pandemic

Prof Peter McCluskey describes As Director of a large eye research centre health programs for remote communities. the changes ophthalmology has (The Save Sight Institute), I had to close our There are many others. Ophthalmologists research labs, get all staff to work remotely, will need to lead these multidisciplinary undergone as a result of COVID-19 suspend clinics, stop electrodiagnostic eye health care teams and manage the use and explores what future eye care testing and pause our clinical trials. We are of community-based screening and digital looks like post-pandemic. now just about to cautiously restart clinical technology. trials and onsite work in a careful, staged Ophthalmology has to shift to The rapid spread of COVID-19 throughout way. It will be many months, if ever, before personal digital technology and the world in a matter of weeks is a we return to “business as normal”. telehealth whenever possible. There are catastrophic, once in a lifetime event that My life as an educator has changed for already apps and attachments for phones has radically changed the world. There good. All hospital and university-based that assess visual acuity and capture high will be enormous economic and social teaching activities are now conducted quality digital fundus images and OCTs. fallout. The pandemic has overwhelmed remotely, mostly via Zoom conferencing. There are remote IOP measuring devices. medical care in many nations and Zoom and similar platforms allow rapid We will need to use artificial intelligence to exposed the fragile nature of medical sharing of high-quality images and inter- manage and interpret the large amounts logistics and its supply chains. active presentations where everyone of data. As there is no specific anti-viral therapy can hear and interact with the presenter. I now manage a significant number of and a low likelihood of an effective vaccine This has been a huge step forward for my patients via telehealth. This is far more at any time soon, it will be many years ophthalmology trainees at Sydney Eye useful and effective than I envisaged. I before we arrive back at a “normal” life after Hospital who rotate across Sydney as well recently conducted my outreach uveitis the COVID-19 pandemic, if we ever do. as to rural NSW, Darwin and Hobart. There clinic at the Royal Hobart Hospital from Social distancing, frequent hand is now equity of access to teaching, as my study in Sydney by pre-organising washing, enhanced cleaning, PPE use, the tyrannies of Sydney traffic and rural/ protocols to assess the patients and then and COVID-19 screening will be the “new remote postings are gone. reviewing them via a combination of normal” for years. Hospital-based models Future eye care will be very different. emails to transmit the images and confer- of medical care will have to change. This Eye disease commonly affects older peo- ence calls with the ophthalmologists, eye The first approved ciclosporin treatment is particularly relevant to ophthalmology ple who often have systemic co-morbidi- trainees and co-managing rheumatologist where crowded, under-funded, public ties, placing many in high risk groups for in Hobart. sector hospital-based clinics provide COVID-19 infection. Crowded hospital Through the Special Interest Groups delivered via nanomicellar technology equity of access to the disadvantaged in outpatient clinics are no longer safe. of RANZCO, we have an opportunity to our communities and tertiary level care for Many of our patients are terrified they set up sub-specialist networks to provide * those with complex eye disease. will catch COVID-19 at our clinics and are telehealth and web-based diagnostic and for Dry Eye Disease in Australia As a uveitis specialist working at Sydney deferring critical care. Social distancing management advice across Australia and Eye Hospital, my unit looks after many and infection control measures will greatly New Zealand. RANZCO should lead the * 1 development of these new systems for First TGA approved nanomicellar ciclosporin ophthalmic solution with a dry-eye related indication patients on systemic corticosteroids and restrict hospital patient numbers for both blinding eye disease. immunosuppressive therapy. We have had clinics and eye surgery for years to come. There are similar great opportunities to restrict our clinic numbers to those with Aerosol-generating surgical procedures for research into eye disease. The disease active vision threatening uveitis requiring require high level PPE and cleaning which phenotype and outcome data generated urgent assessment and treatment, and greatly impacts patient throughput. via all this new technology can be pooled have deferred as many patients as pos- We have to redesign our models of care to generate large databases and registries sible. We are monitoring many patients to greatly decrease dependence on our that will lead to diagnostic breakthroughs PBS Information: This product is not PBS listed remotely and via telehealth. overcrowded, poorly resourced hospi- and improved treatment algorithms. tal-based services. Our aging baby boomer The future of eye care will be different. population will generate large increases There will be challenges, but the opportu- Please review Product Information before prescribing available from in patients needing eye care. There are nity and time to re-imagine the eye health already very effective community based https://sunophthalmology.com.au/pi or Sun Pharma by calling 1800 726 229 care of Australians and New Zealanders is multi-disciplinary shared care models “Social distancing, now. CEQUATM ciclosporin 900 microgram/mL eye drops ampoule. Indications: Increases tear production in patients with moderate to severe keratoconjunctivitis for glaucoma, diabetic retinopathy and sicca (dry eye) where prior use of artificial tears has not been sufficient.Contraindications: Hypersensitivity to the active substance or excipients. Active frequent hand washing, cataract in operation in Western Sydney, Prof Peter McCluskey or suspected ocular or peri-ocular infection, malignancies or premalignant conditions Precautions: Potential for eye injury and contamination: avoided by FRANZCO, NSW not touching the eye or other surfaces with the ampoule tip. Contact Lenses: remove contact lenses prior and reinsert 15 minutes after administration. run by the Discipline of Ophthalmology Careful monitoring of patients with severe keratitis is recommended. Infections: resolve existing or suspected ocular or peri-ocular infections before initiating enhanced cleaning, at Westmead. There are high throughput treatment and if an infection occurs during treatment, withhold temporarily until infection resolves. Effects on the immune system: may affect host defenses remote glaucoma screening and manage- against local infections and malignancies so regular examination of the eye(s) is recommended, e.g. at least every 6 months, when used for long periods. PPE use and COVID-19 Paediatric use: safety and efficacy is not established below the age of 18.Pregnancy: Category C Adverse effects: Very Common and Common: instillation ment clinics operating via Moorfields Eye site pain, conjunctival hyperemia and punctate keratitis. Dosage and administration: one drop twice daily (approximately 12 hours apart) into the affected screening will be the ‘ Hospital in London that rapidly and effec- eye(s). Response to treatment should be reassessed at least every 6 months. Can be used concomitantly with artificial tears, with a 15-minute interval between tively manage very large patient numbers. products. Storage: Store below 25°C. Do not freeze. Store the ampoules in the original foil pouch. Protect from light. Date of preparation: February 2020. new normal’ for years.” Western Australia has very effective tele- This medicinal product is subject to additional monitoring in Australia. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse events at https://www.tga.gov.au/reporting-problems. Sun Pharma ANZ Pty Ltd ABN 17 110 871 826, Macquarie Park NSW 2113 Ph: 1800 726 229. Fax: +61 2 8008 1613. Med Info: 1800 726 229 Adverse events may be reported to Sun Pharma by either email: [email protected] or phone: 1800 726 229. 74 Eye2Eye - Food for Thought Date of preparation: Feb 2020. CEQ02/2020ad1 Reference: 1. CEQUA™ Product Information. 2020 Feb, 2020; Available from: Sun Pharma by calling 1800 726 229. 210mmx297mm_Medicus WA_MAY20.indd 1 18/5/20 2:50 pm