STATE OF THE NATION Australia & New Zealand Eye Health Report 2018 - Specsavers ProFile
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STATE OF
THE NATION
Australia & New Zealand
Eye Health Report 2018
1
© Specsavers Pty Ltd and Specsavers New Zealand Ltd. State of the Nation:
Australia and New Zealand Eye Health Report 2018
This work is copyright. The Copyright Act 1968 permits fair dealing for study,
research, news reporting, criticism or review. Selected passages, tables or charts
may be reproduced for such purposes provided acknowledgment of the source is
included. Permission for any more extensive reproduction must be obtained from
Specsavers Pty Ltd and/or Specsavers NZ Ltd through one of the contact officers
listed for this report.
Disclaimer
While every effort has been made to ensure the accuracy of this document, the
uncertain nature of data, forecasting and analysis means that Specsavers Pty
Ltd and Specsavers NZ Ltd is unable to make any warranties in relation to the
information contained herein. Specsavers Pty Ltd and Specsavers NZ Ltd, its
employees and agents disclaim liability for any loss or damage which may arise
as a consequence of any person relying on the information contained in this
document and any attachments.
Specsavers Pty Ltd
ABN 82 097 147 932
www.specsavers.com.au
www.specsavers.co.nz
Australia
520 Graham Street
Port Melbourne, VIC 3207
T: +61 3 8645 0700
New Zealand
Unit A 26 Triton Dve, Mairangi Bay
Auckland 0632
T: +64 9 475 0250
For information on this report please contact:
Cathy Rennie Matos, cathy.renniematos@specsavers.com
Caitlin Carey, caitlin.carey@specsavers.com
Acknowledgements
This report could not have been developed without the contribution of many people.
A special thank you to the Specsavers’ Optometry Team who worked tirelessly to
analyse the 6.3 million clinical records that were used to inform the research in this
report, to the Specsavers’ Communications Team who spent hours researching
and writing the report, and to Nature and Research NZ who conducted and
analysed our consumer research studies. We are also grateful to our optometrists
and their patients who shared their personal stories with us, as they bring a
human face to our data and motivate us to play our role in reducing avoidable
vision loss and blindness. Finally, a special thank you to our industry partners who
have been invaluable in working together to Transforming Eye Health in Australia
and New Zealand – RANZCO, Glaucoma Australia, Macular Disease Foundation
Australia, Diabetes Australia.
2
CONTENTS
06 EXECUTIVE SUMMARY
11 INTRODUCTION
12 THE EYE HEALTH WORKFORCE
14 EYE HEALTH - THE NUMBERS
14 Prevalence Rates of Eye Disease
21 Optometric Services
35 The Social and Economic Cost of Eye Health
36 THE NATIONS’ RELATIONSHIP WITH EYE HEALTH
36 The Public View of Eye Health
36 The Public’s Understanding of Eye Conditions and Diseases
37 Accessibility and Perceived Barriers
38 An Eye Test is More than a Sight Test
39 Eye Health – A Public Health Issue
41 CAUSES OF AVOIDABLE BLINDNESS
41 Glaucoma
46 Age-Related Macular Degeneration
49 Diabetic Retinopathy
54 Cataract
56 Refractive Error
59 CHILDREN’S EYE HEALTH
60 Optometric Services
61 The Nations’ Relationship with Children’s Eye Health
62 After Eight is Too Late
63 Prevalence of Children’s Eye Conditions
64 Children’s Eye Conditions and the Myopia Epidemic
65 Children’s Eye Screening Programs
67 INDIGENOUS EYE HEALTH
67 Aboriginal and Torres Strait Islander Eye Health
70 Māori and Pacific Islander Eye Health
72 Supporting The Fred Hollows Foundation
75 TRANSFORMING EYE HEALTH
75 Raising Public Awareness
77 Increasing Early Detection
78 Improving Communication and Collaboration Between Professions
81 Improving the Evidence Base
82 REFERENCES
3
TABLES AND CHARTS
TABLES
21 Table 1.1: Total optometric consultations by year
22 Table 1.2: Total optometric consultations forecast for FY25
22 Table 1.3: Referred comprehensive consultations by year
23 Table 1.4: Comprehensive initial consultations by another practitioner by year
25 Table 1.5: Comprehensive initial consultations by year
25 Table 1.6: Brief initial consultations by year
26 Table 1.7: Total initial consultations by year
27 Table 1.8: Other comprehensive consultations by year
28 Table 1.9: Diabetes mellitus consultations by year
29 Table 1.10: Subsequent consultations by year
31 Table 1.11: Visual fields by item number by year
31 Table 1.12: Visual fields by age range by year
32 Table 1.13: Total NZ optometric consultations forecasted to FY15
CHARTS
21 Chart 1.1: Total optometric consultations by year
21 Chart 1.2: Total optometric consultation by age range, FY18
22 Chart 1.3: Total optometric consultations forecast to FY25
22 Chart 1.4: Optometric consultations by type, FY18
22 Chart 1.5: Optometric consultations by item number, FY18
23 Chart 1.6: Referred comprehensive consultations by year
23 Chart 1.7: Referred comprehensive consultations by age range, FY18
23 Chart 1.8: Comprehensive initial consultations by another practitioner by year
23 Chart 1.9: Comprehensive initial consultations by another practitioner by age range, FY18
25 Chart 1.10: Comprehensive initial consultations by year
25 Chart 1:11: Comprehensive initial consultations (10910 & 10911) by age range, FY18
26 Chart 1.12: Brief initial consultations by year
26 Chart 1.13: Brief initial consultations by age range, FY18
27 Chart 1.14: Other comprehensive consultations by year
27 Chart 1.15: Other comprehensive consultations by age range, FY18
28 Chart 1.16: Diabetes mellitus consultations by year
28 Chart 1.17: Diabetes mellitus consultations by age range, FY18
29 Chart 1.18: Subsequent consultations by year
29 Chart 1.19: Subsequent consultations by age range, FY18
31 Chart 1.20: Visual fields by year
31 Chart 1.21: Visual fields by age range, FY18
32 Chart 1.22: Total NZ optometric consultations forecast to FY25
43 Chart 2.1: Glaucoma referrals as a percentage of patients
43 Chart 2.2: Visual fields as a percentage of patients v glaucoma referrals as a percentage of patients
43 Chart 2.3: Glaucoma referrals where IOP is under 22mmHg
47 Chart 2.4: Medical retinal referrals as a percentage of patients
47 Chart 2.5: Classification of AMD referrals sent through Oculo
50 Chart 2.6: Diabetes GP eye reports as a percentage of all patients
50 Chart 2.7: Diabetic eye referrals as a percentage of patients
50 Chart 2.8: Percentage of diabetic eye referrals with macular oedema identified
55 Chart 2.9: Cataract referrals as a percentage of patients
56 Chart 2.10: Refractive error based on dispensed prescriptions
57 Chart 2.11: Distribution of dispensed prescriptions by spherical power
57 Chart 2.12: Distribution of spherical power of contact lens prescription
60 Chart 3.1: Children’s optometric consultations by year
60 Chart 3.2: Children’s vision assessments by year
68 Chart 4.1: State spectacles schemes and estimated need for Indigenous Australians, 2016-17
68 Chart 4.2: Prevalence of trachoma in at-risk Indigenous communities, 2009 to 2016
4
GLOSSARY
ABS Australian Bureau of Statistics
AIHW Australian Institute of Health and Welfare
AMD Age-related macular degeneration
BMES Blue Mountains Eye Study
DHB District Health Board
DMO Diabetic macular oedema
DR Diabetic retinopathy
IOP Intraocular pressure
MBS Medicare Benefits Schedule
MVIP Melbourne Visual Impairment Project
NDSS National Diabetes Service Scheme
NEHS National Eye Health Survey
NHMRC National Health and Medical Research Council
NPDR Non-proliferative diabetic retinopathy
OCT Optical Coherence Tomography
OLEEP Ophthalmologist Local Education and Engagement Program
OMBS Optometric Medicare Benefits Schedule
POAG Primary open-angle glaucoma
PR Proliferative retinopathy
RANZCO Royal Australian and New Zealand College of Ophthalmologists
RE Refractive error
RPE Retinal pigment epithelium
StEPS Statewide Eyesight Preschooler Screening
5
EXECUTIVE
SUMMARY
With an ageing population in both Australia and New Zealand, vision
impairment is expected to emerge as the most prevalent health condition
among older people over the coming years. As 90% of vision loss in Australia
and New Zealand is preventable or treatable, early detection and intervention
is paramount to preventing avoidable vision loss and blindness5.
Optometry plays a critical role in the early detection of eye disease, • The systematic use of
appropriate referrals, and ongoing patient co-management. For the OCT as a screening
past year, Specsavers’ has been focused on outcome-led optometry
which has involved the development of consistent approaches to
disease assessment and management, measuring improvement
tool for every patient
plus benchmarking
effectively increases
90%
of vision loss
of clinical interventions, and benchmarking this against peers and glaucoma detection
published data. rates across all age in Australia and
groups, to near New Zealand is
The introduction and systematic use of Optical population prevalence
preventable or
Coherence Tomography (OCT) technology to as per Blue Mountains
screen all patients for eye diseases has led Eye Study (BMES) (50% treatable5
to overwhelming data that shows the validity more cases detected in
patients 40+ compared to
of this approach in improving detection and
non-OCT practices in 2018 and
diagnosis rates of not only glaucoma, but also 169% more compared to 2017).
diabetic retinopathy and medical retinal disease,
namely age-related macular degeneration. • The majority of patients referred for glaucoma
have intraocular pressure (IOP) within the normal range (ie.
Comparing this data to major eye health studies is designed to less than 22mmHg). The systematic use of OCT is proving to be
assist optometrists in applying evidence-based benchmarks superior for detecting low tension glaucoma - these are patients
to their care of the typical patient presenting to a primary eye with evidence of structural change presenting on OCT, without
health professional, and coupled with increased collaboration raised IOP, visible optic nerve changes or other overt signs of
with ophthalmologists, GPs and patient support groups will glaucoma. Optometry practices using OCT in this manner are
continue to improve patient outcomes and prevent avoidable detecting and referring 49% more patients for low tension
vision loss and blindness in Australia and New Zealand. glaucoma in patients 40+ compared to non-OCT practices.
• A significantly higher proportion of medical retina cases, the
Transforming Eye Health majority of which are age-related macular degeneration (AMD),
are being detected in practices using OCT systematically
An analysis of clinical data from 6.3 million Specsavers’ patients in (69% more cases in patients 50+ compared to non-OCT
Australia has shown overwhelmingly the real and positive impact practices in 2018 and 194% more cases compared to 2017).
that the systematic use of OCT technology on every patient as part 34.5% of patients are being referred for early AMD, 34.9% for
of a standard comprehensive eye examination, combined with clinical intermediate AMD and 30.6% for late AMD.
benchmark reporting and collaboration with medicine through the
RANZCO referral guidelines, is having on patient outcomes in relation • The diagnostic sensitivity of OCT combined with the
to some of the key causes of avoidable vision loss and blindness. additional clinical information it provides, has assisted
optometrists who use OCT on every patient to improve
• Current national Medicare utilisation data indicates that their detection of diabetic macular oedema (DMO) cases.
Australian optometrists perform visual fields on 8% of These practices are identifying and referring 85% more
all patients. To detect glaucoma at currently established cases of DMO compared to non-OCT practices.
population prevalence rates, visual fields should be performed
on at least 10% of all patients presenting to optometry.
6
Optometric consultations
The Need for More currently experiencing some degree
Research and Data of diabetic retinopathy. By 2020, the
are predicted to exceed
projected number of people experiencing 12.2 million in Australia and
Ongoing high quality research and clinical vision loss or blindness from diabetic
data is needed in both Australia and New retinopathy is 13,440 in Australia and
1.2 million in New Zealand
Zealand to better understand prevalence of 2,682 in New Zealand4,8. by 2025
eye conditions and diseases and the impact
of clinical interventions on patient outcomes. • Cataract: as many as 1.5 million Australians
over the age of 55 are believed to have
At present it is not possible with the research cataract6. By 2020, the projected number
and data available to gauge the impact we of people experiencing vision loss or in risk factors being identified through
are having on reducing avoidable blindness blindness from cataract is 126,400 in OCT results and the subsequent need to
in the region. As an industry, we need to Australia and 24,800 in New Zealand4,8. comprehensively assess these patients
coordinate our efforts to capture high quality for ocular disease.
data, aggregate it, analyse it effectively and • Refractive Error: Approximately 2.4 million
share it so that we produce a growing data- Australians and 480,000 New Zealanders • The true number of comprehensive
set across the profession and government. over the age of 40 have some form of consultations for patients with diabetes
Only then will we be able to prove the refractive error22 (22% of that age group) mellitus in Australia is unknown due
validity of interventions to improve detection and based on self-reported data another to ambiguity related to the billing of
and diagnosis rates and subsequently the 1.3 million Australians over the age of 55 patients with diabetes, however 244,000
impact on improving patient outcomes and suffer from presbyopia6. By 2020, the consultations were performed under Item
reducing avoidable vision loss and blindness. projected number of people experiencing 10915 in FY18, representing just 20% of
vision impairment from refractive error, the 1.2 million Australians with diabetes
excluding presbyopia, is 423,793 in registered on the National Diabetes
The Current State of Australia and 92,936 in New Zealand4,8. Services Scheme.
Eye Health in Australia
and New Zealand • The number of visual fields procedures
Demand for in Australia has been increasing steadily
Current prevalence of vision loss and blindness Optometric Services with bilateral visual fields increasing
in Australia is estimated at between 453,0005 68% over the past 10 years. The number
and 822,0004, and in New Zealand around • In Australia, optometric consultations, of visual fields performed annually is
175,0008. In the 2014-15 National Health across all Medicare Benefits Schedule expected to continue growing as more
Survey, over 12 million Australians (55% of the (MBS) item numbers, have increased 51% people are identified with glaucoma
population) self-reported having at least over the past 10 years and are expected risk factors through the use of OCT
one long term vision disorder7. to continue growing at an average of 5% technology. Currently, the majority of
per year. It is predicted that optometric procedures (63%) are performed on
Approximately 90% of vision consultations will exceed 9.5 million by patients within the 55-64 and 65+ age
loss and blindness in Australia 2020 and 12.2 million by 2025. range with the biggest growth coming
and New Zealand is caused from people aged 65-74.
by one of the five major eye • In FY18 a total of 8.7 optometric
consultations in Australia were • Several changes to the OMBS in Australia
conditions: uncorrected or
performed, with the highest volume are recommended to reflect connected,
under-corrected refractive coming from Item 10910 at 2.23 million contemporary practice and the impact that
error, glaucoma, AMD, diabetic (25.7%), followed by Item 10918 at 2.15 technology and data is having on improving
retinopathy and cataract4: million (24.8%) and Item 10911 at 1.23 the management of patients with diabetes
million (14.2%). mellitus and progressive disorders such as
• Glaucoma: 300,000 Australians and glaucoma and AMD. The key one being the
115,000 New Zealanders over the age • Initial consultations performed by introduction of a new item for people aged
of 40 are estimated to have glaucoma, optometrists in Australia in FY18 totalled 45-64 entitling them to a comprehensive
although as many as 50% of these are 4.68 million of which 1.42 million were for eye examination once every 24 months,
undiagnosed9,10. By 2020, the projected people 65+ (representing 38.9% of the rather than every 36 months.
number of people experiencing vision loss age range); 1.29 million were for people
or blindness from glaucoma is 41,900 in aged 45-64 (representing 22.1% of the • In New Zealand, there is no systematic
Australia and 7,287 in New Zealand4,8. age range); 1.44 million were for people means of capturing and reporting
age 15-44 (representing 15.2% of the age on optometric services performed
• AMD: 1 in seven Australians, 1.29 million, range); and 513,000 were for children by community optometry practices.
over the age of 5012 and 1 in 10 New aged 0-14 (representing 11.8% of the However, it is estimated that 781,322
Zealanders, 218,987, over the age of 4513 age range) suggesting that the majority comprehensive eye examinations were
are believed to have AMD. By 2020, the of Australians are not having their eyes performed by optometrists across
projected number of people experiencing tested as regularly as the industry New Zealand in FY18, representing just
vision loss or blindness from AMD is 91,300 recommends. 16.6% of the population. Based on a
in Australia and 16,280 in New Zealand4,8. projected 6% annual growth rate in
• The volume of brief initial consultations eye examinations, it is estimated that
• Diabetic Retinopathy: more than (10916) in Australia is in decline driven optometric consultations will exceed
300,000 Australians41 and between predominantly by people in the 45-64 917,000 by 2020 and 1.2 million by 2025.
52,091 – 65,114 New Zealanders10 are age range due to increased frequency
7
The Cost of Eye Health blindness is very limited with a significant
amount of confusion and uncertainty in
The latest figures available on the cost of relation to risk factors, symptoms and
eye health in Australia and New Zealand treatment.
come from economic analysis completed in
2009 and estimate the total financial cost • The biggest barriers to people having their
of vision loss to be $16.6 billion per annum in eyes tested regularly tie back to a general
Australia4 and $2.8 billion in New Zealand8. lack of awareness and understanding of
At the time optometric services accounted eye health. Thinking nothing’s wrong, lack
for 10% of health system expenditure of time and perceived cost were the main
in Australia4 and 3.5% of health system reasons that people don’t have their eyes
expenditure in New Zealand8. tested. However, issues with everyday
activities such as reading, driving, or
Health system expenditure was projected looking at screens would trigger those that
to rise 60% in Australia from $2.89 billion haven’t had an eye test to do so most.
in 2009 to $4.76 billion in 2020 and 164%
in New Zealand from $198 million in 2009 • While most people have a basic
to $522 million in 2020, while the cost understanding of the role optometrists
of optometric services was projected to play in the delivery of primary health
increase from $267 million to $467 million in care, there is still a lack of awareness
Australia and from $6.8 million to $18.1 million that optometrists can detect major eye
in New Zealand. diseases.
• The majority of people expect their eye
The Public View of test to include everything needed to
Eye Health detect major causes of avoidable blindness
and most believe their care should be co-
While it is clear that Australians and New managed and their optometrist should use
Zealanders value their eyesight, with 62% a platform like Oculo to share their eye care
and 67% respectively saying it was the data with their ophthalmologist and GP.
sense they would least like to lose and
83% and 82% respectively believing their
eyesight is priceless and wouldn’t be willing The Delivery of
to give it up for any amount of money, Eye Health Care
most people are not taking preventative
measures to look after their eye health. • The structure and delivery of eye health
services in Australia and New Zealand
• More than half of Australians and New are markedly different due to funding
Zealanders over the age of 40 have arrangements and the general structure
reported experiencing at least one of health care systems.
eyesight issue that they haven’t seen
an optometrist about, with the most • In Australia, close working relationships
common complaints relating to not being and a more collaborative approach to
able to see up close, or in the distance, as patient care between ophthalmology
well as they used to. and optometry is required to establish
more effective and efficient patient care
• Between a third and a half of Australians pathways and improve patient health
and New Zealanders can’t recall having outcomes.
had an eye test in the past two years even
though 85% think everyone should have • In New Zealand, appropriate funding
their eyes tested at least once every two strategies are required for an eye health
years; and less than a third of people have model which includes services provided
had a conversation about their family’s eye in DHBs and the local community via an
health history. integrated and collaborative approach
to care, between ophthalmology
• While myopia, hyperopia and cataract and optometry, using an effective
are the most recognised eye conditions, communication platform and efficient
the public’s understanding of the major patient care pathways to improve patient
eye diseases that cause vision loss and health outcomes.
ANNUAL COST OF VISION LOSS:
Australia New Zealand
$16.6 billion $2.8 billion
8
9
10
INTRODUCTION
In May 2003, in recognition of the 45 million people in the
world that are blind and the further 135 million people that
are visually impaired, the 56th World Health Assembly passed
resolution WHA56.26 on the elimination of avoidable blindness.
In response to the resolution, the Specsavers entered the
Australian Government Department Australian and New Zealand
of Health and Ageing developed a markets in 2008 with a goal to
strategic National Framework for change the face of optometry Early findings on the
Action to Promote Eye Health and and improve the eye health of impact of certain clinical
Prevent Avoidable Blindness and Australians and New Zealanders
Vision Loss in 2005. by providing accessible and
interventions on patient
affordable eye care to everyone. outcomes have important
The Framework outlined five key Specsavers has worked implications for the eye
action areas that have the potential resolutely towards this goal over
to lead to the prevention of avoidable the past 10 years and recently
health industry
blindness and low vision which were: consolidated its various eye care
1) reducing the risk of eye disease and strategies into a single-minded
injury; 2) increasing early detection; mission: to transform eye health
3) improving access to eye health care in Australia and New Zealand, a
services; 4) improving the systems mission that supports the National This report includes some of our
and quality of care; and 5) improving Eye Health Framework. early findings, which have important
the underlying evidence base1. implications for the eye health
We have already taken industry. In particular, the value of a
It has been 13 years since the significant steps systematic approach to optometry
Framework was developed and while toward addressing key and disease detection for improving
a considerable amount of work has challenges and are in the early detection and intervention
been undertaken by government, to reduce the amount of avoidable
process of implementing
non-government and the private blindness resulting from glaucoma,
sector, the goal to eliminate avoidable new projects while age-related macular degeneration
blindness by 2020 will not be continuing to build on the and diabetic retinopathy.
achieved. While important progress foundations of previously
has been made, there is still a long established initiatives, Over the coming years, it is vital that
way to go to achieve that goal and working collaboratively we continue to work collaboratively
significant challenges to overcome. with government, non- towards our goal with renewed
government and the passion and determination. We
In the 2014-15 National Health must do more to put eye health
industry in an effort to
Survey, 12 million Australians (55% on the agenda and not only raise
of the population) reported having at transform eye health public awareness of eye health
least one long-term vision disorder, and improve health but also drive behavioural change;
up from 9.7 million (51%) in 2001. outcomes for patients. we must continue to improve our
Furthermore, it is estimated that as evidence base and then respond
many as 822,000 people in Australia This inaugural ‘State of the Nation: to what the data is telling us; we
and 175,000 people in New Zealand Eye Health Report 2018’ contains must be systematic in the way
are currently experiencing vision the latest research and evidence on we test patients for eye diseases,
loss or blindness, yet 90% of vision the state of eye health in Australia ensure our optometry workforce
loss and blindness is preventable or and New Zealand. Through the can service the demand and are
treatable through the management of combination of Specsavers’ eye skilled in eye disease detection;
known risk factors and/or treatment. care initiatives, we now have access ensure we have appropriate
to an unprecedented volume of referral pathways; and importantly
With an ageing population, the new data and information on levels we need to continue improving
Australian Government estimates of eye care in Australia and New communication and collaboration
vision impairment will, over the Zealand and the impact that certain between professions to satisfy
coming years, emerge as the most strategies and interventions can patient demand and effectively
prevalent health condition among have on patient outcomes in relation manage patient outcomes.
older people. to the major eye diseases.
11OPTOMETRISTS
Optometrists are primary health care
providers and the first line of defence
in preventing avoidable vision loss and
blindness through the early detection,
treatment and management of eye
conditions and diseases.
By performing eye examinations,
optometrists assess the eye and visual
system, sensory and ocular motor
disorders and dysfunctions of the eye
and the visual system; detect signs of
eye diseases and diagnose refractive
disorders. They are also responsible
for appropriately managing health
disorders involving the eyes using a
multi-disciplinary approach, engaging in
therapeutic management of certain eye
conditions and diseases, and prescribing
glasses and contact lenses.
When an optometrist identifies
signs of an issue within the eye
that requires medical or surgical
treatment, or detects an eye
disease that requires further
assessment and management
by a tertiary specialist, the
patient is referred to an
ophthalmologist.
When an optometrist treats a patient
with ocular manifestations of a systemic
health condition, they will engage in
THE EYE HEALTH
appropriate co-management of the
patient and provide reports to relevant
health practitioners involved in the
WORKFORCE
patient’s care.
As part of a holistic approach to patient
care, optometrists will refer patients to
the appropriate patient advocacy group
for non-clinical support (for example
The structure and delivery of eye health services in Glaucoma Australia or Macular Disease
Foundation of Australia).
Australia and New Zealand are markedly different, due
primarily to funding arrangements and differences in the In both Australia and New Zealand,
general structure of the health care systems. optometrists undergo a minimum of 5
years of university education and are
authorised to prescribe medicines for the
The professions that are engaged in the include general practitioners, nurses, treatment of eye conditions within their
delivery of eye care, however, are similar pharmacists and allied health workers. The scope of practice and training.
and can be broken into two key groups – eye services delivered by the eye health care
health care professionals and generalist workforce include prevention, diagnosis, To practice in Australia, optometrists
health care professionals. management, treatment and rehabilitation. are regulated and registered by
the Optometry Board of Australia,
Eye health care professionals include Optometrists and optical dispensers make up while in New Zealand, optometrists
optometrists, ophthalmologists, orthoptists, the majority of the eye health care workforce are regulated and registered with
ophthalmic nurses and optical dispensers* in Australia, with optometrists providing over the Optometrists and Dispensing
while generalist health care professionals 75% of primary eye care. Opticians Board of New Zealand.
12 *known as dispensing opticians in New Zealand, but for the sake of ease, herewith collectively referred to as optical dispensers.OPHTHALMOLOGISTS ORTHOPTISTS OPHTHALMIC NURSES
Ophthalmologists are medical Orthoptists are allied eye health care Ophthalmic nurses are nursing professionals
practitioners who have undertaken professionals who are trained to that work in hospitals alongside
additional specialist training in the diagnose and manage disorders of ophthalmologists and care for patients
diagnosis and management of disorders eye movements and associated vision with eye disorders and diseases.
of the eye and visual system. problems and sensory deficiencies. In
Australia, they are also trained to perform Ophthalmic nurses complete general nursing
Ophthalmologists are tertiary investigative testing and procedures training then additional training to specialise in
practitioners who provide the under direction of an ophthalmologist the nursing care of patients with eye problems,
full spectrum of eye care, from or optometrist and engage in the whether in hospital, clinic or private practice
performing comprehensive eye rehabilitation of patients with vision loss. under the direction of an ophthalmologist.
examinations to diagnosing
To be an orthoptist in Australia requires
diseases and disorders of the a degree in orthoptics. In New Zealand, OPTICAL DISPENSERS
eye, and carrying out medical there is currently no training for
treatment and complex surgery. orthoptists, they are generally recruited Optical dispensers interpret optical
from the UK. prescriptions provided to a patient by an
Many ophthalmologists are also involved optometrist or ophthalmologist, and fit
in scientific research into causes and cures Orthoptists in Australia work in and service optical appliances such as
for eye diseases and vision problems. many areas including neonatal care, spectacle frames and lenses. While they
paediatrics, rehabilitation, geriatrics, are not permitted to examine eyes, or
An ophthalmologist in Australia or New neurological impairment, community write prescriptions, optical dispensers
Zealand is required to have undertaken services and ophthalmic technology. play an integral role in the eye health team
a minimum of 12 years of training, They are mainly employed by as they are responsible for accurately
comprising of six to seven years at a ophthalmologists, low vision clinics or assessing the individual needs of the
medical school, graduating with a degree in public health services such as hospitals. patient to ensure they receive a suitable
medicine; two years (minimum) as a newly eye wear product and solution.
qualified doctor undertaking basic medical Orthoptists in New Zealand are employed in
training; and five years of ophthalmic public hospitals and have a particular focus In Australia, optical dispensing is deregulated
specialist training and successful on children with eye health problems. (except NSW) and optical dispensers are
completion of examinations set by The required to undertake a Certificate IV in Optical
Royal Australian and New Zealand College Dispensing. In New Zealand, dispensing
of Ophthalmologists (RANZCO). remains a regulated profession and to practice
as an optical dispenser, you must be registered
with the Optometrists and Dispensing
Opticians Board of New Zealand and hold a
current practising certificate.
EYE HEALTH
CARE DELIVERY
AUSTRALIA both Australia and New Zealand. In recent struggles to give all New Zealanders
years, however, Specsavers has led a move equitable access to eye health services.
In Australia, responsibility for the delivery in Australia for a closer working relationship
of eye health care services is spread across and collaborative approach to care between District Health Boards (DHBs) are
both the public and private health care ophthalmologists and optometrists with a under immense pressure and are
system as well as both primary and tertiary view to establish more effective and efficient struggling with demand. Innovative
care. In addition to government funding, patient care pathways and improve eye interventions introduced by individual
private health insurance is an important health outcomes. eye departments within DHBs, aimed
component in the funding of eye health at reducing waiting times and achieving
care in Australia. While the Medicare Collaboration and patient co-management performance targets, are not currently
Benefits Schedule (MBS) covers in full, between optometrists and GPs and other proving to be sustainable or scalable.
or in part, a wide range of consultations, generalist health care professionals is at this
procedures and tests, out of pocket costs point limited, inconsistent and ill-defined. Appropriate funding strategies are
incurred by patients utilising private sector required for an eye health model which
services are often covered by private includes services provided in DHBs and
health insurance. NEW ZEALAND the local community via an integrated and
collaborative approach to care, between
Traditionally primary and tertiary specialist In New Zealand, eye health services are ophthalmologists and optometrists, using
eye health care professionals have operated mainly hospital based and patients often an effective communication platform
independently as silos and co-operation, have to wait long periods for hospital and efficient patient care pathways
collaboration and co-ordination have been appointments, and in outpatient clinics, to improve eye health outcomes.
key issues for the eye health system in waiting to be seen. The current system
13EYE HEALTH –
THE NUMBERS Long-term
vision disorders
increase with age:
10 (0–14)
%
PREVALENCE RATES 93% (55+)
OF EYE DISEASES
Some people are born with Approximately 90% of vision
eye conditions while some loss and blindness in Australia
develop problems as a child. and New Zealand is caused by one
More commonly, however, eye of the five major eye conditions:
the prevalence of vision loss and blindness
conditions develop during uncorrected or under-corrected
in Australia, and have remained widely
refractive error, glaucoma, age- used and cited in both Australia and New
adulthood and become more
related macular degeneration, Zealand. In 2016 the National Eye Health
prevalent with age. diabetic retinopathy and cataract4. Survey (NEHS) was conducted in Australia
Furthermore, 90% of vision loss is and was the first nationwide population-
Myopia and hyperopia are the most preventable or treatable5 either based survey to determine the prevalence
commonly reported eye conditions in through the management of and major causes of vision loss and
Australia and New Zealand, however like known risk factors or through blindness in Australia. Such a survey has
most developed countries, the main causes not yet been undertaken in New Zealand.
effective surgical or non-surgical
of vision loss and blindness are age-related
degenerative eye diseases. After the age treatment to either restore sight Based on self-reported data from the
of 40, vision loss and blindness increases or prevent further vision loss. Australian Bureau of Statistics (ABS)
three-fold with each decade of age1. 2014–15 National Health Survey, over 12
Australia has some of the best eye health million Australians (55%) reported having
The population in both Australia and New research and data sources in the world, at least one long-term vision disorder7, with
Zealand is ageing, both in terms of the however, it is far from exhaustive and is long-sightedness and short-sightedness
number of older people in the population becoming outdated, while New Zealand being the most commonly reported. The
and as a percentage of the population. eye research to date remains limited. There proportion of people with long-term vision
The proportion of the Australian population is no systematic means of capturing and disorders increased with age, from 10% of
aged 55 years and over is projected to monitoring eye conditions and diseases in a children aged 0–14, to 93% of people aged
increase to one in three by 20322, while the national register in either country. 55 and over7.
proportion of the New Zealand population
aged 45 and over is projected to be as high The main data sources available for Based on a number of reports including
as one in two by 20683. monitoring the prevalence of major eye the 2010 Centre for Eye Research Australia
conditions are studies that include an and Access Economics report, “Clear Focus:
With an ageing population, eye examination, sample surveys that The Economic Impact of Vision Loss in
the number of older people collect self-reported information and data Australia in 2009” and the 2016 “National
experiencing vision problems collected for administrative purposes6. Eye Health Survey”, the current prevalence
due to eye conditions and These data sources predominantly of vision loss and blindness in Australia
focus on measuring prevalence of is estimated at between 453,000 and
diseases is expected to increase
vision loss and blindness, meaning that 822,000. In New Zealand, the current
exponentially over future little research or data exists into the prevalence of vision loss and blindness
decades increasing the demand general prevalence of eye conditions is estimated to be around 175,0008.
for, and the costs of, eye health and diseases among the population.
and vision care services. Given the variations in reported data for
The Melbourne Visual Impairment Project vision loss and blindness and the limited
The Australian Government estimates that, (MVIP) and the Blue Mountains Eye Study data available on general prevalence of
as the population ages, visual impairment (BMES), both conducted in Australia in the eye conditions and diseases, this report
will emerge as the most prevalent 1990s, were the first two comprehensive has used a combination of data sources to
health condition among older people2. and internationally-renowned studies of report on eye disease prevalence rates.
1415
GLAUCOMA
Glaucoma is a group of eye
diseases that can cause damage
to the optic nerve often resulting in
the gradual loss of peripheral vision.
While glaucoma is often associated with
increased intraocular pressure (IOP) resulting
from either malfunction or malformation of the
eye’s drainage system, it can also occur with
normal or even below normal eye pressure.
People with early stage glaucoma experience
no symptoms, but without timely detection
and treatment irreversible damage to the eye
may occur causing blurred or misty vision.
This may eventually lead to irreversible vision
loss and even blindness.
Prevalence of Glaucoma
There are different types of glaucoma, however,
Primary Open-Angle Glaucoma (POAG) is Glaucoma Australia estimates that Australia from glaucoma is 41,900,
the most common and accounts for 90% of as many as 300,000 Australians are of whom 18,000 will be blind4.
glaucoma cases in Australia and New Zealand9. currently living with glaucoma although
POAG occurs when, for unknown reasons, as many as 50% are unaware they have Glaucoma New Zealand estimates
the fluid that flows in and out of the anterior the disease9. prevalence of the disease in New Zealand
chamber in the front of the eye passes too to sit at 115,000 people, again with 50%
slowly through the meshwork drain. As a result, Two in 100 Australians are expected of these being undiagnosed10. By 2020
eye pressure builds and starts to damage the to develop glaucoma in their the projected number of people with
optic nerve. This type of glaucoma is painless lifetime9. By 2020 the projected vision loss in New Zealand from glaucoma
and causes no vision changes at first. number of people with vision loss in is 7,287, of whom 3,147 will be blind8.
CASE STUDY: SIMON’S STORY
At 62 years of age, Simon is an active person. epiretinal membrane formation with some
He enjoys the outdoors, boat rides and associated macular oedema.
scenic walks with his wife. Until his most
recent eye test, his eye health was not on his “I was told that there were
radar. After losing his glasses, it took him a symptoms in my peripheral
year to visit his local optometrist to get new vision but it wasn’t until I
ones, and while there it was suggested that was going through one of the
he see an optometrist given it had been over
tests that I realised that I had
10 years since his last eye test.
issues. It just wasn’t obvious
Simon’s eye examination took an in my day-to-day life.” But what I’ve learnt is that it’s so
unexpected turn when his OCT, tonometry important to leave it up to the
and visual field tests all showed strong The ophthalmologist confirmed that Simon professionals to decide that. This
signs of glaucoma so he was referred to an had the chronic simple glaucoma and was has snuck up on me and I didn’t
ophthalmologist for further testing. prescribed Xalatan, one drop in each eye
see it coming. I don’t like thinking
daily to stop the condition worsening.
Simon’s uncorrected vision was 6/12 in about how different my life could
the right eye and 6/9 in the left. IOP was “Losing my eyesight is the have been if I hadn’t walked into
28mmHg in the right eye and 24mmHg only incentive I need to use the optometrist on that day. I
in the left. Corneal pachymetry readings my eye drops every day. It was couldn’t be more thankful that my
were 490 microns in the right eye and a shock to learn that my eye early stage glaucoma was picked
503 microns in the left. Zeiss fields were up because I could not imagine a
sight was deteriorating, a real
performed and results showed both eyes life without sightseeing with my
were outside normal limits. OCT results wake up call. I was raised the
Aussie way – I’ll be right. wife and sharing Sunday drives in
showed retinal nerve fibre loss was outside
normal limits bilaterally. There was bilateral our MX5.”
16AGE-RELATED MACULAR DEGENERATION
Age-related macular In the early stages of the disease, Bruch’s The Macular Disease Foundation of
degeneration (AMD) is a membrane thickens and small yellow Australia estimates that as many as
spots called drusen start to accumulate one in seven Australians, or 1.29 million
degenerative eye disease that
beneath the RPE. These initial signs of people, over the age of 50 have some
damages the macula, the central AMD can have no visible symptoms at all. evidence of the disease and approximately
part of the retina, causing Not everyone that presents with drusen 17% of these people, around 200,000,
progressive loss of central vision. will necessarily lose their vision, however will experience vision loss12. By 2020,
the existence of drusen does increase the the projected number of people with
It is usually related to ageing and chances of developing late-stage AMD. vision loss in Australia from AMD is
predominately develops after the age of 50, The progression of early-stage AMD to 91,300 of whom 53,000 will be blind4.
although certain forms of the disease can late-stage AMD is generally associated with
also affect younger people. an irreversible decrease in visual acuity The prevalence of AMD was estimated at
and occurs because the RPE cells die or 218,987 people in New Zealand in 2016
There are two types of AMD – dry AMD they fail to keep blood vessels from the and approximately 7.6% of these people,
(geographic atrophy) and wet AMD (exudative choroid from growing under the retina. around 19,825, have vision loss from it13.
or neovascular AMD). Dry AMD accounts Approximately 10% of people aged 45 to
for approximately 33% of all cases of late Vision becomes increasingly blurred or 85 experience some form of the disease
stage AMD and is a slow form of the disease distorted, reading becomes difficult, and it is estimated that 199,140 have
causing a gradual loss of vision. Wet AMD colours become less vibrant and people’s early stage AMD while 19,847 have late
occurs when the retinal pigment epithelium faces become more difficult to recognise. stage AMD13. Worsley and Worsley, 2015,
(RPE) cells fail to stop choroidal blood vessels also predicted a 12.9% increase in the
from reproducing under the retina. The prevalence of AMD in New Zealand from
new rapidly growing choroidal vessels are Prevalence of AMD 2014 through to 202614. By 2020, the
fragile and can leak or bleed under the retina projected number of people with vision
causing scarring to occur, leading to loss of AMD is the leading cause of blindness in loss in New Zealand from AMD is 16,280
vision. In these cases, vision changes are Australia and New Zealand, responsible for of whom around 9,100 would be blind8.
often sudden and severe. almost 50% of all cases of blindness11.
DIABETIC RETINOPATHY retinopathy or macular oedema. Proliferative getting regular eye tests16. More than
retinopathy occurs when many of the blood 300,000 Australians with diabetes mellitus
vessels in the retina are blocked depriving are presently living with some degree
Diabetic retinopathy is one of several areas of blood supply. When this of diabetic retinopathy. By 2020, the
the most common complications happens, the brain sends signals to grow projected number of people with vision loss
new blood vessels, which may be abnormal in Australia from diabetic retinopathy is
associated with diabetes
and fragile and grow on the surface of the 13,4404.
mellitus and while everyone with retina and along the surface of the clear,
diabetes is at risk of developing vitreous gel that fills the inside of the eye. In New Zealand, the prevalence of diabetes
diabetic retinopathy, it affects These blood vessels have thin, fragile walls mellitus by district health board (DHB) area
that can leak blood into the centre of the eye is estimated to range from 4.17% to 8.35%.
around one in three people
causing blurred vision and blindness. Macular The Ministry of Health estimated 260,458
living with diabetes15. oedema occurs when fluid leaks into, and New Zealanders were diagnosed with
accumulates in, the macula causing swelling diabetes mellitus as at December 2015 and
Diabetic retinopathy can be easily managed and blurred vision. This is more likely to occur projects an average annual growth rate of
if detected and treated early and almost all as the disease develops. Around 50% of new diagnoses of 5%17. New Zealand’s Māori
cases (98%) of sight-threatening diabetic people with proliferative retinopathy also and Pacific Island populations are particularly
retinopathy are preventable4. Diabetic have macular oedema4. at risk, with 8% of Māori and 10.1% of Pacific
retinopathy occurs when diabetes mellitus Islanders having diabetes, compared to 2.9%
damages the tiny blood vessels inside the of New Zealanders with European descent18.
retina. In the early stages of the disease, the Prevalence of
blood vessels of the retina can develop small Diabetic Retinopathy Approximately 20% to 25% of New
swellings in the walls (micro aneurysms) Zealanders with diabetes mellitus have
but as the disease progresses, some of the Diabetes Australia estimates that 1.7 million some form of diabetic retinopathy, equating
blood vessels that nourish the retina can people in Australia are living with diabetes to between 52,091 and 65,114 people19.
become blocked. Diabetic retinopathy often mellitus although around 30% of these Māori and Pacific Islanders are more likely
has no visible symptoms and can progress to are undiagnosed, and more than 100,000 than New Zealanders with European
advance stages without the patient realising people are newly diagnosed each year15. descent to develop sight-threatening
they have an issue with their eyes. diabetic retinopathy. By 2020, the projected
Around 1.2 million Australians are registered number of people with vision loss in New
Vision loss as a result of diabetic retinopathy with the National Diabetes Services Scheme Zealand from diabetic retinopathy is 2,682,
can occur in one of two ways – proliferative and of these, around 630,000 are not including 353 Māori8.
1718
CATARACT
A cataract is a clouding of the eye’s
naturally clear lens. The lens is made
predominantly of water and protein, with
the protein arranged to let light pass
through and focus on the retina. Some of
the protein may clump together and cloud a
small area of the lens. When this happens,
the lens becomes opaque and the amount
of light that passes through it is reduced
and scattered, and the image cannot be
correctly focused on the retina. Over time
31%
of Australians
the cataract may grow larger and cloud
more of the lens resulting in poor vision. aged 55 are affected
Cataracts can develop over many years by untreated
and have no visible symptoms early on.
cataract
There are four main types of cataract – Prevalence of Cataract
age-related cataract; congenital cataract;
secondary cataract (where the cataract is In Australia, it is estimated that untreated
linked to certain other health issues such as cataract affects almost 1.5 million people
diabetes mellitus); and traumatic cataract, over the age of 556, which represents 31% according to the Ministry of Health, 16,420
(where cataracts develop as the result of an of that age group. publicly-funded cataract operations were
eye injury either soon after or years later). performed nationally in 201621. The total
By 2020, the projected number of people number of cataract operations is likely to be
There are also three main forms of cataract with vision loss in Australia from cataract is double that when private surgeries, which
– nuclear cataract, which occurs in the 126,400, of which 11,350 will have cataract- are not publicly reported, are included21. By
centre of the lens; cortical cataract, which related blindness4. 2020, nearly 22,800 New Zealanders are
radiates from the outside of the lens to the projected to have cataract-related vision
centre; and subcapsular, which starts from In New Zealand, there are no reported loss and around 2,000 are projected to have
the back of the lens20. figures for untreated cataract but cataract-related blindness8.
REFRACTIVE ERROR Prevalence of Refractive Error
More than half of all vision loss in There are four main types of refractive More than half of all vision loss
Australia and New Zealand is caused error – myopia (short-sightedness where in Australia and New Zealand is
by refractive error5, whereby the shape light focuses in the front of the retina caused by uncorrected or under-
of the eye prevents light from focusing so distant images are blurred caused by corrected refractive error5.
precisely on the retina resulting in a excessively steep curvature of the cornea
blurred image. or excessive axial length of the eye or Approximately 2.4 million Australians and
both); hyperopia (long-sightedness 480,000 New Zealanders over the age of 40
The length of the eyeball, changes in where the light focuses behind the retina have some form of refractive error22, which
the shape of the cornea, or ageing of so close images are blurred caused by the represents 22% of that age group and based
the lens can all cause refractive errors. curvature of the cornea being flat or the on self-reported data, presbyopia affects the
Symptoms include blurred vision, eye axial length of the eyeball being short); sight of 1.3 million Australians over the age of
strain, tiredness, reduced concentration astigmatism (a focusing error that causes 556. By 2050, it is predicted that there will be
and headaches. Uncorrected refractive asymmetric blur at all distances mostly 22 million Australians and New Zealanders
error occurs when a person’s vision caused by the shape of the cornea or by with myopia, up from 4 million in 200023.
is reduced because they either need slight tinting of the lens); and presbyopia
glasses and don’t have them, or the (an age-related vision difficulty at normal By 2020, the projected number of people
prescription in their current glasses is reading distance caused by the loss of with vision loss from refractive error,
not correct. Refractive error can affect flexibility in the muscle in the eye that excluding presbyopia, is 423,793 in
people at any age. changes the shape of the lens). Australia4 and 92,936 in New Zealand8.
1920
OPTOMETRIC SERVICES Private health insurance has limited uptake
in New Zealand compared to Australia and
the government only has a few limited
Access to, and utilisation of, eye health participating optometrists under the Medicare programs in place that provide financial
services are imperative if we are to Benefits Schedule (MBS), essentially making support to eligible people. These include
successfully eliminate avoidable vision loss standard comprehensive eye examinations the ‘Children’s Spectacle Subsidy’ from the
and blindness in Australia and New Zealand. available to residents at no charge24. Ministry of Health for eligible children 15
Regular eye examinations are required for years of age or younger; the urgent and
people of all ages, genders and ethnicities for In New Zealand, however, the government essential need funding for adults suffering
the prevention, early detection and treatment does not provide funding for universal hardship from the Ministry of Social
of eye diseases and conditions. access to eyecare outside of the District Development via hardship grants that
Health Boards (DHBs). Almost all residents of must be repaid to the crown; and the ‘Get
In Australia, residents with a valid Medicare New Zealand are required to pay for all costs Checked’ program for people with diabetes.
card without optometry restrictions, as well associated with services provided by an Additionally, the Accident Compensation
as certain categories of visitors to Australia, optometrist, which is a disincentive to access Commission will provide eye examinations
can claim benefits for services provided by care in the community. for treatment of injury due to an accident.
OPTOMETRIC SERVICES IN AUSTRALIA
To gain a better understanding of the (Items 10912, 10913 and 10914) It should be noted that on 1 January
demand for specific optometric services • Other Comprehensive Consultations – 2015, the Australian Government
in Australia, a 10-year analysis of the Diabetes Mellitus (Item 10915) introduced a 5% reduction in optometry
following Medicare item numbers has been • Subsequent Consultation (Item 10918) MBS fees, an indexation freeze to July
undertaken: 2018 and a change in frequency of
Visual Fields, categorised under the MBS comprehensive eye examinations which
• Comprehensive Initial Consultations as Computerised Perimetry Services, had a moderate but direct impact on the
(Items 10900, 10910, 10911, 10905 and (Items 10940 and 10941) have also way optometrists claimed optometric
10907) been analysed due to their importance services during FY15 and FY16, but did
• Brief Initial Consultation (10916) in the detection of glaucoma. not affect the overall trend of optometric
• Other Comprehensive Consultations services delivered in Australia.
OPTOMETRIC CONSULTATIONS
From July 2008 to June 2018, Medicare item numbers, has increased by 51% over the past 10 years is presented in Table
benefits have been processed for 71.7 the past 10 years with an average increase 1.1 and Chart 1.1. The share of optometric
million optometric consultations. The total in services of 4.7% per year. The number consultations by age range in FY18 is
number of consultations, across all MBS of optometric consultations by year over presented in Chart 1.2.
Table 1.1
Total Optometric
consultations by year
Source: Australian
Government, Department
of Human Services -
Medicare Items Reports
Chart 1.1 Total Optometric consultations by year Chart 1.2 Total optometric consultations by age range, FY18
9000000
15-24
8.31%
8000000
2
8. 5-3
7000000 68 4
+
% 65 6%
6000000 .6
30
35-44
5000000 9.62%
4000000
3000000 4
0-1 %
2000000 29
10.
55 .61%
1000000
16
-6
15.7 4
0%
4
5
0
45-
FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 FY18
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