Discuss your family’s eye history this JulEYE.

It’s as simple as having a conversation and as serious as saving your eyesight.

The RANZCO Eye Foundation (Royal Australian & New Zealand College of Ophthalmologists), a national not-for-profit organization, dedicates the month of July to its annual community awareness campaign.  JulEYE is aimed at educating Australians about eye disease and this year is encouraging everyone to discuss their family eye history. Despite 75% of vision loss being preventable or treatable, many Australians are still not finding out if eye disease is part of their family history to determine if they’re at risk and need to have their eyes checked.


RANZCO Fellow, Professor Frank Martin AM says: “To ensure we preserve our eyesight, Australians need to be more aware of their family’s eye history. If you have a family history of eye disease, a medical condition that can have eye related issues such as diabetes or are over the age of 40, eye testing every two years is essential as it is the most effective way to identify problems early. So this July, find out about your family’s eye health history.”

CEO of The RANZCO Eye Foundation, Jacinta Spurrett explains the JulEYE campaign, now in its sixth year, continues to educate Australians about eye disease.

“Too many young people equate vision loss or blindness to old age, but eye disease, like cancer, is indiscriminate and can happen at any age. More than 200,000 Australians are currently suffering from vision loss related to eye disease and every year a further 10,000 Australians will lose part of their vision or go blind. It is very important that you find out if you have a history of eye disease in the family and if necessary, be referred to an Ophthalmologist to have your eyes tested this July,” Spurrett adds.

“Each year we aim to reach more and more Australians with our message. Our focus in the first week of JulEYE is to encourage Australians to discuss their family’s eye history and to get their eyes tested if there is a history of eye disease. We will also highlight the real and increasing rate of diabetic retinopathy. With over 1.1 million Australians currently diagnosed with either Type 1 or Type 2 diabetes , it is vital that eye health check-ups are part of their overall diabetes management. Throughout JulEYE we will continue to challenge Australians to start talking about their family’s eye health and make it part of their family health discussions,” Jacinta Spurrett said.

Joining the JulEYE call to action is INXS band member and ‘JulEYE’ Ambassador, Kirk Pengilly; renowned Australian legal academic and 2011 Senior Australian of Year, Professor Ron McCallum AO, who has been totally blind since birth; former Director of the National Gallery of Australia, Betty Churcher AO who suffers from macular degeneration; and one of Australia’s highest-selling independent musical artists and motivational speakers, Lorin Nicholson who is also legally blind.

No one should take his or her eyesight for granted.

An eye test can detect the main causes of vision loss such as glaucoma, macular degeneration, diabetic retinopathy and cataracts. Eye disease is not just an affliction of the elderly – many of these diseases are hereditary and can cause blindness in babies, teenagers and adults alike. To find out where you can be tested, or to donate to The RANZCO Eye Foundation and support eye health research and sustainable development projects, visit www.eyefoundation.org.au or to join the conversation, go to: http://www.facebook.com/EyeFoundation


Do glasses weaken your eyes?

The popular belief that glasses weaken your eyes is a myth.

If you wear glasses, chances are you’ve wondered from time to time if they’re making your eyesight worse. Not while you’re wearing them, but when you take them off.

Pretty much everyone will need glasses at some point in their lives. And when it happens to you, you’ll probably ask yourself the question on the lips of specs wearers everywhere: do glasses weaken your eyes?

Struggling to focus on printed matter is an unfortunate sign of ageing. Changes to the lens of the eye as you get older mean you have to move the page further and further away before you can see properly. It’s called presbyopia and it strikes us all, usually by our mid 40s. And most of us end up having to wear glasses.

If you think your eyesight’s got worse since you’ve started wearing glasses, you’re far from alone. But the truth is many eye conditions, including presbyopia, get worse over time by themselves, specs or no specs.

In other words, it seems harder to read things without your glasses because it is. But it was going to happen anyway, and your glasses aren’t to blame.

What your specs have done is got you used to seeing more clearly. So when you take them off, the contrasting blurriness is more noticeable.

Glasses don’t change the process of presbyopia or other eye conditions. But take them off, and your eyes might seem a tad lazy at mustering any remaining focusing power. That’s because the muscles that bend and straighten the lens of your eye haven’t worked as hard when your specs have been doing some of the job.

But your glasses haven’t made your vision worse. The real problem isn’t weak focusing muscles; the real problem is your eye’s lens has become less flexible so it can’t focus as well. And there’s not much you can do about that.

Wearing sunglasses to protect your eyes from UV light might help delay the stiffening of the lens that causes presbyopia. But the only way to escape it completely is to die young. Not a great option!

So if you want to see well throughout life, wearing glasses or contact lenses is pretty much inevitable – and not harmful. You might as well just accept it (and blame your high school careers adviser for not steering you into the lucrative field of optometry!)

Thanks to Professor David Atchinson, Queensland University of Technology for expert information and Jordan’s Seafood Restaurant and HineSight Optometry for filming assistance.


Article appeared on ABC Health & Wellbeing 

by Cathy Johnson

Published 01/07/2008

eyes all over

Eyes All Over – 36th Annual AONA Conference

36th Annual Australian Ophthalmic Nurses Association Conference – Eyes All Over

The clinical team from FOCUS Eye Centre attended the 36th Annual AONA Conference in Sydney over the weekend, with the theme for 2018 set as Eyes All Over. 

Our clinical team was well represented at the conference with Ophthalmologist and Deputy Director of the Lions NSW Eye Bank Dr Con Petsoglou presenting the Welcoming Address on corneal graft surgery and Orthoptist Sally Turner presenting on IOL selection for spectacle free vision. Both presentations were well received by conference attendees and discussed latest technology in corneal graft surgery and information to consider when planning cataract surgery in order to provide better patient outcomes.


Technology was a popular topic at the conference with advances in ophthalmology discussed throughout the day, as well as specific cases on uveitis, keratoprosthesis, clinical education, holistic patient care and updates on the NSQHS standards.


Focus Eye Centre prides itself on ensuring our staff are well versed and keep our Eyes All Over the latest advances in ophthalmology to provide to our patients.









bionic eye

Major step taken toward bionic eye trials in Australia

A major step towards helping the blind to see again has been taken, with an Australian-developed ‘bionic eye’ receiving ethics approval to start human trials.

Professor Jeffrey Rosenfeld at the Monash Vision Group says patient recruitment for the first trial will begin in the next two months.

“This is a very major milestone for us,” Prof Rosenfeld told AAP while at the Health Beyond Research; Innovation Showcase in Sydney yesterday.

He said the approval granted by the Alfred Health Ethics Committee is a vindication of what his team has achieved so far.

“We can now start manufacturing enough of the devices to go into our first patient,” he said.

“I would aim to do one or two patients to start with just to do very detailed testing and make sure the device is doing everything we are hoping its going to do.

“Then once we have shown that, we can then start doing more patients and get other centres to take it on as well, both in Australia and overseas,” he said.

The Gennaris Bionic Vision System, or bionic eye, comprises a miniature camera worn by the user on custom designed headgear.

This is linked to a processing computer – a bit bigger than a mobile phone – which transforms the images captured by the camera to patterns and dots like pixels.

Each of these dots stimulate a tiny 5mm computer chip containing 500,000 electrical transistors that has been surgically implanted in the brain via a wireless antenna worn on the back of the head.

“So it bypasses the eyes altogether,” explained Prof Rosenfeld.

“Anyone with glaucoma or who have lost their eyes through trauma are very suitable for our device because it’s going directly into the brain,” he said.

Prof Rosenfeld says much like the Cochlear ear implant, the brain would have to slowly adapt to the ‘artificial’ vision.

While it doesn’t promise complete restoration of vision, the professor is confident it will give some sight back to those who are completely blind.

“What we hope is that the person will be able to recognise shapes in front of them like a saucer and cup or a spoon, where the doorway is, whether people are moving or not; these are the sorts of things people should get out of it. They may also be able to read large print as well,” said Prof Rosenfeld.

The device has been in development for several years.


This article appeared on TVNZ on Wednesday 6th June 2018

Keratoconus Treatment Corneal Collagen Cross Linking to be supported by Medicare

Corneal Collagen Cross Linking (CCXL) for keratoconus will be added to the Medicare Benefits Scheme from 1 May 2018.

The lone awaited news has been welcomed by the Royal Australian and New Zealand College of Ophthalmologists (RANZCO), including the RANZCO-affiliated Australian and New Zealand Cornea Society, who have been calling for this change for a number of years.

Access to rebate for CCXL through Medicare will make this important treatment available for people who were previously unable to access it due to cost and availability.

In Australia, people with keratoconus will often require corneal transplantation, which, while often necessary, is a complex and invasive procedure that requires donor corneas to be available and has a long recovery period. However, if these patients are able to undergo timely CCXL, which uses ultra violet (UV) light and drops to help slow the progression of the condition, it is likely that they can avoid corneal transplantation altogether.

“This is an important step that brings an innovative and effective treatment option to the many people living with the effects of keratoconus in Australia,” said Professor Gerard Sutton, Chair of the Australian and New Zealand Cornea Society. “From 1 May these people will have available to them a less invasive option that could mitigate the need for a full corneal transplant and that can either stop or slow down the progression of this visually impairing condition. This is a hugely positive and very welcome change.”

Keratoconus causes a person’s cornea to change shape over time, often resulting in blurry vision and impacting people’s ability to undertake every day tasks, in particular causing difficulty driving at night.

Bright lights can start to appear streaked, glare and halos can appear around lights and over time visual function can become progressively worse making it difficult to go about daily life.

“The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) endorses the federal government’s initiative in recognising the importance of crosslinking for the prevention of sight threatening disease, and in providing financial support for patients suffering from progressive keratoconus. We are delighted that this important innovation is being made more readily available for those that need it,” said RANZCO President, Associate Professor Mark Daniell.


mivision | 11 April 2018

Number of Aussies living with cataracts on the rise

An increasing number of Australians are living with cataracts, particularly women aged over 80, according to new data released by the Medibank Better Health Index.

More than 700,000 Australians were affected by cataracts in 2016-17, an increase of 139,000 compared with 2010-2011. The figures, released to coincide with International Women’s Day, also showed than 18.5% of women aged over 80 were affected by the condition, compared with 13.4% six years ago.

“It’s well known that the risk of developing cataracts increases as people get older, however this new data also suggests there’s been a slight rise in the number of Australians affected,” Medibank clinical director Dr Sue Abhary said.

The numbers also indicate women are more likely to have cataracts than men, with 4.4% of Australian women affected compared with 3.5% of Australian men.

According to The Fred Hollows Foundation, this gender imbalance is reflected worldwide, with women around 1.3x more likely to have a visual impairment than men. As a result, women comprise around 55% of the 36 million people who live with blindness globally.

“We know vision impairment and blindness have far-reaching implications, not just for the women affected, but also for their families and for progress towards many of the UN Sustainable Development Goals,” Fred Hollows CEO Mr Ian Wishart said.

“To achieve the Sustainable Development Goals, as well as targets for Vision 2020, we must eliminate all forms of inequity in access to eyecare for women and girls.”

Vision 2020 Australia has committed to working with its members both locally and abroad to help provide women and girls with access to eyecare services, and CEO Ms Carla Northam said it should be a priority for all countries.

“Gender inequality in eye health is clearly a global issue, and we strongly support all of our members doing this work locally and globally,” Northam said.

“Addressing gender imbalances in eye health will go a long way towards reducing avoidable blindness around the world.”



Could vitamin B3 be the answer to treating glaucoma?

A humble vitamin B3 supplement could be the key to treating one of the biggest causes of irreversible vision loss in the world.

Researchers from the Centre for Eye Research Australia (CERA) in Melbourne are conducting a world-first human trial of an over-the-counter vitamin supplement to treat glaucoma, a disease of the optic nerve which affects 60 million people worldwide.

Professor Jonathan Crowston is the lead investigator of the study and Dr Flora Hui is the Research Fellow conducting the six-month clinical trial. They hope to prove that therapeutic use of high dosage vitamin B3 (nicotinamide) could be used to support existing therapies for glaucoma, such as daily eye drops or in severe cases, surgery.

“Imagine your car’s engine is running a bit rough and as a result, the car doesn’t drive smoothly. If you top up the engine with oil, the car runs better, even though you haven’t fixed the underlying problem,” explains Dr Hui.

“Our study hopes to confirm that vitamin B3 can protect nerve cells from dying, in a similar way that adding oil to a faulty car engine can still allow it to run more smoothly,” she concludes.

Professor Jonathan Crowston leads the Glaucoma Research and is Managing Director of the Centre for Eye Research Australia. “Glaucoma currently has no cure and vision loss is generally thought to be irreversible,” he said.

“We have recently discovered that in the early stages after an injury, visual function can in fact recover, but that the ability to recover diminishes with increasing age. We have developed clinical tests that now allow us to look for visual recovery in the clinic and are beginning to look at treatment that could boost recovery. Our premise is that if you can improve optic nerve recovery after an injury that we can reduce the risk of glaucoma progressing,” said Prof Crowston.

In 2017, a US research team led by Prof Simon W.M. John and Dr Pete Williams from the JAX laboratories in the USA, found that vitamin B3 given to glaucoma-prone mice prevented optic nerve degeneration and glaucoma. In fact, this treatment also reversed the negative effects of ageing in the mouse eye. “We were very excited by these findings and are now looking at the effect of vitamin B3 in glaucoma patients,” said Prof Crowston.

World Glaucoma Week is 11-17 March 2018

Recruitment for the vitamin B3 trial has reached capacity. To register your interest in future clinical trials with CERA, please register your details at Clinical Trial Registry Web Sight

This research was made possible by the generosity of the Jean Miller Foundation, the Jack Brockhoff Foundation, The Marian & E.H. Trust and the Ophthalmic Research Institute of Australia.

YAG Laser Vitreolysis

Treating Floaters with YAG Laser Vitreolysis

Many people suffer from vitreous floaters, while benign in nature they can become quite frustrating and troublesome. Eye floaters can be clumpy or stringy; light or dark – they are caused by clumps or specks of undissolved vitreous gel floating in the dissolved gel-like fluid (vitreous) in the back of the eye, which then casts a shadow on the retina when light enters the eye. Taking the concerns of patients seriously, and treating them with either YAG laser vitreolysis or floater only pars plana vitrectomy, can make a significant improvement to their everyday quality of sight.

Though not new, YAG laser vitreolysis has advance to a degree that allows the successful relief of symptoms from troublesome floaters in many patients. The inability to superimpose the illuminating light source of the laser with the path of the laser beam has been a problem. The goal of treatment is to disrupt floaters into smaller fragments rather than vaporize them. However, a new design to the YAG laser, developed by Ellex in Australia, has combated this issue by allowing superimposition of the viewing, lighting and treating axes. The YAG laser causes optical breakdown of vitreous opacities converting them to gas which leaves the eye via the retinal venous vasculature. If remnants of the posterior capsule following capsulotomy are hit by a YAG laser, they fragment rather than vaporize. This is seen with direct visualisation as a solid chunk of matter becoming a gas bubble and rising in the vitreous cavity.

How the Procedure is Performed:

The pupil needs to be maximally dilated. Topical anaesthesia is used to allow a contact lens to be placed on the eye but the procedure itself is painless. No sedation is necessary. Generally, it takes about 10-15 minutes. There are no known long term risks with the YAG laser vitreolysis, however it is possible to damage the crystalline lens (causing an instant cataract), hit the retina (causing a retinal burn) or cause a rise in intraocular pressure.

If you suffer from floaters, we encourage you to come in for an assessment and speak to one of our highly trained professionals to determine if you are suitable for the treatment.


New treatment to fight against sight loss caused by AMD

Patients regain sight after being first to receive retinal tissue engineered from stem cells

  • Successful trial on patients using new stem cell based treatment for wet age-related macular degeneration (AMD).
  • Results from a clinical study suggest the treatment is safe and effective.
  • The study is a major milestone for the London Project to Cure Blindness and could lead to an ‘off-the-shelf’ treatment within five years.

The first patients to receive a new treatment derived from stem cells for people with wet age-related macular degeneration (AMD) have regained reading vision.

The results of this ground-breaking clinical study, published in Nature Biotech, described the implantation of a specially engineered patch of retinal pigment epithelium cells derived from stem cells to treat people with sudden severe sight loss from wet AMD. It is hoped that it will also help treat dry AMD in the future.

It’s the first description of a complete engineered tissue that has been successfully used in this way.

The study is a major milestone for the London Project to Cure Blindness, a partnership between Professor Pete Coffey from University College London and Professor Lyndon da Cruz, a retinal surgeon at Moorfields Eye Hospital NHS Foundation Trust.  The Project has also been supported by the UCL Institute of Ophthalmology and the National Institute for Health Research (NIHR).

AMD is the most common cause of sight loss in the UK, and can lead to a rapid loss of central (reading) vision. The two patients who underwent the procedure, a woman in her early 60s and a man in his 80s, had the severe form of the condition (wet AMD) and declining vision.

The study investigated whether the diseased cells at the back the patients’ affected eye could be replenished using the stem cell based patch. A specially engineered surgical tool was used to insert the patch under the retina in the affected eye of each patient in an operation lasting one to two hours.

The patients were monitored for 12 months and reported improvements to their vision. They went from not being able to read at all even with glasses, to reading 60-80 words per minute with normal reading glasses.

Photo of Douglas Waters, patient to receive trial treatment.

Douglas Waters, 86, from Croydon, London, was one of two people who had received the treatment at Moorfields Eye Hospital. He developed severe wet AMD in July 2015 and received the treatment three months later in his right eye. He says: “In the months before the operation my sight was really poor and I couldn’t see anything out of my right eye. I was struggling to see things clearly, even when up-close. After the surgery my eyesight improved to the point where I can now read the newspaper and help my wife out with the gardening. It’s brilliant what the team have done and I feel so lucky to have been given my sight back.”

Professor Lyndon da Cruz, consultant retinal surgeon at Moorfields Eye Hospital NHS Foundation Trust said:

“The results suggest that this new therapeutic approach is safe and provides good visual outcomes. The patients who received the treatment had very severe AMD, and their improved vision will go some way towards enhancing their quality of life. We recognise that this is a small group of patients, but we hope that what we have learned from this study will benefit many more in the future.”

Professor Pete Coffey, UCL Institute of Ophthalmology said:

“This study represents real progress in regenerative medicine and opens the door to new treatment options for people with age-related macular degeneration. We hope this will lead to an affordable ‘off-the-shelf’ therapy that could be made available to NHS patients within the next five years.”

Robert Dufton, chief executive of Moorfields Eye Charity said:

“The results from this trial are fantastic and the culmination of years of research by the London Project team. Philanthropy has played a critical role in the London Project since its inception and we are delighted that this support continues through Moorfields Eye Charity. This ground-breaking milestone demonstrates the real impact philanthropy plays in creating life-changing moments, such as helping someone regain their sight.”

Successful trials of new treatment at Moorfields in fight against sight loss caused by AMD

Glaucoma Research: A Year of Progress

Glaucoma Research: A Year of Progress
Dr. Simon Skalicky & Clin Assoc Prof Andrew White | 28 February 2018

Greater knowledge of disease risk factors, new approaches to detection and monitoring, and innovative treatments are positively impacting glaucoma outcomes.
Over the past year we’ve seen a continued shift towards surgical/laser management of glaucoma, coupled with depot preparation medication trials rather than drop therapy. A major prospective trial looking at the efficacy of depot bimatoprost intracamerally has just finished recruiting (ARTEMIS 1) and two more are still underway (ARTEMIS 2 and ATHENA). Other similar trials are underway as well as assessment of an ocular ring releasing bimatoprost.1,2

Should We Add Vitamin B3 to the Water?
The paper with the biggest potential therapeutic impact this year described the potentially protective role of Vitamin B3 in glaucoma. A team from the Jackson Labs in the US fed vitamin B3 to mice prone to ocular hypertension, resulting in a significant reduction in the risk of ganglion cell death. This effect was even greater than targeted gene therapy treating the proposed metabolic/inflammatory pathway implicated in the disease process.3 Small scale clinical trials have already started. Much like the findings from the Nurses Health Study and nitrates, there seems to be an increasing role for dietary and nutritional supplementation in preventing glaucoma and/or halting progression.4

Minimally Invasive Glaucoma Surgery
Undoubtedly in 2017, glaucoma clinical practice focused on minimally invasive glaucoma surgery (MIGS).

MIGS represents a broad group of small surgical devices characterised by minimal conjunctival dissection, short operating times, rapid recovery and a good safety profile. This is a rapidly expanding field with trans-trabecular devices (eg iStent, Glaukos), increasingly performed in conjunction with cataract surgery.

Other devices are available, with a growing body of supportive data, such as the Cypass (Alcon), which creates a cyclodialysis cleft and drains to the suprachoroidal space and the Hydrus microstent (Ivantis), a fenestrated curved tube that enters, passes through and dilates Schlemm’s canal.

Currently, Medicare restricts the use of these devices to only at the time of cataract surgery, although work is underway to expand the availability for the procedure to a wider body of glaucoma patients, and potentially allow stand-alone MIGS procedures.

There is still a scarcity of robust MIGS scientific data. A meta-analysis of all MIGS papers released up until 2016 found that while overall safety data from MIGS is reassuring, good head-to-head random clinical trials comparing MIGS devices to one another or to traditional glaucoma surgery is lacking.5 As clinicians in this field, it is imperative we collect quality local data that evaluates MIGS in real-world clinical practice, and audit through communal software platforms such as the Save Sight Registry.*

Hydrus was compared head-to-head with selective laser trabeculoplasty (SLT) in a small (n=56) case series. Hydrus resulted in a greater reduction in medication dependence than SLT at 12 months.6

Filtration Surgery
Glaucoma filtration surgery (eg. trabeculectomy, tube surgery) involves creating an aqueous drainage pathway from inside the eye to the subconjunctival space. Some preliminary results have been released for the Primary Trab vs. Tube Study (PTVT) that attempts to settle the question as to whether a primary drainage tube may be better than trabeculectomy as a first surgical procedure for glaucoma. In a word, no.7,8 IOP control was better in the trabeculectomy group, especially in those with lower starting IOP. The complication rate was similar despite more early complications/interventions in the trabeculectomy group.

The Xen Gel Implant (Allergan) is a soft collagen implant that is inserted, ab interno, from the anterior chamber into the subconjunctival space creating a bleb. In many ways it is more similar to traditional filtration surgery than to other MIGS devices. It is increasingly used as an alternative to trabeculectomy, although quality head-to-head studies comparing Xen to trabeculectomy are few.

The Xen was shown to be effective in uveitic glaucoma, despite the potential for sight-threatening complications of hypotony, bleb infection9 or suprachoroidal haemorrhage10 (ie similar complications to a trabeculectomy).

Lasers in Glaucoma
The efficacy and safety of SLT in the treatment of open angle glaucoma (OAG) continues to be supported by the literature. SLT was evaluated in Afro-Carribeans with primary OAG (POAG) and found to have a 12 month success rate of 78 per cent.11 In Belgium, SLT was evaluated as replacement therapy for medically controlled OAG; it was able to completely replace medical therapy in 77 per cent of eyes after 18 months12 and improved treatment related quality-of-life (QoL)13 with similar efficacy between phakic and pseudophakic eyes.14 However, when 24-hour IOP rhythm was evaluated by the contact lens sensor Triggerfish, SLT was not shown to alter the amplitude or pattern of the IOP rhythm.15

Angle Closure and Glaucoma
Angle closure is frequently missed, both among patients referred for cataract surgery who are often dilated without prior gonioscopy, and among patients with POAG who can develop phacomorphic angle closure with age. Two studies from Canada elegantly demonstrated this; of patients referred for cataract surgery, 1.5 per cent were found to have undetected narrow angles,16 and one in 11 patients, with a diagnosis of OAG referred to a tertiary glaucoma centre, were found to in fact have angle closure.17

Dysphotopsia is a rare but debilitating complication of laser peripheral iridotomy (LPI). Previous data suggested the frequency of this can be reduced by temporal placement of the LPI.18 However, a larger (n=595) Indian/US RCT found that location, LPI size, and amount of laser energy used did not affect the frequency of dysphotopsia reported.19

Another large Indian study confirmed that LPI hastens the development of cataract.20 These findings support the landmark EAGLE study that compared early clear lens extraction (CLE) to laser iridotomy in the management of primary angle closure glaucoma (PACG). CLE showed greater efficacy and was more cost-effective than laser iridotomy.21

Externally applied micropulse cyclophotocoagulation (M-CPC) is an alternative mode of laser delivery to continuous wave cyclophotocoagulation (CW-CPC). Micropulse has a high post-treatment inflammation rate (46 per cent after three months) and a similar but potentially lower complication profile than CW-CPC.22 More head-to-head studies are required comparing micropulse to continuous wavelength and to endoscopic CPC to better elucidate this rapidly developing technology.

Monitoring and Detection
We have yet to improve the 50 per cent undiagnosed glaucoma rate in Australia. However, new advances in diagnostic technology, a greater drive for optometry-led detection, and an emphasis on first-degree relative screening such as through the TARRGET study may improve the detection rate.

Australian-developed tablet-based perimetry has the potential to revolutionise glaucomatous monitoring, allowing home or waiting-room self-screening for glaucoma. It is easy to use and sensitive to glaucomatous progression.23,24

Three separate studies have confirmed the importance of central (eg 10-2) visual fields in glaucoma diagnosis to complement 24-2 fields; the latter might miss early glaucomatous defects. This trend persisted irrespective of the type of field machine used.25-27 Furthermore 10-2 changes had a greater impact on vision-related quality of life (QoL) than 24-2 changes.28

The frequency of monitoring for glaucoma patients continues to vex strained clinics. One study found twice yearly visual field testing had similar sensitivity to thrice yearly for detecting glaucoma progression, provided two quality baseline tests were available for reference.29 These findings support the UK Glaucoma Treatment Study, in which a few early visual fields established a firm baseline; this allowed sensitive detection despite greater intervals between later field tests.30

OCT-angiography (OCT-A) continues to be explored in glaucoma. Adding to vascular loss previously described at the optic nerve head, new studies have found macular vascular density declines in glaucoma.31,32 However this finding was not consistent; one study found the macular vessels were spared in glaucoma.33 In addition, the diagnostic sensitivity of OCT-A is lower than traditional OCT metrics (RNFL and MGC complex thickness).33

One drawback of OCT analysis glaucoma is a floor effect of the peripapillary RNFL (sensitivity is lost in advanced disease). In agreement with prior studies, the ganglion cell inner plexiform layer metric was again shown to be more sensitive for advanced glaucoma than the peripapillary RNFL and continued to demonstrate progression once the RNFL had reached its floor effect.34,35

More data has supported the water drinking test, finding IOP spikes induced by the water-imbibed challenge were predictive of future glaucomatous progression.36

The Genetics of Glaucoma
The last few years have seen an explosion of genes identified in glaucoma pathogenesis. Novel loci include: for POAG (ABCA1, AFAP1, GMDS, PMM2, TGFBR3, FNDC3B, ARHGEF12, GAS7, FOXC1, ATXN2, TXNRD2); PACG (EPDR1, CHAT, GLIS3, FERMT2, DPM2-FAM102); and pseudoexfoliation syndrome glaucoma (CACNA1A).37 There are so many genes implicated that work is beginning to move towards better phenotyping of glaucoma for targeted gene studies, and studies looking at the functionality of these genes and interactions with each other (ie. is it combinations of gene anomalies rather than a single gene that is causative?). Stay tuned.

Health, Socioeconomic and Lifestyle Factors
Smoking was the smoking gun for glaucoma in 2017. A Spanish cohort population study of 16,797 participants over 8.5 years demonstrated a direct association between current smokers and glaucoma incidence, and the risk increased with number of pack-years.38

Additionally, a retrospective study looking at risk factors for rapid glaucoma progression showed rapid progressors were older, had significantly lower baseline IOP and central corneal thickness, and significantly higher rates of cardiovascular disease and hypotension.39 Further prospective study needs to be done to better understand the pathophysiology behind this finding.

A Taiwanese study evaluated the influence of different socioeconomic factors on vision-related quality of life in glaucoma. A lower education – but not income – affected QoL detrimentally, suggesting the importance of additional counselling for patients with a lower educational level to help them cope with the disease.40

Other Medical Therapies
Drug development for new glaucoma therapies has been slow but continues.

Rhopressa (Netarsudil 0.02 per cent) is a once daily topical agent with two mechanisms of action and two targets. Rhopressa targets rho-kinase (ROCK) and a norepinephrine transporter (NET). Trial results (ROCKET1-4) yet to be published seem promising. The most common side effect was mild redness of the eyes.

A combination product, Roclatan, is a once daily, combination of netarsudil 0.02 per cent + latanoprost 0.005 per cent made by the same company (Aerie Pharmaceuticals). Initial results from two trials (Mercury 1 and 2) also seem promising.

A new pathway for treatment was discovered this year that may also show promise. The angiopoietin-Tie2 system is crucial in the development and maintenance of Schlemm’s canal and hence IOP control. Antibody mediated activation of Tie2 resulted in an increase in drainage apparatus in Schlemm’s canal when injected in mice. Further development of this pathway may lead to a new IOP lowering agent in the future.37

As clinical and laboratory science marches forward, we must stay nimble in our approach to clinical practice, and translate the new knowledge into better, more efficient and more inclusive glaucoma care delivery to all patients.

Clinical Associate Professor Andrew White is a clinician scientist ophthalmologist at Westmead Hospital with a subspecialty interest in glaucoma. He is a Clinical Senior Lecturer and has research affiliations with the University of Sydney at both the Save Sight Institute and Westmead Millennium Institute where he has an active laboratory. Clin.Assoc. Prof. White has multiple peer-reviewed scientific publications and published conference abstracts. He is a regular invited speaker at overseas conferences and is actively involved in training medical students, registrars and fellows in cataract and glaucoma. He also lectures optometrists and optometry students in Glaucoma.

Dr. Simon Skalicky, FRANZCO, PhD, BSc (Med), MPhil, MMed, MBBS (Hons 1) is a glaucoma subspecialist in Melbourne. He is a Clinical Senior Lecturer at the University of Sydney and University of Melbourne. Dr Skalicky is widely published and actively involved in teaching. He is a federal Councillor for Glaucoma Australia and Associate Advisory Board member for the World Glaucoma Association. Dr. Skalicky specialises in glaucoma and cataract surgery.

*To find out more about participating in the Save Sight Registrar Glaucoma module visit: https://frbresearch.org/au