Eye screening and care: treatment pathways and professional roles along that pathway

Before we begin today we would like to
acknowledge the traditional custodians of the lands across Australia we are
meeting upon and pay our respects to elders past and present. My name is Tamara Swann and this is Avinna Trzesinski. We are both researchers at the Australian
Indigenous HealthInfoNet and have worked on our recent eye health projects
in partnership with The Fred Hollows Foundation. Thank you for joining us for
today’s webinar. We are pleased to introduce our guest presenters both
affiliates of The Fred Hollows Foundation, Dr Kris Rallah-Baker who has
become quite renowned as Australia’s first Indigenous ophthalmologist and Dr
Madeleine Adams, an ophthalmologist who has also worked extensively with
Aboriginal and Torres Strait Islander people across Australia. Both Kris and
Madeleine are joining us from Queensland today and I’ll allow them to introduce
themselves further shortly. The theme for today’s webinar is eye screening and care
and our guest presenters will be discussing aspects of eye screening for
Aboriginal and Torres Strait Islander communities such as, treatment pathways
and the various professional roles involved in eye screening and eye care.
We will have about 10 to 15 minutes after the presentation for Q&A but
please feel free to send any questions or comments through that come up for you
during the presentation using the chat facility and I will save these for the
Q&A at the end. It is worth noting that Kris recently assisted us with the
development of a short animated video and key fact sheets about eye screening
and we’ll share the links to these at the end of the webinar. I’ll also let you
know that webinar is being recorded and will become available on HealthInfoNet
shortly, just in case you missed something, or would like to share this with other colleagues. I’m now going to switch over
to Kris and Madeleine for the presentation. Hi there so I just spoke to Kris and he
actually has an emergency so he’s going to be joining us shortly. So, hello
everybody, I’m Madeleine, Kris and I work together in Queensland and also in Caloundra and in regional Queensland as well and we’ve both worked in Central
Australia together and also both worked in Perth together so we seem to be
working as a team quite a lot so it’s appropriate that we’re presenting this
together. Kris and I trained together in
Queensland – that’s us at our graduation looking very proud of ourselves – and
we’re both ophthalmologists. So today we wanted to give you a little bit of an overview of the Australian eye health system. Hope we’re not teaching anyone
to suck eggs but we’re going to keep it reasonably basic but of course happy to
answer any questions that arise as we go along. So first of all, in terms of the
issue of screening in Australia, there is a big country – we don’t really have a national health service like other countries do – which can make screening slightly
harder to implement. We also have different systems and different
standards of eye care really depending on the region that people live in and
that’s because of issues in terms of barriers of access to care, just to do
with geographic location and also to do with socio-economic issues and often
language problems. So they can exist both in urban and rural and remote and
they will have as everyone I’m sure who is listening understands, they will have their own
issues to address. So also of course the the funding differs from state to state
and we have not just – so federal Medicare funding, we also have state based
services and then we have non-government organisations like [The] Fred Hollows [Foundation], The IDEAS (Indigenous Diabetes Eyes and Screening) Van, The Lions Outback [Vision] Van who also assist in the implementation of
screening and other eye health programs. So today we’re also going to just talk
through the different roles that patients may meet as part of both the
screening process but also that work in eye health more generally.
So this is not a hierarchy of seniority but just to explain a bit how it works:
there are only 800 ophthalmologists approximately in Australia. So clearly
everybody in Australia who has an eye issue will not be able to be seen by an ophthalmologist. So the point of screening is to work out who needs to be seen by
an ophthalmologist. So ophthalmologists are responsible for intervention – so that is
both medical and surgical intervention in eye health. Optometrists, who we work
closely with, are also responsible for intervention but their intervention is
to do with refraction – that is glasses. We don’t dispense glasses as ophthalmologists,
optometrists do and also many optometrists also have undergone
therapeutics training and they are able to dispense a limited range of
medications as well. General practitioners generally, although they
are vital in supporting screening programs, themselves – obviously there’s a
spectrum of interest and experience in eyes – but GPs themselves are not, have
limited ophthalmic trainings. [Which is] true for most ophthalmic doctors to be honest
because they can’t be expert with everything but they in GP practices
there are cameras to photograph and they will screen people that have high risk
of eye diseases but they will then normally pass them on the optometrist. To
see an ophthalmologist it requires a referral from either an optometrist or
GP. So health workers also play a pivotal role in screening often, or most of the
time, working alongside GPs but also sometimes in mobile eye health units
such as The IDEAS Van or The Lions Outback Van. And then the last category of
eye care professionals are orthoptists. These tend to work
closely with ophthalmologists generally within the clinics or hospitals. They
provide clinical support – they tend to be the experts and the technical side of
imaging to support the clinic – and also they screen and they pass on to
an ophthalmologist.
So when we’re talking about screening we just thought we just
recap what that actually means and what is the point of screening. So screening
according to the WHO (World Health Organisation) is pretty much what, well you can see the
definition on the screen, but it’s about working out, from a large population,
who’s at risk of having a disease identifying those individuals and then
allowing them to access intervention. So at each stage of this process of course
it’s up to the patient whether they choose to participate to have tests to
receive treatment or advice or even just support. So in the UK where there is a
National Health Service they have implemented diabetic eye disease screening to significant effect. Prior to them implementing national screening, diabetic
eye disease was a leading cause of irreversible visual loss in working age
adults, and that is no longer the case. Now the leading cause is inherited eye
disease. So [that] indicates that if we can get screening right it’s of primary
importance. In the last year we have initiated, when I say we I mean more broadly Australia, has initiated the Keep Sight program which is intending to move us
towards having a national diabetic eye screening program. And this is aiming for
all eye health professionals to register and then conduct eye checks, record these visits and then the patient’s themselves will get reminders on their phones or
through email to prompt them to come back at the required interval according to
their disease level. And also diabetes health professionals can also register
and then they you can refer on through that system for
patients to receive eye health checks. And so we do have some local screening
programs already in place: the IDEAS Van in Queensland and Victoria, obviously you have the WA Lions Outback Van, VOS (Visiting Optometrists Scheme) in the Northern Territory and Brien Holden
Institute and they will work collaboratively with state and federal
programs to improve access to eye health, eye health care.
Okay so we’re just going to talk about each of those people on that chart a little bit and they’re
all here. So you know Australia, obviously Australia globally is well placed – at least in terms of eye health overall. There are still some groups who – and some areas where the the standard of eye care is lower and we are moving to try to
improve this, particularly for Aboriginal and Torres Strait Islanders to close the gap
where, even though that is closing which is heartening – that has gone in the
last twenty years from ten times more likely to have irreversible
blindness to three times more likely – there’s still much work to be done.
Health workers working in the communities often are the ones on
the ground responsible for taking the photographs with the cameras, if it’s a
diabetic screening, but also involved in trachoma programs so we were going to talk about the pathways for each of those so if I’m talking to a lot of
health workers you already know this, but obviously there are multiple avenues to become a health worker: so some will, and it depends again on on the
state and the region, so some health workers will train on the job and some
will train elsewhere and obtain a formal certificate, and then continue with
further training on the job. So and health workers often will work more generally
not just in eyes and there will be [those] specifically working, for instance we
have Fiona in Alice Springs Hospital who just works in the Eye Department and
then there are others and then others will work of course in non eye specialties.
So an optometrist – so my optometrist in the practice just
told me that that the last part of the slide is incorrect because now apparently it’s
all a Master’s or a Doctorate [degree] to become an optometrist so it’s a relatively
long training in terms of undergrad, they do six years at University. They are eye care
professionals and their area of expertise is refractive eye care so
basically diagnosing people who need to wear glasses to improve the vision.
Refractive error is the largest cause of visual impairment in Australia so a
large number of people who require glasses to be able to see well do not have access to achieve those [glasses] so improving the coverage of optometrists
in rural and remote areas is a relatively low hanging fruit in improving people’s
vision. So yes, they train predominantly in – there’s the QUT (Queensland University of Technology) in Queensland – and there’s Melbourne and Sydney and it’s a four to six year masters or doctorate.
So an orthoptist also is eye specific and they do either four years
as a primary degree as a masters or they can do another science-based degree and then do two years of a Master of Orthoptics as a post-grad. They are
particular experts in alignment disorders – so children with what we call
strabismus, or squints – but they also tend to be highly skilled in a technical side
of imaging and assisting ophthalmologists in the clinic.
So GPs, I think everybody’s happy with what a GP is, as a general practitioner they probably
have the hardest role because they have to be across everything, they do medical
degree and then a minimum of four years graduate training. There’s two colleges that train the GPs: The College of Rural and Remote [Health] and also the Royal College of General
Practitioners. And I said before although they’re vital in the role of eye health, they’re not specific to eyes because they have to be across all
specialties to some degree. And then we have the ophthalmologist
which is Kris and myself: so we do six years as an undergrad and then probably
the typical length of training after that would between 10 and 15 years.
We often would do some non-ophthalmic… and then you get into a training program and then after you finished your basic training program
then maybe you typically do fellowships in a subspecialty and often that’s undertaken overseas. So one point of confusion for patients – and who can blame them because our names are very similar – is that they often [think they are seeing an] optometrist when they’re seeing us or vice versa and so just the easiest way
really is to say that ophthalmologists are just eye doctors and it’s perhaps
easier to use that term whereas optometrists the primary degrees and
is in optics and therefore we don’t give out glasses and they don’t do surgery
really is probably the easiest way to explain that. So we’re not gonna
talk a lot about refractive error because even though we manage that surgically that’s really the optometrists domain but it is important to remember the
refractive error is the most important cause of visual impairment and that it
is relatively easily treated and inexpensively with the administration of
of spectacles. So in terms of diabetes – so we’re going to talk about the areas that have been focused on in The Fred Hollows [Foundation] plan and which are diabetes, trachoma and cataract and we won’t talk so much about refractive error. So
first of all just in terms of the diabetic eye: there are some sort of
key figures to remember about diabetes – and key points – and one that we’d like to
make is that, although we’re going to talk now a lot about diabetic
retinopathy, that diabetes increases the risk of blindness by 20 times and that
isn’t all about diabetic retinopathy. Diabetics are at high risk of
having strokes; they’re at high risk of having ocular surface disorders; and neuropathy, which can mean they can have non-healing ulcers on their eye;
the complications diabetes can cause them to have glaucoma, rubeotic glaucoma and also they’re more likely to have primary open-angle
glaucoma – so that glaucoma is when the pressure is raised in the eye and that causes a deleterious effect on the optic nerve which takes the signals
to the brain from the eye and so being a diabetic increases your risk of glaucoma
– another [form] of irreversible blindness; often can have shifting refractive error
which makes it difficult for them to be able to see because the requirement for
glasses is changing all the time; they get cataracts earlier and cataracts in
diabetics can be a problem because it’s difficult to follow the disease which is
occurring in the back of their eye; and also they can have, other than diabetic
retinopathy they’re more likely to have blocked vessels at the back of the eye
which can also cause visual loss and require treatment. And when they have … that can affect the eye movement as well so they can end up
experiencing double vision. So diabetes is bad news, or certainly uncontrolled diabetes is bad news, for the eye and so we need to be watching these patients carefully.
So diabetic retinopathy and maculopathy present the biggest threats division. And we’ll show you some pictures in a
minute, to explain a bit more what we’re talking about here.
Retinopathy occurs because the vessels in diabetics are diseased, and
so the eyes are the only part of the body where you can see that in action.
So we know that diabetics can have peripheral vascular disease and can have
issues with loss of sensation in their legs and poor vascular supply to the
peripheries. But in the eyes, we can actually see the diseased vessels.
So these diseased vessels mean that the eye – which has a very high metabolic rate – isn’t
getting the oxygen and the nutrients it needs. That causes it to produce a chemical called VEGF (vascular endothelial growth factor), which can cause abnormal new vessels to grow and you can have
problems with bleeding and leaking. We’ll show you some pictures in a second. But this disease – diabetic retinopathy – actually presents a real risk of
severe visual loss and by severe visual loss – that means, that if you could read
the bottom of an eye chart you’ve moved up to the top of the eye chart.
I would no longer be able to drive and function is difficult.
So that risk is about 40% in a year, if you have the first type of the
retinopathy, which is the proliferative diabetic retinopathy. So as ophthalmologists we want to avoid people ever getting to that stage.
We want to try and spotfire reduce that from happening, and control our risk
factors. So in terms of maculopathy, this is when the macular or centre of the vision develops swelling and that’s to do with the
chemicals that are released, because of compromised blood supply to the eye, and that also can cause visual loss. Because it’s the center of the vision patients tend to be quite symptomatic. The issue with retinopathy, these patients are often not symptomatic until they are at end-stage disease.
Whereas maculopathy, even though it affects the centre, patients tend to notice things earlier on. But both of these things can be treated
effectively. We should not be going blind from diabetes in Australia,
because we should now be able to prevent it. In particular, we know that in
Aboriginal and Torres Strait Islander people of those who have diabetes, 40% will have some type of diabetic retinopathy and 10% have vision threatening diabetic
retinopathy. The risk factors for developing diabetic
retinopathy or maculopathy or indeed any diabetic related eye
disease – the biggest one is duration – so if you have diabetes, the more likely you
are to have diabetic related complications, and that is
not a modifiable risk factor, unfortunately. But control is. So control the diabetes is really important and we’ll
talk about that more … risk factor, smoking makes diabetic
complications much more severe and they tend to happen earlier.
Pregnancy also increases the risk of having diabetic related complications, not just
to the eye, but to the whole body. In terms of effective screening, a disease has to be reasonably common, and diabetes is.
Also there has to be some intervention which is effective.
We have that – diabetic eye disease meets criteria for screening.
We have a National Health and Medical Research Council Guidelines on when we
should start screening people with diabetes. So part of that is there’s no
point screening a population where the proportion that’ll have disease, will
be very very low. We know that with type 1 diabetics – so that’s the type of
diabetes that develops in childhood. It’s a sudden onset, so they go from
relatively having normal sugar control to abnormal sugar control.
Because the duration is the biggest cause of having diabetic retinopathy maculopathy, they don’t have any diabetic eye disease presentation, so there’s no point
seeing them when they’re first diagnosed. Whereas type 2 diabetics which tend to be the,
more likely to be the middle-aged diabetics, they often will have had
disease for a long time before it’s actually diagnosed. And so we know that
on diagnosis 1 in 3 type 2 diabetics already have diabetic eye
disease. So after 15 years of having diabetic retinopathy, 90 percent of type 1s even though we don’t see them start with, 15 years later almost all of them are
going to have a degree of diabetic retinopathy. Then for type 2 diabetes, some patients end up requiring insulin for their control, and in that group they behave quite similar
to type 1s. Most of them will also develop some type of retinopathy.
90% after 15 years, if they have better control and don’t require insulin,
then that figure is about 50%. But each year, 5 to 10 will progress from
having no disease to having retinopathy. So that means that we need to watch
diabetics – That is, we need to screen them. When should we screen? So for type 1 we
don’t need to start screening until 5 years after they’ve been diagnosed. For type 2 we
screen immediately, and then the NHMRC (National Health and Medical Research Council) guidelines offer 2 yearly screening. Except for Aboriginal and Torres Islanders … screening. My perspective on
this would be that I think, so when we talk about screening, we’re saying that
they should either have photographs taken or they should attend an
optometrist. As I said before, we all know that diabetics have a higher risk of a
number of different eye conditions including glaucoma. Many people would recommend that those above forty [years of age] should attend an optometrist once a
year for glaucoma screening. So ideally, I tend to tell my patients to see an
optometrist once a year. Also, the advantage of that is people tend to
remember a yearly visit, whereas remembering a two-yearly visit
people are less, I find they’re less likely to remember. So that’s a good
thing about the KeepSight program, is that when your patients are registered for
that, they will get a SMS (short message service) to remind them that they need an eye health check
if they’re still at the screening stage. And that will either [be] with an
optometrist or with a health worker for a photograph.
So this is one of the cameras. There two main cameras across Australia which have been installed for photographic screening for diabetes: a DRS (Digital Retinography System) and a CR-2. I think we
have more DRS in Queensland and of course each has its own pros and cons.
They are reasonably easy to use, they both [require] some skill and so there’s some training when they’re implemented. The issue of course is that
you can take pictures, but somebody needs to look at them, and then grade
them to decide what stage of retinopathy they have – and that also differs at the
moment from region to region. So we’re just going to talk a little bit about what we mean by the different stages of retinopathy. The mild one we
can see on the screen there, to be counted as a mild diabetic retinopathy, they are only allowed to have microaneurysms. Microaneurysms are when the vessel wall is unhealthy you get these little
outpouchings. The tiny little red dots in the photographs. If they have a couple of
tiny little red dots and nothing else than they’re classified as mild.
One of the reasons, well the main reason that we need to know what stage
they are is – the stage determines their risk of going on to develop sight
threatening disease. So if you’ve got mild disease, you only have about a 1% a year chance of going on to get the proliferative type. A few slides back –
when I was talking about proliferative disease – saying that of course, proliferative
is important, because then they have a 40% chance of severe visual loss in a year.
So if they have mild disease we’re not too worried, they can remain in the
community and be screened…once a year or once every two years. So for
moderate disease, they basically have a little bit more than mild they’ll have a
couple of hemorrhages around the place but they won’t be in all 4 quadrants or
all 4 sectors of the eye. You may see and some hemorrhages, they look slightly bigger red dots on the photographs. They’ll probably have more microaneurysms and
sometimes I mean so the exudates are more to do with macro-ophthalmology. These photos by the
way are from the International Council of Ophthalmology. Official … screening
photos, they’re freely accessible on the web and it’s a good document to read
anyway about diabetic retinopathy. So once you have moderate eye disease, your risk of
developing sight threatening disease is about 3 percent a year. Or up to 3 to 5%.
So moderates tend to be seen by an ophthalmologist once a year at this point.
So severe disease is when we all get a little bit edgy about it. Severe of 4 quadrants of hemorrhages, they also can have, there’s a strict
definition they can have something called
IrMA (intraretinal microvascular abnormality) or beading. They’re basically again again just specific signs on the
photographs and the ICO (International Council of Ophthalmology) PDF (portable document format) has some examples of what they look like. So the
issue with severe disease is that they have about a 50% chance of going on to develop
proliferative diabetic retinopathy. Then you can see the final photograph is
proliferative. This patient’s obviously had a little bit of laser as well which is
what some of the white dots are, but there’s abnormal vessels which have grown,
because there’s so much of this chemical VEGF (vascular endothelial growth factor) being pumped out. There are more hemorrhages around the place, and you can see that the architecture of the
eyes begin to look quite abnormal. Okay so that’s basically the grading.
So in diabetic macular edema – although you can get a sense of it being there
when you look at the photo – it’s best detected using an OCT (optical coherence tomography). An OCT takes a cross-sectional image the macula. Generally these exist in an optometrist or
in a hospital eye clinic. So if a diabetic… that has a visual loss, should be tested basically by an optometrist and/or an ophthalmologist. And an OCT would form part of that exam. So overall what should we be telling our
diabetic patients, and why? So we go on and on about control of diabetes but
from our perspective as eye specialists, we know that if we get diabetics to
control their blood sugar really really tightly and really well – below 7% HbA1c
in the old-school terminology or now we call it 53 mmol/mol – they
reduce their risk of developing it in the first place by approximately 75%,
which is huge. And if they … then we can reduce the progression by about
50 percent. And similarly if they can control their blood pressure very tightly – that
is, below 130 over 80 – then the risk of progression is reduced by about
50%. These are kind of big figures they’re not saying ‘oh you’ll reduce it by a
little bit’, it will make a big difference to their chance of developing sight
threatening disease. Obviously you would like them to stop smoking.
We will send on a type 2 diabetics to the GP to be given a script for a drug
called Fenofibrate – which it has been shown in big trials to slow the
progression of the … and the other point we just like to flag is that
pregnancy is a nightmare for ophthalmologists with diabetic patients – they need to be watched very closely during this time – because the eye disease
can progress much more quickly. And so really, individuals who are planning to
become pregnant, should see their – if they have diabetic eye
disease – should see their ophthalmologist during the planning stage and then they
should be seen regularly during the pregnancy. And then for the risk – the heightened
risks of progressive disease persist for about 18 months after the
pregnancy. So just quickly on the treatments for diabetes – we have had laser
for a long time now. We still use it for proliferative disease, that works by
basically killing off – which is a horrible way of putting it – but the retina which is very
sick and not working well anyway, in the periphery – that’s producing the
chemical which is wreaking all the havoc. So for a long time that was our only
treatment now we tend to have lighter — combined with injections into
the eye and we inject a drug which directly inhibits a VEGF (vascular endothelial growth factor) chemical so
they are anti-VEGF drugs and there’s basically three that we use and they’re all much of a muchness really. And that bottom middle photo is just a schematic of
where we’re injecting into the eye. So the issue I suppose with these infections is
in the context of diabetes that we generally like to give a loading dose of
monthly injections for three and then we try and send them out but for patients
where this is in terms of — it can be difficult. Moving on I can’t go to my next slide, okay. Okay so, I’m supposed to be talking about
trachoma, so trachoma obviously is of great health and political importance in
Australia so we are the only wealthy Western country that still has
trachoma. So active trachoma that is the, trachoma is transmitted by a fly, exists
mainly in hot and dusty environments which of course is Central Australia, and
trachoma now of course is found basically in Aboriginal children mainly
in Central Australia, and so and – have been instrumental in working
towards eliminating trachoma in Australia. So the WHO (World Health Organisation) talk about the SAFE approach to trachoma
and when you read SAFE we back to front because the first thing is addressing the
environment so individuals that live in overcrowded environments are more likely to develop it. It’s important that there is good both hand and face hygiene when individuals have active trachoma they need to be treated with antibiotics but
not just those individuals but the whole community, because otherwise it will just
be re-transmitted back into the affected individuals, and then for the later stages of the disease which we try and avoid people getting to then there are surgeries that we perform. So even though the active conjunctivitis is found in
children, predominantly in Central Australia, the later stages of the disease
can be found anywhere in Australia because obviously people don’t
necessarily stay in the same place and so it’s something that we need to
actually look for in people with ocular surface disease.
So, it starts off as a nasty conjunctivitis it predominantly affects
the upper lid so these funny pictures are basically when we’ve obviously inverted the upper lid, in the later stages you get this what we call subtarsal scarring so the lid isn’t
sitting right on the eye and eventually the lid can turn in on itself and starts
to scratch the surface of the eye with the eyelashes obviously that’s not good
and if that continues for a long time you start to get scarring on the surface of the
eye and that can lead to blindness. So lastly, when we talk about cataracts we’re talking about cloudy lenses and again
this is an important cause of visual impairment in Aboriginal and Torres Strait Islanders and often it goes missed until people have fairly late disease and that can happen in any section of Australian society and cataracts are probably,
are the most commonly performed operation, ophthalmic operation in
Australia intravitreal injections which we mentioned before for diabetes are now
the most commonly performed ophthalmic procedure in Australia, so cataract
surgery, is the answer to cataracts so there is no medical treatment for
the clouding of the lens at this point and the surgery that we perform
basically involves you can see that the top schematic is just showing the
cloudy lense so we make tiny little cuts in the front of the eye we go in with a
which is like a [barbed] vacuum cleaner is what it looks
like, which is an ultrasound machine and we break up the cataract in to
pieces and then we remove it, relieve the capsule or the bag that the cataract sits in in place and then instead of the cloudy cataract we replace it with an
artificial lens which is a small little disc of plastic, so okay basically I don’t
know if you can do it in the video but this is like a large version of one
and so they’re foldy and we can fold them and inject them so you can
make tiny little moons in the eye, 30 years ago there
were large moons made and it’s much more invasive procedure but now most people
recover within days rather than weeks and most people see better again the
same day or within days, so it’s a very satisfying operation as a surgeon
because it has very high success rates and can really transform peoples lives. So I was going to show you actually what an actual eye well but the,
I don’t know if you see on there but they’re super tiny. We do
measurements of the eye to maximize the visual outcome afterwards, so each
person will require a slightly different strength of lens. Depending on how long
the eye is under the cornea, so we take measurements beforehand we choose the
most appropriate lens and that’s the one that we put into the patient’s eye. So
cataract blindness is reversible blindness, and requires reasonably
straightforward if technical injury, and that’s all of my sides and Kris
hasn’t appeared, so are there any questions? Thank you very much Madeleine, yeah it’s a
shame that Kris has been called away to an emergency so we won’t have
him involved but if you’ve got questions for Madeleine please send them
through now. I think Kris has just joined. Okay we have a question here Madeleine
that says, any correlation between renal and eye disease? Well yes I mean so effectively that as I was saying when we look into the eye we can see that
there is vascular disease, so it’s a window into the vascular health of the
patient in terms of the diabetic patient, so there isn’t like a direct correlation
that you could plot on a graph but certainly, so when we meet a diabetic and one of the things we ask them is have they had any other diabetic complications? And patients who
had renal issues are more likely to also have eye disease basically or
retinopathy also. Hi Kris, welcome.
Hi how are you? Sorry I was caught up, we had an emergency. My deepest and most sincere apologies. We’ve just had a que-, we are starting
some questions so you might be able to join in with those. Rosalie has asked
can you please talk more about the role of Avastin injections?
Yeah sure so Avastin is an injection that’s placed directly into the eye into the back the
eye, into the vitreous which is the jelly that sits at the back. It’s used
for a number of conditions: wet macular degeneration is one, and in the context
of this webinar, diabetic changes of the macula. So there are a number of
injections which are the same class of drugs and Avastin is the trade name of
one of those: Bevacizumab. There are two others and they are all, they all have
the same basic mechanisms of action and effectiveness, and they’re usually
prescribed once a month at least three injections, and depending on their response of condition they can be ongoing, monthly or two-monthly or even up to three-monthly
injections, between the injections. Did you have anything to add Madeleine in
terms of what Avastin is and uses? Yes so yeah absolutely, also so we use it
for the maculopathy so in the webinar Kris we were talking about maculopathy
and retinopathy, so now so as you said Avastin is one of three anti-VEGF (vascular endothelial growth factor)
drugs in Australia but we use it not only for the maculopathy to try and dry
up that fluid at the centre and restore like a normal contour and architecture
which is associated with a return to better vision, but we also use it for the
retinopathy type so when people have the proliferative
eye disease we know the anti-VEGF injections also can treat that.
There are big studies in the states that show so in the olden days
we just had laser as an option as a treatment for that, we actually could
just use these injections alone, but the reality is that the treatment is
invasive and you’re required to have monthly injections for a long time if you use
them solely for that, so I think you and I Kris both do a similar thing that we
use a combination of laser and Avastin injections in treating proliferative
disease, and as he said we tend to do monthly injections to start with with Avastin or the other ones Lucentis or Eylea, and then try and extend the
patient out. So with diabetic eye disease the injections are not for life, which is
I think is an important thing to say to the patients too, because some
indications for instance the wet age-related macular degeneration it’s
very difficult to stop the injections, and that the disease will recur, but
often with diabetes you can have a year or 18 months of injections and you may
then be able to stop injecting particularly if we’ve been able to get
their diabetic control improved, don’t you think? Yeah, absolutely. Okay, if anyone has any further questions and would like to type them in the chat box, I’ll give you
another minute. I don’t know if you can see this but Rosalie has commented that
she’s delighted to see and hear from the famous Dr Kris thank you for such a great lunch. Thank you, sorry I’m late. Is there any particular slides that you want to go back to Madeleine that Kris might have some further to elaborate on? So, I think we probably covered most of it, we spoke, I spoke quite a lot about diabetes
I may have glossed over slightly over the trachoma slides a bit more because I was, I think you were planning to speak was there anything in
particular that you wanted to talk about with trachoma Kris?
I mean, I’m sure you did a wonderful job Madeleine and I wouldn’t want to repeat what you’ve already said it’s essentially about the WHO (World Health Organisation) guidelines, the SAFE (surgery, antibiotics, face washing, environment) guidelines trachoma is a disease of social
disadvantage, and being one of the healthiest, sorry one of the wealthiest
nations in the world, it is not a good situation to be in to still have
trachoma existing in our Indigenous communities. It’s a whole response
that’s required to treat the acute disease, treat the long-term disease in
terms of the eyelids with surgery, but then also address the housing issues
that go along with that. And I think it it’s been said many times but it is an
embarrassment that developing nations have been able to eradicate it, but we
haven’t yet. The strength basis though is that we are getting ever
closer to eradicating trachoma as a problem in this country. But it is an illness of social disadvantage and [The Fred] Hollows [Foundation] and a number of other
organisations are working very very hard to eradicate it, which we will get to at
some point. Okay, thank you. You mentioned the KeepSight program
Madeleine, could you give us a little bit more information about that? Sure, so the
KeepSight program was actually the brainchild of the Center for Eye Research Australia in Melbourne, and they have a number
of stakeholders including support from the pharmaceutical industry. But the idea really is for it to become a national screening program for diabetes.
But anyone who’s involved in eye health that performs diabetic screening
can register, so you can just Google ‘KeepSight’ and you can register as a provider. And then your patients will be reminded, so addition to any reminder systems that
your own practice or hospital have, so if the patient should for instance leave
the area or change address or they will continue to be prompted to return
for screening visits, which I think is really huge and could be a game-changer
for Australia. Because we do have a mobile population across such
a big geographic area, implementing a screening program is much harder than in
the UK where you have got one health system over a tiny little country. And so I
think it gives us hope that we may improve our stance on reversible
blindness from diabetes. So please register if so, it includes health
workers, optometrists, anyone who’s administering screening can register as
a provider. They obviously have to talk to your patient and make sure that they
give consent to be included in the program, and there’s information on the
website on KeepSight as to, which you can get patient information which you
can give to your patients, and also for you to read about what it entails. Okay,
and one further question we had was, it’s around eye health in remote centres
where there is a lot of pull on Aboriginal health workers to be
delivering acute care, how can eye health be prioritised? So both Madeleine and I have done a lot
of work in rural, remote and outreach and in fact we’re both Fred Hollows [Foundation] fellows
based in Alice Springs, and we saw a lot of, in the smaller very
isolated communities, health workers who were responsible for a lot of the
triage and initial assessment of patients. The question is to, did
the question come from a health worker? I’m sorry I’m not sure who it came from. It’s an in-house question and it’s yeah about Aboriginal health workers and
their ability to prioritise eye health when there’s such a pull to other areas
of health that are quite acute. Yeah, okay, so a number of issues come up I
guess the first is that there are some, there are variable training modules depending on the jurisdiction that the individual
works in, is the first point so there are varying levels of access to knowledge.
The second point is that The Fred Hollows Foundation through their country plan is
working to reinforce the Indigenous health worker workforce
particularly in the area of ophthalmology that is out there. Apart
of that strategy going forwards is about enhancing knowledge and enhancing the
ability to triage and have a better idea around acute issues as opposed to
you know sort of emergencies opposed to something you can see the next review or
visit. Third part is that wherever the individual is, there is a public
hospital base that will have an ophthalmology opinion available, so for
example in Central Australia where Madeleine and I worked, that’s Alice Springs hospital and there’s always either an ophthalmologist or a training fellow or
registrar available for opinion, and what they’ll want to hear is they’ll want to know
what’s happened to the patient, what’s the basic history and if we can get an idea
around a vision so to do a visual acuity is a really really useful thing. But
there’s always opinion available at the end of the phone if the individual can
get those those few basic pieces of information that’s an enormous help to
the person taking the call. So people are out there on their own but if they are
able to do a vision and get a reasonable idea around you know is this trauma or
does the patient, have they been known to the service before, what’s the degree of
vision loss? Those pieces of information are critical to the person at the other end to help them make a decision. Don’t forget optometrists as well, that they,
that often there may be optometry support as well particularly in rural and remote
areas, and optometrists that work in those areas tend to be highly skilled,
and also will be able to escalate on to ophthalmologists if
if required. So to you know collaborate I suppose so you can make some
friends in the optometry sphere. Okay, so we’ve got another question come through
from Sharon: is an OCT (optical coherence tomography) the only equipment that can be used to detect diabetes
macular edema? Definitively yes I mean you can see it clinically on examination
and you can get a sense of it being there on a photograph, but for instance
to for when we diagnose it we use an OCT to access PBS (pharmaceutical benefits scheme) funded medication for its treatment. We are required to submit an OCT showing that there’s edema
there, so ideally yes. And so a patient that has reduced vision should, with
diabetes, should have an OCT as part of their assessment. To add to that as well, we can not only pick it up on the OCT but then subsequent OCT’s it gives us a
measurement and that helps us determine the effectiveness of the treatment, so is
the thickness getting worse staying the same or reducing? So it gives us an objective
measurement. Okay Sharon says thank you. We might have to wrap it up there. I’d
like to offer Kris and Madeleine a huge thank you for sharing their time with us
today, and extend thanks also again to The Fred Hollows Foundation for helping
to make this webinar possible. Thank you all for being part of our [Australian Indigenous] HealthInfoNet webinar and please check out our new research resources for eye
screening and care that are available. I’m just going to pull up the links now for
you. And if you’ve got any further feedback please feel free to contact
myself or Avinna, and we’ve also got the contact details up there for Madeleine
and Kris. Thanks very much for having us on. Thank you. Okay thank you everyone. Bye bye.

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