RANZCO 2022Laying the Foundations
for Equitable Eye Care
WRITER Melanie Kell
RANZCO’s 53rd Scientific Congress took place in Brisbane in late October. The sun was shining, the restaurants were full, and the city was abuzz with locals and eye care professionals alike, who were excited to be out and about.

CRYSTAL BALL GAZING

A range of disruptions are occurring in our workplaces right now and Professor Ben Hamer, described as a global expert on the future of work, had some surprising and not so surprising messages to offer about what eye care professionals attending RANZCO Congress can expect to experience in the coming years.

• By 2025 millennials will be the dominant demographic and largest proportion of managers in the workplace,

• By 2030, many organisations will have moved out of the CBD and we’ll be operating within satellite areas or neighbourhood business districts,

• Up to 80% of workers will be temporary – the traditional nine-to-five, five-day-a-week employees won’t exist,

• Rather than being on a standard contract, workers will pick and choose the benefits they want as part of their employment packages,

• Employees will demand fair and transparent pay (and bonus) structures,

• When choosing their employer, workers will value purpose over profit, with their decisions based on environmental and social governance,

• We’ll all place more merit on an organisation’s environmental and social impact report than its profitability,

• Employees will also demand greater access to mental health and well-being services, available 24/7 and,

• When applying for a new job, they’ll ask for referees within the organisation who can provide information on workplace culture, leadership style etc. It’s an employee’s world!

It’s a common fear that robots will take over our jobs, however there’s no need to worry. Prof Hamer said that although organisations will invest more in technology, as happens when faced with a tight, or recession-like economy, by 2030, robots will only make up 5% of jobs. These lost jobs will be offset by new workplace opportunities as our skill sets evolve.

OPHTHALMOLOGY INTO THE FUTURE

Having created a vision for the future of our workplaces, it was up to Associate Professor Nitin Verma AM, outgoing President of RANZCO, and his team to set out the future for ophthalmology in the form of the College’s strategy for 2030 and beyond.

This living document has been worked on since a meeting with the then-health Minister in March 2021, who challenged the College to come up with a plan to make eye care more sustainable and accessible, as demand for services increases into the future. A steering group was established in May 2021 to do this, comprising Fellows and staff of the College. Going forward, Dr Kristin Bell (clinical lead) and Committee chairs Dr Justin Mora, Assoc Prof Ashish Agar, Assoc Prof Angus Turner, Dr Shweta Kaushik and Dr Jesse Gale will drive the implementation of the plan. Since then, the group has worked in consultation with stakeholders to develop the plan, which is expected to change over time. Assoc Prof Verma particularly noted Dr Bell’s extensive work in this process.

The six key pillars that form the 2030 and beyond plan are workforce and training, service delivery, closing the gap, preventative health, sustainability, and global eye health. Importantly, tangible first steps have already been set out and were discussed by members of the steering group.

In his address to the audience, which summarised the plan, Assoc Prof Verma said a healthy ophthalmology workforce was dependent on a healthy public ophthalmology service across Australia as this is where most training does – and should – occur. He said more training positions were needed in public hospitals, particularly in regional areas. To tackle the workforce maldistribution across Australia, a new Regionally Enhanced Training Network has been established and two registrars from regional areas have been selected to commence training via this network in the new year. They will be regionally based for 60% of their training.

Assoc Prof Verma didn’t hold back when addressing the need to advocate for more public ophthalmology services, particularly in rural and remote and outer urban areas where services are lacking.

“Chronic inadequate investment and inequitable delivery of public hospitals has had, and continues to have, the biggest impact on the Indigenous population as service delivery is largely dependent on public hospitals and no gap services. We need to ensure Aboriginal and Torres Strait Islander people share in decision making when developing and implementing solutions to close the gap.

“RANZCO recommends special measures to facilitate access to health services… and a novel approach to funding all health care services – not just ophthalmology – to Aboriginal and Torres Strait Islander peoples within the current national health reform agreement network.

“There’s a broad consensus that unless we make fundamental changes, the costs of preventable illness and resulting healthcare demands will continue to be a major issue for governments and individuals alike. Preventative healthcare needs to be embedded within the national healthcare funding framework as an essential mark of healthcare,” he said.

Assoc Prof Verma said RANZCO would continue collaborating with stakeholders to advocate for a national children’s screening program as evidence highlights its role in ensuring early intervention and minimising the impact of key disorders on children’s developing visual systems. Investment in vision technology research will also continue, in an effort to implement universal national screening programs for diseases such as diabetic retinopathy.

In support of the national climate change strategy, Prof Verma said RANZCO continues to work to support the health industry in its effort to build climate resistance and reduce emissions. Practical steps include reducing doctors’ carbon footprint, minimising waste, and advocating for procurement practices that support sustainability of resources.

On improving the region’s health, Assoc Prof Verma said the College will respond to health needs, as expressed by countries in the region, by supporting government activity with service delivery, overseas aid packages and soft diplomacy.

“As doctors we have responsibility for not only a strong country but strong regional eye health,” he said.

The next steps are to prioritise key areas in the plan for advocacy to government, to continue stakeholder engagement, and seek new partners to help implement the initiatives. Additionally, RANZCO will seek to further involve members and standing committees because it’s not RANZCO the organisation that can achieve change, “it’s RANZCO Fellows who do the job”.

TACKLING GLOBAL INEQUITY

The Fred Hollows Foundation lecture, delivered by Professor Claire Gilbert from the United Kingdom, made recommendations to address inequities in eye health on a global scale.

Noting the wide variation in the prevalence of vision impairment between and within countries, she said some can be explained by demographic, genetic and environmental influences; most is explained by variable access to eye care.

A wide variety of access and outcomes from cataract surgery sees poor, non-literate, rural women and widows in low- and middleincome countries least likely to access cataract surgery. There is also wide variability in the quality of cataract surgery. There is no available data on other causes of vision impairment.

Prof Gilbert declared that “political and social changes are needed to address the root causes of inequity… the lack of access to high quality services is unnecessary, avoidable, unfair and unjust – it is inequitable”.

A United Nations resolution calls for member states to ensure access to eye care services for their population and encourages them to put in place an integrated whole-ofgovernment approach to eye care, building synergies with other development priorities. Additionally, the World Health Organization (WHO) has developed evidence-based packages for essential eye care services with indicators for monitoring. If adopted by governments, eye care would be included in health workforce planning and development, health financing, schemes which reduce out-of-pocket expenditure, adequate infrastructure, technology and medicines. Additionally, eye care service provision would be monitored and reported to the WHO and effective cataract surgical coverage would be considered as an index indicator.

“ …although organisations will invest more in technology… by 2030, robots will only make up 5% of jobs ”CLINICAL PROGRAM

Embedded within a program of serious clinical lectures and rapid-fire sessions, a light-hearted afternoon focussed on the real world of intraocular lenses (IOLs) for presbyopes and cataract patients entertained presenters and young Fellows alike.

In the first half of the session, Dr Andrea Ang, Dr Tanya Trinh and Dr Nick Toalster were put in the precarious position of arguing for why they would only implant presbyopic patients with monofocal, extended depth of focus and multifocal IOLs respectively.

In the session’s second half, Dr Ben LaHood argued for hydrophilic multifocal IOLs in cataract patients, while Dr Elaine Chong presented the case for only implanting hydrophobic multifocal IOLs in the same patients.

In reality, all of the doctors use a variety of IOLs, dependent on each patient. Neverthe-less, their strong arguments for and against various modes were an effective way to communicate features and benefits. The over-riding preference was not to implant IOLs in presbyopic patients if their long-distance vision is good. Extensive chair time is necessary to discuss options and outcomes and it is essential to ensure the patient understands the technology. Dr Chong said patients must realise they will never regain the vision they had at 16.

DAME IDA MANN MEDAL

Dame Ida Mann medal recipient Professor Helen Danesh-Meyer delivered a fascinating presentation on the complicated relationship between the eye and brain, which is a topic of her extensive research.

Having provided an overview of her current published and unpublished research she said her “over-arching assessment is that there is clearly an intimate interplay between the eye and the brain that we are only beginning to appreciate. This interplay extends to include late-stage nerve degenerative diseases and is likely to have a clinical role in diagnosis, prognosis, and management”.

Having briefly described Dame Ida Mann’s contribution to ophthalmology in the early part of her keynote, Prof Danesh-Meyer concluded by paying tribute to the extraordinary pioneer’s approach to research. She said her collaboration with leading authorities worldwide, across multiple fields, is instructive for researchers today.

“As I have observed through my own research and experiences, diverse collaborations and rich experiences help maximise scope and impact of scientific discoveries. Visual science is increasingly a global team sport. In the words of Ida, we use research to answer the age-old question of ‘what makes you get what you get when you get and why’. And surely nothing can be more important than that.”

REGISTRIES: GUIDING CARE

Studies require significant time, energy and analysis – using statistical skills and an understanding of inherent assumptions – but registries are so much easier.

So began a fast-paced review of a growing number of registries actively collecting data on eye disease in Australia. Dr Lawrence Lee presented a compelling argument for why ophthalmologists should be contributing their own patient data. For a start, doing so is rewarded with professional development hours. Then there are the learnings that can be derived from outcome audits of patients’ treatment journeys – at a clinician, practice, national and/ or international level. Contributing to registries also presents opportunities to participate in national and international audits, to receive invitations to contribute data, co-author publications and publish your own data.

A major barrier to participation in registries is the perceived time required to enter a patient’s information at baseline and then at every follow-up. Prof Mark Gillies – described as the “father” of this speciality as he conceived Save Sight Sydney’s registries – reassured the audience that time should not be an issue.

As the registries were designed for clinicians by clinicians, they are easy to use, and probably the most efficient way to track your outcomes. He said clinicians can choose to keep data for their own use or give permission for it to be used more broadly.

Save Sight Sydney now comprises four established registries: Fight Retinal Blindness; Fight Glaucoma Blindness, Fight Corneal Blindness (which includes keratoconus and dry eye registries) and, Fight Inherited Retinal Blindness. Coming soon are Fight Uveitis Blindness and Fight Tumour Blindness registries. In addition to the Save Sight registries, we have the Australian Corneal Graft Registry, the Australian and New

Zealand Registry of Advanced Glaucoma, and the Australian and New Zealand Society of Retinal Specialists’ Registry.

In the future, it will be possible for this increasing amount of data to be combined with clinical imaging for overlay with artificial intelligence in a cloud environment. In doing so, participating clinicians will be better positioned to personalise treatment strategies for individual patients, in real time and based on a vast body of real-world evidence.

DESIGNS FOR VISION BREAKFAST

At a breakfast hosted by Designs for Vision, attendees heard from ophthalmologists Drs John Males and Brendan Cronin about their use of the Oculus Pentacam and Corvis for early detection and decision making in cataract, cornea, glaucoma and keratoconus patients. With software, these two devices work seamlessly together and, they said, are invaluable when examining the anterior segment.

Prof Michael Belin from Tucson, Arizona, who developed the ABCD Keratoconus Staging Module for the Oculus Pentacam, explained the clinical benefits of the comprehensive maps it generates. The most recent iteration to the staging display includes parameters for patients one year after cross-linking, enabling patient monitoring to continue post-treatment.

There is published evidence validating that using the ABCD maps, clinicians can identify true progression of keratoconus, on average, six months prior to identification using Kmax or imaging. And as Prof Belin said, this is the data that should be used for treatment decision making, “The goal of treating patients is to prevent sequela, not to wait for sequela and then intervene.”

Armed with this information, there’s no need to wait for the patient to lose vision and then try to halt progression – you can intervene and prevent damage before it occurs, Prof Belin said.

TRAINING TRAINEES

At a Zeiss breakfast, we heard about an advanced trainees’ program that is subsidising the cost of premium intraocular lenses (IOLs) for use by registrars in training.

Leading the discussion, Dr Ben LaHood said as a trainee, he was only exposed to monofocal IOLs, and this remains the case for most trainees today. One survey found that 90% of senior Australasian trainees had not implanted a multifocal IOL. This lack of experience means early career surgeons are unprepared and lack confidence to implant these premium IOLs. Yet there is significant and growing demand among presbyopes for multifocal IOLs.

A program initiated by Assoc Prof Michael Goggin is enabling this experience to be gained while training in the public hospital environment. He negotiated first with Bausch & Lomb and then with Zeiss to procure premium IOLs for the program, at the price his hospital (Queen Elizabeth Hospital Adelaide) pays for toric IOLs.

“ … there is clearly an intimate interplay between the eye and the brain that we are only beginning to appreciate ”As an experienced surgeon Assoc Prof Goggin said the evolution of lens technology means what can be achieved for patients has been “massively improved”. While presbyopia correcting IOLs are not the answer for every patient, those who can benefit from them should have them. He stressed the need for preoperative chair time to determine the desired refraction and said patients need to understand that they may not be entirely spectacle free.

NURSE WORKFORCE SURVEY

Alongside RANZCO Congress, orthoptists, practice managers and ophthalmic nurses attended their own dedicated conferences. At The Australian Ophthalmic Nurses conference, Dr Heather Machin revealed findings from Australia’s first national survey of nurse engagement in eye care. Two hundred and ninety people responded to the survey, with 238 responses analysed following data cleansing. Of respondents, 36% work in eye only facilities and 64% worked in mixed care facilities. Responses showed most (88%) of the participants were satisfied with their work, with the youngest and oldest among the groups most satisfied. However, 68% of participants stated their intention to leave the profession within 10 years, leaving a potentially significant gap in the health workforce at a time when demand for eye health services is rising. The impact of this intent increases when considering concern expressed over the lack of graduate nurses coming into the profession.

Dr Machin called on the profession to proactively pursue graduates by encouraging employers to include and increase eye service placements/rotations as part of the graduate nurse workplace program.

She said it was important for existing eye care nurses to mentor graduates and to advocate for funding to employ more of them. Additionally, she said the Australian Ophthalmic Nurses Associations needs to amalgamate. Calling for change she said the current federated system requires too many resources, which limits the capacity of of the profession to mobilise and support nurses' needs today, and ensure access to service, for Australians, into the future.

The 54th RANZCO Congress will take place in Western Australia in 2023 from 20–24 October.


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