Article

INTERNATIONAL PERSPECTIVES

DOWN UNDER: RESEARCH VERSUS REALITY

In this 2017 series of articles, we are exploring different contact lens markets around the world. We ask: Is contact lens fitting very different in various parts of the world, and can we learn from each other? To help address this question, we looked at the work from The International Contact Lens Prescribing Survey Consortium that is published every year in the January issue of this publication (Morgan et al, 2017). This consortium shares global results of what contact lenses are fit and who fits them. Every year, it is apparent that different countries have very different fitting profiles.

This time, we look at Australia and New Zealand: accounting for close to 25 million and 5 million people and representing the 53rd and 123rd places in populations of countries worldwide, respectively. Although together they represent less than 0.4% of the world’s population, their influence on the international contact lens industry and profession is disproportionately higher—largely due to the advanced level of their optometry profession, their universities, and their global research profile. But while this is so, the question is how does this region relate to other parts of the world in terms of contact lens prescribing?

Part-Time Wearers

The percentages of part-time wearers (three days or less per week) appears higher in this region than in other countries, representing 28% (Australia) and 18% (New Zealand) of their respective new fits reported. In comparison, part-time wear is 12% overall for all countries represented in the survey and is only 3% in the United States.

Traditionally, a higher rate of part-time wearers has been associated with prescribing rates of daily disposables (DD), most likely due to the fact that DD lenses are more economical when worn less frequently per week. Indeed, this trend seems to be true for both Australia and New Zealand; within the soft lens modality, DD lenses are prescribed in 60% of cases in Australia and 55% of cases in New Zealand. In general, this percentage among all participating countries is 38%, with the United States trailing with 17% of soft lens fits being DD. Australia and New Zealand are both in the top 10 of DD prescribing countries of the 33 markets represented in the International Prescribing Survey. Another factor in the high use of DD lenses is the popularity of outdoor activity, camping, swimming, surfing, and sports in general.

Intuitively, rigid contact lenses are considered as a modality for full-time wear, because they require adaptation and are often used for critical vision correction needs. So, whether it is a coincidence or not, rigid lens prescribing rates are relatively low in this region; Australia reported 4% for non-orthokeratology (ortho-k)-related prescribing, and New Zealand reported 3%. The general feeling is that rigid lens fitting is more prominent in New Zealand than in Australia. This is backed up by previous editions of the survey, in which New Zealand showed considerably higher rates of rigid lens fitting compared to Australia (19% versus 6% in the 2014 survey and 7% versus 4% in the 2015 survey data) (Morgan et al, 2015; Morgan et al, 2016). Australia does not even make the selected group of countries reporting more than 35 rigid lens fits in the 2016 survey, while New Zealand does. In the United States, rigid lens prescribing is 6%, and overall (all countries) this is 7%. Ortho-k fitting accounts for 2% and 1%, respectively, in Australia and New Zealand (2% worldwide).

Lenses fit with the indication “anti-myopia”—a specified option in the survey—are consistently low throughout the region (close to 0%) for both rigid and soft lenses. However, this is true for almost all countries combined in the survey; only a few countries, including Hong Kong and China, score higher in that regard in either modality (rigid or soft) for myopia control. This field is still in its infancy, and we would expect to see significant growth.

Research Advantage

Despite low prescribing rates for rigid and ortho-k lenses, a significant proportion of ortho-k research comes from this region. Specifically, Australia has played a dominant role in the revival of modern ortho-k from both a design and a technology standpoint, including the development of a new standard for corneal topography. However, this appears to be a specialized field and has not yet translated to what local eyecare practitioners are prescribing.

There are currently six universities offering optometry programs in that region, and all have played roles in the development of contact lenses and in understanding their physiological impact: Deakin University, Flinders University, Queensland University of Technology, University of Auckland, University of Melbourne, and the University of New South Wales, plus there is the Brien Holden Vision Institute. These institutions are instrumental in research leading to improved understanding of the risk of lens wear, development of silicone hydrogel (SiHy) materials, myopia control, ortho-k, keratoconus fitting, and improved lens designs.

Silicon(e) Valley

With our tongues in our cheeks, we might consider Australia and New Zealand to be the “Silicone Valley” of our industry. Although a number of countries fit high numbers of SiHy lenses, Australia and New Zealand have embraced SiHy materials. With SiHy comprising 74% of all soft lenses in Australia and 77% in New Zealand, this puts them at the head of the leading group of prescribers. The average among all countries is 55%, just above half of all fits in this material.

Considering DD lens fits, SiHy lenses outpace traditional hydrogel as the first-choice material. In Australia, SiHy versus hydrogel is 36% compared to 19%, respectively; New Zealand has SiHy at 36% and traditional hydrogel materials at 17%. Conversely, eyecare practitioners in all other countries combined prescribe 12% SiHy and 19% traditional hydrogel materials for DD.

Finally, regarding extended wear, SiHy materials were originally launched to be fit on an extended wear basis, and today extended wear accounts for 4% and 2%, respectively, for Australia and New Zealand—lower than the average of 9% for all countries combined. Appropriately, the percentage of SiHy materials used for extended wear is 100% in both countries, but only 49% on average for all participating countries.

Education

Contact lens prescribing is performed almost solely by the profession of optometry in Australia and New Zealand, which is not true for all regions in the world, as we have seen previously in this series. As described earlier, there are six universities that train optometrists, and leading international experts and key opinion leaders are often affiliated with these institutions.

Moreover, the International Association of Contact Lens Educators (IACLE) came to be at the University of New South Wales in Sydney, where its headquarters is still located. IACLE currently has 826 active members from 70 countries worldwide. It is the leading provider of educational and information resources essential to contact lens educators worldwide. Members have access to an extensive list of resources, and advanced educators can enhance their professional status through its Fellowship (FIACLE) program.

The list of individual contact lens leaders and educators to emerge from this region is extensive; in fact, it is so large that any attempt to list them would be beyond the scope of this article. Adding to the described high level of contact lens education, the region also hosts a number of high-quality international meetings on general and specialty contact lens fitting in both Australia and New Zealand. For example, the International Cornea and Contact Lens Conference was held this past September in Sydney. And, the Orthokeratology Society of Oceania biennially hosts a very successful international specialty lens meeting.

Final Thoughts

You could characterize Australia and New Zealand as having embraced DD lens fits; a number that, at least to some degree, may be driven by the higher number of part-time wearers. It also has accepted SiHy materials as a first choice for soft lens designs. Extended wear is certainly not very popular, although when it is prescribed, the lenses are all in SiHy materials.

It may be noted that Australia and New Zealand represent a small market, but it has a pretty large impact on the international contact lens community. This is surely driven by research from a number of the educational institutions in the region.

Also, in terms of technology and lens design, Australia and New Zealand lead the way in many respects. This seems particularly true for myopia control research with contact lenses (including orthokeratology) and with soft specialty lenses as well as with specialty rigid contact lenses, such as keratoconus designs.

In addition, we should mention that the region holds a special place for high-quality education in general, illustrated by IACLE as an organization, which had its birthplace in the region and still keeps its international headquarters there. CLS

Special thanks to Dr. Alan Saks for his valuable input as well as to Professor Nathan Efron and Dr. Wanda Lam, who coordinate the fitting surveys in Australia and New Zealand, respectively.

For references, please visit www.clspectrum.com/references and click on document #265.