A Clear View - Improving indigenous eye health

Hello, I'm Norman Swan. Welcome to this program on improving eye health in Indigenous communities. Indigenous children are usually born with better eyesight than non-Indigenous children. Yet by the time they reach adulthood, they're six times more likely to be blind and three times more likely to have low vision. Most of that vision loss is preventable, and certainly most of it is treatable. This program covers different eye diseases and how to treat and prevent them. We have two filmed case studies as well. You'll find a number of useful resources available on the Rural Health Education Foundation's website: Now, let's meet our panel. Tim Henderson is an eye specialist from Central Australia. - Welcome, Tim. - Hello. Thank you. Tim visits over 30 remote Indigenous communities each year with the eye team, providing a comprehensive specialist outreach program. He's also Senior Lecturer in Ophthalmology at the Northern Territory Clinical School of Flinders University. Anna Morse is an optometrist, and the project manager of the Aboriginal eye-care service of the Indigenous centre for eye-care education, based in Darwin. - Welcome, Anna. - Thanks, Norman. Anna provides and facilitates optometry services to many remote-community health centres and Aboriginal medical services across all regions of the Northern Territory. She also provides training in eye healthcare for primary-healthcare staff. Barbara O'Connor is the regional eye-health coordinator from Woolloongabba in Queensland. Barbara is a descendant of the Noonuccal tribe from North Stradbroke Island, and currently works for the Aboriginal and Torres Strait Islander Community Health Service providing services at Woolloongabba and outreach across South-East Queensland. - Welcome. - Thanks, Norman. Hugh Taylor is Melbourne laureate professor, holding the Harold Mitchell Chair of Indigenous Eye Health at the University of Melbourne. - Welcome, Hugh. - Thank you, Norman. Hugh's research interests include blindness-prevention strategies, infectious causes of blindness and the relationship between medicine, public health and health economics. His current work focuses on Aboriginal eye health and trachoma. So welcome to you all. Hugh, just expand a little bit on those statistics I gave earlier in terms of the eyes. Sure. As you said, Norman, Aboriginal children have less poor vision, a fifth less poor vision, in fact much better vision, than mainstream kids. But by the time Aboriginal and Torres Strait Islander adults reach the age of 40 or above, they have six times as much blindness. Almost all that blindness is unnecessary. It's either preventable or treatable. 32% of blindness is due to cataract. We have refractive error that cause about 14%, and diabetes and trachoma both cause about 9% of blindness. As I said, 94% of this vision loss is unnecessary, but a third of the people have never had an eye exam. They have not had the treatment or the prevention that they need. Barbara, this has to have an enormous impact on communities. Yes, it does. The health of the individual with diabetes is the eating habits, also controlling how much they eat, what intake they take with their sugar. Also, hygiene - it's trachoma. It's a very important issue too. Anna, the optometrist is often the first port of call for finding out a lot of these things. Absolutely. The main trigger for people to have their eyes checked is them noticing a change in their vision. Often the first person to see is an optometrist. It's not uncommon for that optometrist to pick up diabetic retinopathy, even perhaps when people don't know that they're diabetic yet. So optometrists are a vital link in the chain in the eye-care team. NORMAN: And not enough of them. No, apparently not, especially in the very remote locations. We can always do with more optometrists providing services there. Hugh, you've got research which suggests that access to optometrists is directly related to the vision of a community. Yes. There's data that shows that the longer an optometrist is working in an Aboriginal medical service, or AMS, the better the vision and eye health of the people in that community, whereas there's no relationship between the number of optometrists or the amount of time that they're available in the community or the town. - It's appropriate services. - Appropriate, culturally acceptable services provided within the AMS lead to much better outcomes. What are the trends, Tim? You'd think with the discussion of diabetes and everything else that we should be tracking seriously downwards. I think the coverage for screening populations is improving. There's a better understanding of the range of disease issues that the population faces. But there are significant challenges to getting enough outreach services in place. We ideally need three optometry visits per eye-specialist visit to begin to get comprehensive coverage and pick up the rate of problems that exist. But we are getting a bit better, Hugh? Please tell us we are. Yeah, we are getting a little bit better. In the mid-'70s, when I first started working in this area with Fred Hollows, the rate of blindness in Aboriginal people was eight times higher than it is in mainstream. And now it's only six. It's a little bit better, but we've still got a long way to go. Is there much difference between city and country, Anna? Perhaps surprisingly, not so much. The Indigenous Eye Health Survey showed that vision impairment and blindness didn't vary much across whether people were in urban locations or rural. - Presumably not so much trachoma? - Not so much trachoma. There were slight differences in specific conditions, such as trachoma and blinding cataract, but overall rates of vision impairment and blindness, which can indicate that while services may be available in an urban location they're not necessarily accessible. So not necessarily available through an Aboriginal community-controlled health organisation or in a setting where people feel comfortable and free to access that service. What other barriers are there for people accessing services? The service delivery in the regions outside of the urban. There's not enough services in the rural and remote areas, possibly across the whole of Australia, with optometry followed through by ophthalmology. So accessing services, transport to cities if they do need the treatment, that's a large problem within those areas. So I say, not having the service deliveries in the rural and remote areas. Even something as simple as refractive error, Hugh, we're not getting right? Refractive error causes half of the vision loss in Aboriginal people. This is for distance vision. But the thing that's even more important, I think, is poor near vision. 40% of Aboriginal and Torres Strait Islander adults cannot see normal-size print because they don't have the right pair of reading glasses. We need to make sure that we provide those refraction services with visiting optometry and visiting eye services. We can cure uncorrected refractive error instantaneously with a pair of glasses. So it's presbyopia as well we're missing? Absolutely. That's often one of the overlooked refractive errors. Studies worldwide have shown that the impact on people's quality of life with a pair of reading glasses can be significant. Everything that you do looking up close, especially in this day and age, which is about half of your day, is affected. Barbara, to what extent are GPs working in Aboriginal medical services checking both distance vision and near vision? Visual acuity for distance is tested, but not for reading. The GP speaks to the client, they will bring forward that they can't read the newspaper or can't see distance. Then it's referral to an optometrist. Tim, this is outrageous. We're missing presbyopia because people aren't doing a simple check with a standardised font-size chart? At the very least, you can ask if they're able to read small print, or see it. NORMAN: And give it to them. So the big message from this program, if you're a general practitioner, you should be checking for presbyopia, at least in a crude way. Certainly in every health check, one should. Even if it's a case of placing a book or paper on the desk and saying, 'Can you see this print?' Somebody who doesn't read, you can still ask them to point out the letters or which way the Es are pointed. So don't take it for granted, 'Yes, it's fine.' Actually test it. Even if you can't read they're still requiring to see things near. You need good vision to be able to thread a needle, clean a gun, adjust a carburettor, even to prepare food, let alone checking your medicines or your blood sugar. What about cataract, Tim? Cataract is well worth picking up, because the impact you can have from cataract surgery, which we'll cover later, is so dramatic. Overall we reckon around 3% of Indigenous adults suffer from cataract vision loss, and blinding cataract is 12 times more common in the Indigenous populations we look after. Of those, 65% needing cataract surgery have been operated on, which leaves a significant portion that still need surgery. And diabetic retinopathy, Anna? That follows trends of significant increases in diabetes in itself compared to two or even one generation ago, where there was hardly any at all, to now rates of around or above 30% in Aboriginal people. Following along with that is obviously a higher prevalence of diabetic retinopathy. Diabetic retinopathy is more common also if people, along with diabetes, have hypertension and high cholesterol. The triad of those increases your risks of getting diabetic retinopathy. Importantly, only about one in five Aboriginal people with diabetes had had a recent eye exam, so the required eye exam in the previous one year, which means there is a chance of retinopathy progressing without it being detected. All this is overlaid, Hugh, on a disparity in the provision of services across Australia? Yes. If you look at the distribution of eye services, either performed by an optometrist or an ophthalmologist, you see how patchy and variable they are across the country. In remote areas, one would need to increase services at least three or fourfold to bring them up to the level that the rest of the country enjoys. There's clearly a shortage of services. To what extent are glaucoma and macular degeneration prevalent in Aboriginal communities? Very low numbers. It's really not that significant a contributor to the population we're looking after. What are the key health-promotion messages that we're trying to get over, Anna? There are a few important messages. A really important one, given that a lot of this vision impairment is preventable or treatable, is for people to be aware that losing vision is not a normal part of getting older. There's something that can be done about it. Important is that you should get your eyes checked regularly. Get your eyes checked once every two years, or once every year if you're diabetic. Relating to particular conditions such as trachoma is around keeping your face clean, and blowing your nose for the kids, as well. Tying in with diabetic retinopathy is if you keep good care of your general health, then that can protect your eyes also. And smoking, presumably, or did you say that? - I didn't say that, but yeah. - Smoke gets in your eyes. It's also a very bad combination with diabetes, as well. Hugh, you're trying to get the health check changed for Aboriginal people to be much more systematic about the eyes. There's a lot of talk about whether one should have a vertical or a horizontal program, or a high body part or holistic. What's really important is to have comprehensive primary care doing the basic eye care that they need to do. Basic eye care is to make sure, first of all, that people having a health check get their vision properly checked, particularly near vision, as we were taking about. Any problems with near vision, refer them. You don't have to manage that, just initiate the referral. The second thing is people with diabetes. Make sure that Aboriginal and Torres Strait Islander people with diabetes get their eyes examined every year. At the moment only one in five are getting that. It's just terrible. Now, let's look at an Aboriginal medical service in Katherine, which has an eye-health program with a regional eye-health coordinator called Dorothy Butler. Dorothy provides screening and education and coordinates specialist eye services. My name is Dorothy Butler. I'm the eye-health coordinator at Wurli Wurlinjang Medical Centre in Katherine, in the Northern Territory. The main eye-health problems that come through my clinics are diabetics with diabetic retinopathy, cataracts, pterygiums basically the most important ones. - Hi, Dot. - Hi. What's the problem? I've got a referral here. ICEE has been working in close collaboration with the Wurli eye program, and particularly with the regional eye-health coordinator Dot Butler for about the past four years. That's been to provide optometry services regularly here so that patients who are current clients of Wurli can access eye care regularly. DOCTOR: Look up. The main eye-health problems in the Top End are similar to the main eye-health problems in Indigenous communities, particularly in remote communities in Australia. Chin onto here now. Leading causes of vision impairment and blindness are refractive error. That means people who need spectacles to correct their vision but don't have spectacles. Also cataract. There's much higher rates of blinding cataract amongst Aboriginal people for a number of reasons, including lack of access to surgery or fear around having surgery. That all looks fine. If you have a look here, this is an example of an eye, cut in half so we can see. Another leading cause is diabetic retinopathy. That's where there's bleeding on the retina, which if unchecked can cause vision loss that can't be returned. Particular emphasis is given to diabetic patients so that they can have annual dilated retinal exams. The retina looks normal. What I'm going to do today is take a photograph of your eye to check if there's any changes with the diabetes and your eyes. Diabetics have to be screened once a year. I try to make it out to each community once a year and see as many diabetics as possible. That's your macular there, that you see in part of your eye. That's nice and clean. This is your optic nerve here at the front. You've got a very good eye. No diabetic retinopathy, no changes in your eye. - So I'll see you again in one year's time. - OK. Also, we see all the clients who require reading glasses. I organise glasses for them and do ready-made readers for them. What you need to do is select a frame. Across Australia, it was estimated there were about 120,000 Aboriginal people who were not receiving a basic-standard level of eye care that they should be receiving. Oh, they're better. They look better. The ICEE's programs enable access to low-cost spectacles. That's been recognised as one of the main barriers to improved vision in Aboriginal people - the inability to affordably correct refractive error. These are much better. - Morning. - Hiya. There are so many links in the chain in the eye-health system, from early detection, so that involves Aboriginal health workers especially. Also people wanting to access those services. That's where the role of the regional eye-health coordinator is so important. Would you like to come this way? I'm going to check your vision. Yes. Hand like that over your eye, then you look up there and you point. Right. Cover one eye up. Start from the top and point which way it's going. They provide that vital link to the community as trusted members of the community in which they live. Also making sure that the optometrist who provides the services are culturally aware and practise in a culturally appropriate way to make people feel comfortable about accessing those services, then ensuring that referrals to other levels of eye care are followed through. DOROTHY: The challenge I have in running the program is getting clients to come in, to make sure my clients see the optometrist. We have a system where I've got a bus driver. I give them the list, they go out to the communities, pick clients up, bring them here, then take them back again. - Hello. - Hello. Come to have your eyes tested? - Have you had them tested before? - No. The optometrist visits Wurli three to four times a year. We do normally four to five days' service. R... ..N, V... I decided to do remote-area locums for a number of reasons. Firstly, professionally I think there's a great value in being able to provide eye care to remote areas. I find that particularly enjoyable. Professionally it's a challenge, because the clinical work that we do here is far different than we do in our own practices at home. Do you notice any difference if I do that? What difference do you notice? - It'll go bigger. - Good. We're finding that the more locum optometrists get involved, the more it spreads by word of mouth about how great the program is. We're continually contacted by optometrists around the country who are keen to get involved in our programs. Our thanks to Wurli Wurlinjang Aboriginal Health Service staff and clients for allowing us to film their eye-health program. Tim, talk to us a bit more about cataracts in Aboriginal and Torres Strait Islander communities. It was mentioned earlier, they're much more common proportionally within the population. The impact that we can have by undertaking cataract surgery is really quite considerable. The aim is to pick people up early enough to treat them promptly. There's been quite a lot of work done looking at figures for the rates of cataract surgery being undertaken. Even in the relatively established outreach services - we've got a graphic which shows this - the Central Australian outreach is doing OK. That's a relatively well-established program. But some of the programs that outreach services are developing, there's quite low rates of picking people up and undertaking cataract surgery. All of them are well below the national average. NORMAN: The rate should be higher than the national average. TIM: Much higher, because the rate of cataracts in the population is much greater. NORMAN: Hugh, what do we need here? Do we need to get son of Fred back to get barefoot eye doctors into Aboriginal communities? Cam Hollows is training to be an orthopaedic surgeon rather than an ophthalmic surgeon, so we won't get that son of Fred. With the trachoma program in the '70s, we had a number of surgical blitzes an army field hospital at Armata, another one at Utopia, then through the '80s and '90s they were repeated. That's not the way to go now. What we need to do is build capacity. Blinding cataract is 12 times more common in Aboriginal people, cataract surgery is seven times less common. It's that lack of surgery. The number of cataract operations we have to do would only be in order of 2,000 or 3,000 additional cataract operations for Aboriginal people each year. When we do a quarter of a million cataract operations across the country... NORMAN: You should be able to squeeze in another few thousand. It's not a big deal. But it's the organisation of the services to get that done. So it's the commitment and recognition of the importance, and getting people off the waiting list and operated on. Anna, do you think people are competent at diagnosing cataracts when they're not ophthalmic? Possibly. There are a few different ways you could pick it up. The best way to pick it up is with a slit lamp. So it depends how confident people feel using a slit lamp for a basic assessment of the anterior eye. That's the best way to pick it up. If it is a more dense cataract you can pick it up with a pen-torch observation. You would hope that you wouldn't have to wait until it looks that obvious before people are proceeding to surgery. How do you suggest the GP approach this in an Aboriginal medical service? What concerns about cataracts? Because fundoscopy itself might not get you there. If you're taking the basic steps of checking vision and finding there's something that's not going to be corrected with glasses, then the next thing to look for is cataracts, because of the relative frequency with which they occur. Are they different from cataracts in the mainstream community? The principal process is related to age - the longer you live, the more likely you are to develop a cataract. But the incidence of cataracts is greater if there are high levels of diabetes. It tends to cause cataracts to develop sooner. Presumably, they're later so they're harder to operate on. They're certainly more challenging to operate on. Patients will tend to present later, so the cataracts are more advanced. The surgical procedure is essentially the same but can be more challenging if a cataract is advanced. Can you do this in a country hospital? It's appropriate that it's done in a sterile operating environment. The highest standards of care should be provided for every patient. - You do it in Alice? - In Alice Springs, in a sterile theatre. People have to leave their communities, which they won't like. They do, but as I say to people who have asked, I wouldn't do this to my mother in a remote community so I won't do it to anybody else. Equally you want to provide the best care you can in the most comfortable environment. So we do go a long way to make patients feel as comfortable as possible. We encourage people to bring with them health workers or relatives, and someone who can sit with them and translate if English is not their first language. We often go through things in detail explaining the process for what they can expect. So there are no surprises along the route. Staff are very used to looking after patients who are not comfortable about being in theatre. Do you fully correct with the intraocular lens? Yes. You aim for emmetropia, that is, not long-sighted or short-sighted. In other words, giving people good distance vision. They'll just need reading glasses on top of that for close activity. Before we go to Hugh, what about follow-up? Normally they're seen the initial morning straight after surgery, and provided everything is satisfactory, which is the case for virtually all patients, they can go home, and we will review them when we're next in the community. Ideally they should have an optometry check after six weeks, by which time the refractive instability will have stabilised and patients are given drops to take over the first couple of weeks while things settle down. Hugh, I first met you when you were living in America and you did this study of Chesapeake fishermen. - Yeah. - You related cataract to UV light. You've gone back on that. No, UV light is an important cause of cortical opacity. But the population-attributable risk is relatively small. In temperate areas of Australia, UV accounts for about 6% increased risk of cataract. Smoking accounts for 6% - 8% increased risk of cataract. Diabetes accounts for again about 6% increased risk of cataract. The important thing with cataract though is everybody will develop cataract if they live long enough. So the solution to cataract vision loss or blindness is not trying to get lifelong protection, which is really hard to do. One should minimise their UV exposure of course, but even minimising it, you run the risk of developing cataracts. What we need to do is have proper services to deal with it. So it's minimally preventable? - Minimally preventable... ANNA: Unless you can stop getting older. ..but maximally treatable. Modern cataract surgery is miraculous, and can restore very good vision very quickly, very reliably. So the real emphasis is on the provision of surgery. How good do you think Aboriginal medical services are at the cataract? How confident do they feel, do you think, Barbara? With a good optometry service to pick up the cataracts, the referral process in urban areas, there is a long waiting list. But in the rural and remote areas, with optometry servicing, it isn't picked up by the GP, it's picked up by referral to optometry. If there's a long waiting list people get sceptical about whether they should look for it. It's very hard to convince them there's this process within the hospital system for cataract surgery, and it is a very long waiting list. Which is the problem you referred to. It's not insurmountable but you've got to organise services. We could operate on all Indigenous people with cataracts by Christmas if we had the will to do so. It's eminently doable. Susan asks, 'I'm a graduate nurse about to start work in South-West Queensland. What aspects of patient assessment should I be looking for to alert me of early-stage eye disease?' Anna? Visual acuity is your main marker. Always check visual acuity. We like you to check near vision as well, to check for presbyopia. Optometrists are also very passionate about people checking pinhole visual acuity. If people aren't familiar with what a pinhole is, it's an occluder that has a lot of tiny, pin-sized holes in it. If someone has refractive error and they look through a pinhole, it will improve their vision significantly. That will quickly tell you whether their vision loss is related mainly to refractive error, or a major cause of it. If the pinhole doesn't significantly improve their vision it's more likely that there's some underlying pathology, which could be cataract, could be something going on at the retina. Importantly, people should have their eyes comprehensively examined by an optometrist every two years, and every year if you're diabetic. From Susan's point of view, have a Snellen chart, have a reading chart. Yeah, and a pinhole occluder. Joan from Kalgoorlie asks, 'In regard to improving community access and knowledge about eye health, can remote-health clinicians assist in screening, identifying and providing information to communities, or could there be a forum or annual event which could provide an annual health focus in remote communities? What do you think, Barbara? I think you may be better to answer this. I know that in Albany, for example, they have a health fair, which also happens very often in other communities, where there can be a specific one-off emphasis on health that would include eye health. But I think the practitioners in the primary-care clinic, whether they be doctors, nurses or Aboriginal health workers, can do a lot just promoting basic primary care by checking people's vision. And if they have a problem, initiate the referral pathway. You measure blood pressure and you treat it, but you forget to check vision. There's a lot we normally do when we visit remote communities. Both optometrists and the eye-team visits will take every opportunity to upskill all the staff we meet when we're visiting. I take your point from earlier, Hugh, the one-off big blitz is really not the way you want to do it. If you do the once-a-year thing it's got to be sustainable with a service underneath it. That's exactly right. It's making sure that the primary-care services and staff do that initial step of primary eye care, checking vision and initiating the referral pathway. Murtaza from Queensland asks, 'Does alcohol contribute to eye-health problems, and if so, to what extent?' Tim? Yes, it can. Extremely high levels can cause toxicity of the optic nerve. And eye injury. The more direct route where alcohol causes problems. There are high levels of assaults and alcohol-related behaviour which can cause significant problems. There's also been a variable linkage with one of the types of posterior or subcapsular cataract, which is more common in younger people, related to alcohol. Robyn Main, from the Optometrists Association of Australia asks, 'Would having more Indigenous optometrists help to increase more Aboriginal and Torres Strait Islander patients to present for eye exams, and if so, what are universities doing to foster this recruitment?' I'll ask you the first part, Barbara. If you had more Indigenous optometrists, would people be more likely to go and see them? Very much so. It's the same with Indigenous doctors and nurses. It would help a lot, and it would encourage the community to come in more because they're more comfortable at that level. Anna, do you know what's happening about training Indigenous optometrists? I don't know that there's any optometry-specific focus. I know that there's a range of scholarship schemes, like the Puggy Hunter Memorial Scholarship for health-related practices. I'm not aware of optometry-specific approaches to getting more Indigenous optometrists out there. There are two Indigenous optometrists now, and there are a handful, less than a dozen, who are currently training. But there are also an increasing number of Indigenous doctors, about 120, 130 doctors, and about 150 Indigenous medical students. So there's quite a lot of work there to build up that Indigenous health force. Of course they'd be terrific, but that's not a rate we can accept. We've got enough optometrists and ophthalmologists who can provide the eye care we need today. We don't have to wait for a decade or two to train more Indigenous staff, although we want to train staff as quickly as we can. Final question for this segment - Simon Dorante-Day from the Aboriginal and Torres Strait Islander Public Health Journal in NSW asks, 'Do the members of the panel consider that the availability of nutritious and fresh foods is an issue in terms of improving eye health?' Putting the health effects of diabetes aside. I was in Beswick a fortnight ago, and I was really impressed with the very good range of fresh fruit and vegetables in that store, which is part of the change that's come on through the Northern Territory intervention in or to the fullest thing. Diet is very important in terms of diabetes. There is some marginal evidence of it being important for macular degeneration, although as Tim said earlier, macular degeneration is basically not being seen at the moment in Aboriginal people. NORMAN: Tragically, they don't live long enough. That's part of it, but it's also partly the genetic basis. 80% of AMD is gene-related. If you don't have the genes to start with, you may not have the same propensity. Let's talk about Bill's eye health. He's 58 years old, lives in Cloncurry. Diagnosed as having type-2 diabetes three years ago. As part of his extended health check for diabetes, he's been asked about his vision. He says it's fine, but he admits to having difficult in seeing small things, although the reading glasses he got when he last saw the optometrist five years ago still help him. What should you be doing about this? Anna? The important thing to note is his last eye exam was five years ago. So, educating the patient about the importance of annual eye exams. That's where retinal photographs can be really useful - Tim will talk about that a bit later - as a way to show people what the back of their eye looks like, and why we're trying to protect it from bleeding. Having said that, this man could still have some severe retinopathy going on while his macular is intact, and he could still have 6/6 vision. This why it's important to have a comprehensive eye exam to pick it up in the first place. It's only looking in the back of the eye that makes the difference? You don't know it's there until you look. - It could just be presbyopia getting worse. - It could be. Which would be good news. Take us through a systematic approach. You've got some photographs of retinas for us. Dot, in the snippet we saw earlier, was talking about the different parts of the eye, and showed us what the inside of the back of the eye looks like. You've got the central optic nerve, where the main nerve comes in and produces that little yellow circle. The red lines are the blood vessels. The central part of the vision is in the middle of the picture. It's that part that tends to get affected by diabetic retinopathy within patients that develop adult-onset diabetes, which is what we most commonly see. The aim is to pick problems up early enough. We've got a picture that shows some of the early changes you see related to diabetic changes. Damage to the blood vessels produces small areas of bleeding and leaking, and the small white specks show areas where there's leaking within the substance of the retina. It is possible to see thickening within the appropriate viewing, and there's some nice, new technology which allows us to see and demonstrate the thickening on the scans. It's an OCT - an optical coherence tomographer. The nice thing about that for me with patients is that you can show them a picture which allows them to see that there is clear thickening. The way that the presentation is produced is as a large red spot on the area of involvement. You can show it to the patient, and they go, that's not good, is it? And you say, no, it isn't. We've got a nice picture there. The little red dot at the top right-hand corner. Obvious problem, therefore we need to treat them with laser to stabilise that area. Tim, I'm delighted you've got a fancy new toy to look at the retina, but people watching this are Aboriginal health workers, GPs working in Aboriginal health services. What are they looking for, crudely, to say the alarm bells are ringing? I'm happy for absolutely everybody to look inside an eye who's comfortable doing so. Anybody who does, if they see anything, we want to see that patient. Little specks of red, specks of white, white fluffy areas related to cotton-wool spots, the other thing you sometimes see. Let's see more of that so we get a sense of what's going on. TIM: These are the things you might see. This is an eye that doesn't look that bad, but has proliferative diabetic retinopathy. That is, there are new vessels at the disc. The little white fluffy bits referred to as CWS are the cottonwool spots. You get abnormal truncation of some vessels, the IRMA bit referred to. Changes in the big blood vessels, and the other dots and blots that I mentioned earlier. NORMAN: That is one that you might miss, scarily. TIM: You might, and it's quite a salutary picture because it doesn't look that bad. But once you see something that doesn't look right you've got to make sure it's looked at. Then we can pick up the signs of the proliferative changes which means the patients need laser. If you manage to get to somebody on time and keep on top of the progression of diabetic retinopathy, you'll end up doing quite a lot of laser for patients. We've got a nice picture, which is the appropriately treated proliferative diabetic retinopathy patient, who has had somewhere in the region of 4,000 - 5,000 burns in each eye. NORMAN: 4,000 - 5,000? TIM: 4,000 - 5,000 over a series of treatments. This young man was able to continue to play cricket, run his business and look after his young kids. NORMAN: How many do you do at a sitting? Normally do around 1,000 burns at a sitting. It depends on the patient's tolerance and how quickly you've picked them up. Some people are able to come back for regular, shorter treatments. But usually with the remote patients we're looking at, we want to treat them as heavily as possible as soon as possible when you pick up problems. That sounds massive, Hugh. Presumably the temptation is to undertreat? That's certainly been the feature of a number of audits that have been done both in Aboriginal communities, but particularly in mainstream and developed-country settings. The important thing with diabetic retinopathy is that 98% of the blinders can be stopped with appropriate and timely laser treatment. To get that laser treatment in time, you need that regular exam, looking for changes in vision and in the retina at the back of the eye. You've got a series of pictures of somebody you've been dealing with. This is a friend and colleague working in an Aboriginal health centre who said recently that she wishes she'd realised how serious it was early on. She's kindly agreed to let me show some of the photographs we've taken. In 2008, here she is having just had very heavy laser in the left eye. You can see all the little white spots. But she's also got some early changes in the right eye. If we go on to the next year, you begin to see the local leaking changes in the right eye. NORMAN: Where are you seeing them? TIM: In the right eye, on the left of your picture, the little white specks. NORMAN: That's near the macular. TIM: That's threatening her sight. She will have had focal macular laser after that. The left eye shows an area of haemorrhage that's more anterior to the retinal surface. You can see that streak of red across the surface. That's because she's got proliferative vessels still at the disc which have not gone away, or they've regressed but not closed down, which is the aim of the treatment. She went on to get a progressive scarring process. The right eye now looks far more dramatic. Despite the laser she'd had in that eye, she got extensive recurrent haemorrhages. That's what bleeding inside the eye looks like. Patients will describe having seen these blobs trekking across their vision and getting in their line of sight. The problem is, you can have a relatively clear line of sight with blood all around it, and patients will feel they've got good, normal vision, then suddenly it will go because you've got this sitting there. The left eye, although the picture doesn't look as bad, had progressive-scarring changes, which happens with retinopathy. That can pull the retina off. She went on to visit my vitreoretinal colleague in Adelaide, who cleared out a lot of the scarring and separated the tractional areas, then put oil in to push the retina flat. NORMAN: This is a vitrectomy? TIM: Yes. Why oil and not gas? Oil is more commonly used for some patients because the scarring processes are difficult to push back, but also because these patients are flying back to Central Australia and you can't fly with gas in the eye. How is your vision with oil? Because you lose vision with the gas bubble. Not as good, because it does change the refractive index. But it's better to have reduced vision than to go blind without treating it. What about the follow-up? It's pretty major eye surgery. It doesn't come much more major than a vitrectomy. It is. But usually we'll see patients when they make it back to Central Australia. When they go to the remote communities we can bring them relatively often if necessary and keep in touch with the community. Often we visit them in the near future, so we can see them back home. Do people get on quite well at home after this sort of major eye surgery, Barbara? Yes, they do. I find that in follow-up with the health workers within those regions after they go home. NORMAN: They're grateful for the surgery? - Very grateful, yes. It's known in the community that they can go away, have surgery and come back. We've had a question asking whether the NH and MRC guidelines are relevant for diabetic retinopathy, whether they're relevant for Indigenous communities? Absolutely. And the guidelines have a specific section for Aboriginal and Torres Strait Islander people. The recommendation for eye exams for mainstream Australia is that they need to have an eye exam once every two years. In general, in the mainstream, the goodness of control is such that the progression or incidence of retinopathy is quite low. But in general, the control in Aboriginal people is not so good, so the recommendation is that they need to have their annual examination of visual acuity and the retina. So what we're saying is entirely consistent with the NH and MRC guidelines. Anna, I know we've been banging on about it, but we need to nail refractive error. This is outrageous. It's a scandal. - As an optometrist... NORMAN: Uncorrected refractive error. I'm sure, being myopic yourself, Norman, you would appreciate - if you take your glasses off... NORMAN: Don't ask me to do that. - ..and try to survive 24 hours... - I'll bump into walls. We can see the way uncorrected refractive error can affect people's quality of life. It's the major cause of avoidable or treatable vision impairment in Aboriginal people, contributing about half of that. The important thing, it's one of the most cost-effective health interventions you can do in terms of the improved quality of life, by providing a pair of glasses for clearer vision again. Elviana asks, 'What complimentary and alternative medicines are recommended for eye disease confronting the Indigenous Australian population nationally?' Good, clean water. The key for that is... NORMAN: Nothing more natural than that. - Nothing healthier than water. Good, clean water. Keep the face clean. For trachoma, that really is the key. Clean faces, strong eyes is the key message for trachoma. We have another question when it scrolls up. Gerard asks, 'Will we get rid of trachoma ever in this country, and will we certainly do it by 2020?' Trachoma disappeared from mainstream Australia 100 years ago with improved living conditions. In the last five or ten years trachoma has disappeared, because of trachoma programs, in countries like Ghana, Oman, Morocco, Vietnam. If those countries can get rid of trachoma, we can. It's straightforward to do. In Ethiopia for example, this year, they will treat 28 million people. That's more than the population of Australia. We've got a maximum of about 40,000 people in the trachoma areas. It's clearly within our goal. Prime Minister Rudd two-and-a-half years ago made a commitment for Australia to eliminate trachoma. The progress that I've seen just in the last couple of weeks in the Northern Territory is extraordinarily exciting. Real progress is being made. If we do things right, we can eliminate trachoma easily. Let's look at a remote Aboriginal community, Bulla in the Northern Territory, that Hugh has been talking about. Health workers from Katherine West Health Board and Bulla community members are using the trachoma story kit to educate people about trachoma and how to prevent it. Let's have a look. CHILDREN: Clean face, strong eyes! Katherine West Health Board covers a region that's approximately 2% of Australia. It's a very large area. There are seven communities in the region. Sometimes you will travel by four-wheel drive to these communities. Some of them are 600km away from town. Sometimes you'll need to fly. Depending on the weather, they might be inaccessible. To get there sometimes is one of the biggest challenges. The objectives of the Healthy Skin And Eyes program, and in particular the trachoma initiative, is to improve the health and wellbeing of all community members. Australia is the only developed nation to have endemic levels of trachoma in its indigenous populations. And trachoma is an entirely preventable form of blindness. The trachoma story kits were developed with Indigenous eye-health units and the Ngumpin Reference Group, which are unique to Katherine, in that they're elders and community members who help to guide the way in which we make health-promotion resources. My name is Jack Little. I've been living in the Bulla community since 1975. I was the first Aboriginal health worker in the Katherine West region. My role is to educate my people while they're still young, and make them be aware of all the health matters. We're going to show you some pictures, and Jack is going to talk to you about what happens if you get too much trachoma bug. You can share, then we'll collect them up. See this top one here? (Aboriginal word) they're called. When he turns in, he makes the eye go (Aboriginal word) - blind. You can't see. It's getting worse. (Aboriginal word). OK? Once someone has repeated episodes of trachoma, there's a chance they'll develop trichiasis, which is the inturning of lashes that rub against their eye. If untreated, that can cause blindness. One of the aims is to identify people with trichiasis and offer them surgery within an appropriate time frame. As a clinician I think the trachoma kits are valuable, because they help you to improve your skills in recognising trachoma and trichiasis. With the kids, the trachoma kit is really good. It actually shows you how they get trachoma, and what happens and how you can prevent it and all that stuff. It's all about the education, the screening, then the follow-up and the importance of hygiene. If you don't follow up with the hygiene, you may as well be flogging a dead horse. He starts getting a runny nose because he didn't wash his face. That's why this one has got it now. We cannot see the germ that we are looking for with the natural eye. We can look at a microscope. All these little, bad things. Alright? If they don't understand, I speak their language. I say, (speaks Aboriginal language) That means, if can't wash your eye, your eye's going to go no good. Buggered up. We are lucky. We've got a big river, and we've got heaps of water in the bathroom or wherever. So the kids can go and wash their eyes and they wouldn't get it. Out in the desert there's too much dust, and there's no water at all. That's the reason out in the desert they're getting too much of that trachoma. The trachoma team organised for a mirror to be put out in the front room. We notice that the kids are using it a lot. From there, we'll say, what do you think your faces look like today? Is it clean? Does it need cleaning? Then we can assist to clean it. It's all part of the hygiene business. That mirror has been a great help. What kids tend to walk away with at the end of a program is that clean faces mean strong eyes. That's branded throughout the trachoma story kits. That's the message they seem to take home and enjoy. The kids will run up to you in the community and say, 'Clean face, strong eyes. See, Miss?' Our thanks to the Bulla community and Katherine West Health Board for allowing us to film that great example of prevention. I'll come to trachoma in a second, because I had a few questions about refractive error while that film was on. First of all, a question, Anna, about the spectacle schemes that might be available for people. There's a bit of confusion about what's available and what's not, and how. There's confusion because there's so many different schemes in the different States. Some schemes cover everyone who's on a healthcare-type card, such as the Queensland scheme. The Northern Territory scheme covers you if you're on a pension card. That means, people who might be low-income earners and can't necessarily afford spectacles through optometry shops can potentially miss out on correcting their vision. Because of that, there are a few small, low-cost spectacle schemes with more flexible payment options available. That has significantly increased people's uptake on glasses, simply because they can now have an affordable option to correct their vision. Once they've got glasses, Barbara, do they wear them? Yes. Well, some, they don't. But the ones they make now with metal frames... - A better style of frames. - They've still got the old plastic ones, which aren't popular. A question from Dom from New South Wales - 'Is there any data or experience on the safety of routine pupil dilation for looking at the fundus without doing an assessment for glaucoma in the Indigenous population?' Tim? In the studies that we did, one of the steps we put in as part of the assessment was the shadow test, where you shine a light from the side of the eye. If there's a significant shadow, it means the front part of the eye is shallow. You've got a shallow anterior chamber. Those are the patients at risk of dilation. The incidence of provoking angle-closure glaucoma is something like 1 in 60,000. It's not common. I say, I'd far rather treat that one patient if it means the others have been looked at properly. We mentioned the NH and MRC guidelines, and they clearly recommend pupil dilation to examine retinopathy. The benefit far outweighs any theoretical risk. It's like opening the door rather than looking through the keyhole. Robin from Queensland asks, 'Anna, could you break down the refractive error types for Indigenous people - presbyopia, myopia, hyperopia, astigmatism?' I don't have exact stats on what contributes, but definitely hyperopia is more common than myopia amongst adults. There have been changes in more recent years, a relative myopic shift. That could relate to a slight change in lifestyles. People are now looking up close a lot more than they previously had done. NORMAN: Getting away from the far horizon. - Yeah, perhaps. But presbyopia, pretty much everyone once they get over the age of 40, give or take, everyone on the planet will get presbyopia. That affects Aboriginal people equally. Thank you very much. And astigmatism? I can't... Relatively rare. Mostly astigmatism goes with high refractive error. We did a detailed study years ago looking at the distribution of refraction in Aboriginal and non-Aboriginal adults. Aboriginal people basically don't have the degree of myopia - low, medium and high myopia - that's so common in Caucasians. That's exactly what we found in Central Australia as well. Hugh, briefly, what is trachoma? Trachoma is a chronic eye infection caused by Chlamydia trachoma, a bacteria. Children get infected in the first years of life. If you look underneath the eyelid, you'll find the swollen, inflamed conjunctiva with little trachoma follicles. That inflammation goes on and causes scarring. You'll find underneath the eyelid in older children and young adults, scarring. With time, that scarring will contract. NORMAN: We've got some photographs. It will turn the lashes in. The top left-hand photograph shows the swollen conjunctiva with the follicles. The top right-hand photograph has the scarring. The bottom photograph, you can see the lashes turning round, called trichiasis, rubbing the cornea to go and cause blindness. Hugh, talk to me about the distribution of trachoma across Australia. Trachoma still occurs in about two thirds of the remote communities. This map shows particularly in Central Australia but also in Western Australia and South Australia, trachoma is still a problem. WHO has said a threshold of more than 5% of children having active trachoma as a threshold of trachoma as a public-health problem. We also know there are at least isolated pockets in Queensland and in New South Wales as well. And the determinants? Trachoma really occurs around poor hygiene. We've got a graphic that shows this cycle of poverty, crowding, decreased water supply. But the key to it all is facial cleanliness, or the lack of children having a clean face. Those infected secretions can easily pass from one child to another and continually restoke the infection and the inflammation. NORMAN: Diagnosis? Diagnosis is relatively straightforward, as we saw Jack Little in that video clip showing all those WHO photographs. You avert the eyelid and look at the undersurface of the eyelid. If you're doing a standard grading you would use 2.5-time loops. Fred Hollows used to teach me - a blind man on a galloping horse on a dark night without a light could diagnose trachoma. All you have to do is look at it. Tell me about the WHO SAFE project. The SAFE strategy is the strategy WHO has developed to combat trachoma. It's got four elements. The acronym SAFE puts them in the wrong order from a public-health perspective, but it's better than EFAS. S stands for surgery to correct the inturned lashes, the trichiasis. A is the azithromycin or antibiotic treatment to eliminate the infection. NORMAN: That's once a year? - Or once every six months in a hyperendemic community. If the rate is very high, it's probably worth treating everybody every six months. So an annual or twice-annual antibiotic. F is for facial cleanliness. As we saw in that video clip, clean faces, strong eyes. E is environmental improvement. In the Aboriginal communities, that really is making sure that washing facilities are safe for kids to use - they can get to the basins, the taps work, the drains work, having mirrors, that sort of stuff, so the kids can keep their faces clean. We need to change the social norm so it's not acceptable for kids to run around with dirty faces. Let's talk about Mavis, who's 70 years old. She's been complaining of sore eyes. She's come in from a remote community to Mildura to live with her family. She comes into the Aboriginal medical service every few weeks complaining of sore eyes. She's given artificial tears, soothing eye medicine, but each time she returns with the same problem. She was seen by the ophthalmologist about five years ago, who didn't notice particular problems. She was also seen by the optometrist, who gave her reading glasses, but this didn't help her symptoms either. I think this illustrates the problem of trichiasis. Even though Mavis may be seen in a rural area, if she grew up in a remote community, she's very likely to have had trachoma as a child. The three things to remember about trichiasis are the three Ts . The first is, think about it. If you don't think about it, you won't look for it. The second is, you need to use your thumb to lift up the eyelid so you can lift the lashes off the globe if they're touching on the globe. The third thing, you need a torch because it's dark in there. You need to be able to see these black lashes. It's really important, you should never let any Aboriginal person walk out of your clinic who's complaining of sore eyes without specifically excluding the presence of trichiasis. If they have trichiasis, they can have the surgery to rotate the lashes in the lower eye margin so the lashes point out and save their vision. You can see this photograph at the top, it's got trichiasis of the lashes pointing down, rubbing on the eye. The bottom photograph is after surgery with the lashes pointed out. You'll stop people going blind by doing that. Can you do that surgery locally? It can be done in the community if you have a treatment room or sometimes in a dental clinic, but often it's easier to bring the patient into a central hospital, as Tim would do in Alice Springs. It must be satisfying when you've treated it properly, Barbara? Exactly. It'd be more comfort for them. NORMAN: To what extent are communities aware of trachoma? Most of the communities would be if they're in an area where it's prominent and there have been generations of it before. But places like Queensland, where it's not very prominent... NORMAN: But still occurs. But it's not identified by the GPs. The point, we found, is that while the community knows there's trachoma there, a quarter of the clinic staff and a third of the teachers don't realise they're in an area where the trachoma occurs. If they don't realise they're in a trachoma area they won't do anything about it, or even look for it. So it's really important for the clinic staff to know whether they're in an area where there is trachoma, so they know to be vigilant and aware of it. Ocular injuries? Ocular injury is a very alarming subject but fortunately not that common. The recent study by the Australian Institute of Health and Welfare was looking at this at a national level, and found that around 6% of emergency department admissions were related to eye problems. Of GP consultations, only about 1 in 500 was related to an eye injury. Of those presenting to ED only about 3% require hospitalisation, and most of those, two thirds of them, occur in men. Men are more likely to be involved in trauma that will result in significant ocular injury. About half have bony fractures around the eye and superficial injury, and most of them have been caused by falls, assaults and motor-vehicle accidents. What's interesting is that hospitalised injuries are three times more common in the Aboriginal population. NORMAN: When they occur, they're more severe? Much more severe. What are the golden rules for looking after somebody in this situation? If you think there's been a chemical splashed in the eye, wash it out immediately, irrigate the eye, then ask more questions. The sooner you get on with irrigation, the better. NORMAN: Even if you think there might be a penetrating injury? Then you do the minimum necessary to decide whether or not to worry about it. As soon as you're worried about it, send that patient for specialist care. They may require surgery. So quick assessment and triage? TIM: Yes. Is the CARPA manual much help? The CARPA manual is excellent. Both the CARPA manual and the CRANA manuals, the outlines on how to assess eyes are brilliant. They're really well written for allowing people who have very little experience looking after eye problems to be able to do a step-by-step guide as to what they need to do, both for checking vision, but also things to look for, and suggestions on making sure you put anaesthetic in to make it comfortable for the patient while you assess them, and using fluorescing eye drops to see if there's evidence of surface damage. If you follow the steps in the CARPA and CRANA manuals, it'll make it much easier if you're not sure what you're doing. A really good resource, and widely available in remote communities. - Do you want to comment, Hugh? - The two manuals are excellent. Hugh, you've looked quite a lot at the provision of services coordination, and you see it as a system problem as much as anything. I think there really is a health-system issue here about the need for really good coordination. We've looked at this in a number of different ways. One thing is to look at how well the visiting eye services are coordinated - visiting optometrists, ophthalmologists - with the clinic or with the local hospital. We assessed a number of different projects. Those that are well coordinated were far more efficient. They cost less, saw a lot more patients, have a much higher throughput, because it was not the reduplication. People were doing things they should do. Before Hugh goes on with that description, describe good coordination to me, Tim. Good coordination is ensuring the patient flow, the patient journey, does not hit roadblocks at every opportunity. You pick up patients promptly, you make sure that those that need further specialist attention are transferred appropriately with the right support in a timely fashion so they get the care they need as soon as possible. NORMAN: Hugh, everybody knows the clinical pathway? Well, in the good services, that's what happens. In the other services you'll find that people are not sure where to go or how to refer or are not able to reach the service. Or you might have one eye practitioner come today and another one come next week without any communication between them. It really is important to have that patient pathway properly coordinated. There's so many steps along the way that patients can leak out of that pipe, if you like. Whether you're going from the GP to waiting to see the optometrist or being referred by the optometrist to the ophthalmologist on a waiting list for surgery, it's really important to have that well coordinated. NORMAN: We'll go back to those first graphs because they're really dramatic in terms of the impact of coordination. I didn't give you enough chance to explain. One of the graphs we did go over that we found particularly interesting, which is the next one after this, is showing the impact of having an optometry service in an Aboriginal medical service. NORMAN: Which is what you were talking about earlier? HUGH: Right. There is no correlation between how many optometry services are available in a community in terms of Aboriginal health or visual health. But the longer an optometrist stays working in an Aboriginal health service, the better the vision and eye health of the Aboriginal people is. That really gives that importance of integrating these visiting eye services into Aboriginal medical services. Barbara, what's your take on the ideal service or different models of care that you've seen that work? What I've found that does work well is studying with the regional coordinator, going into the communities, making them aware of eye checks, bringing through optometry. The referral pathways from getting those patients from the community up to a consulting ophthalmologist is very difficult. In rural and remote areas it's the transport. And in the urban areas with the AMSs, the optometry service there is getting them into the hospital system, which is a very long wait. Coordination with the regional eye-health coordinator plays a huge role in going even outside the AMSs to rural and remote areas where there are not many AMSs, but there are health services in that area, and working with other health services as well to target communities where there isn't an AMS and working closely with the AMS for pathways into the hospital system. - Everybody knows what's happening. - Yes. Anna, tell us about the Visiting Optometrists service. The Visiting Optometrists Scheme is a Commonwealth Funding scheme to fund outreach optometry. As the maps previously showed, the distribution of the eye-care workforce across Australia is currently inequitable in terms of the glut of service providers being in the major metropolitan areas, and the more remote and very remote you go, the greyer or whiter it got on those maps. So VOS exists to try and encourage, facilitate and enable optometry services in remote and very remote locations. As Hugh said, if they're not coordinated, the right hand doesn't know what the left is doing, you're not necessarily making it better. - Absolutely. Any optometrist who participates in a VOS program should work with the regional eye-health coordinator, within the Aboriginal Medical Service jurisdiction and particularly with the ophthalmologist in that region to make sure they're working in the most appropriate and effective ways in terms of a team-based approach. And the Medical Specialist Outreach scheme? MSOAP for short is another Commonwealth-funded program which aims to support outreach work by medical specialists to as many remote communities as possible. It covers a lot of specialty areas, but supports some eye work too. It's different in different States as to how much it's integrated. At various stages it's been more supportive or less, in my experience. Hugh, what resources are available for people in this area? When you asked that question, I was thinking, how much more money do we need to properly fund MSOAP and VOS, and I'll take a raincheck on that one. I assume that money is not necessarily the answer here. It actually is a lot of the answer, in that we need to make sure that the service is properly resourced to provide the needs on a population basis. We need to have two or three times as many visits through MSOAP and VOS. We need to have four or five times as many people in the sort of role that Barbara plays, as a regional coordinator, coordinating those patient journeys. And they need to be people specifically identified. So money is a need in that larger scale. But in terms of things that are more immediately doable like trachoma control, there's some great material that's been developed, as we saw in that video clip, and develop with community involvement and consultation promoting this 'clean faces, strong eyes' message. The goanna has become the mascot on this. It was launched publicly in Darwin at the footy match ten days ago. There's a lot of resource material for primary-school kids, at the clinic level, at community level, to try to help change that social norm about facial cleanliness. And clinical guidelines as well. And detailed instructions on how an Aboriginal or community health service or a region can put together and manage a trachoma-control program. There's some really exciting results coming out of the Northern Territory, particularly in WA, over the last 6 or 12 months. Real progress is being made. Anna, you want to suggest some resources? There's other resources around general eye-health education that ICEE has developed through consultation. These are the I See For Culture eye health educational resource kits. They're largely image-based. There's a couple of flip charts. They talk through understanding about common eye conditions, particularly covering diabetic retinopathy, cataract and trachoma. They're basically designed to assist health workers to educate their patients, particularly understanding what treatment can be done to prevent those conditions. What are your take-home messages for the audience? For the people working at a primary-care clinic, there are three things I'd really emphasise. One is the need to check near vision and distance vision at every health check. Another is to make sure that all people with diabetes get their eyes looked at every year. That's really important. Third, for those in the outback communities, keep the kids' faces clean. NORMAN: Barbara? The annual eye check, even when they go to see their GP. I feel GPs should be a little bit more trained in the area of eye health. When they go to their GP, to bring forward, if there's no optometry, make sure that they get their eyes checked or are referred to an optometrist. And don't take, 'Doc, I've got no problems' for an answer. - No, exactly. NORMAN: Anna? The main point I'd want to get across is to community members. Losing your vision is not a normal part of getting older. Most of it is either preventable or treatable. Take care of your eyes. Get them checked every two years, or every year if you're diabetic, and you can live a life with great vision. NORMAN: Tim? - Summary. Let's close the gap, not our eyes. We've finished. And I hope you've got a lot out of this program on eye-health issues and Aboriginal and Torres Strait Islander communities and the importance of prevention, screening and treatment. We're grateful to funding bodies for making this program possible. They include the Australian Department of Health and Ageing, the IOOF Foundation, the Vincent Fairfax Family Foundation and Allergan Australia. And we gratefully acknowledge the services that helped produce the case studies and provided the photos. You can see them on the screen. Thanks to our panel members for contributing, but thanks also to you for taking the time to attend and contribute. If you're interested in obtaining more information about the issues in the program, there are a number of resources available on the Rural Health Education Foundation's website: rhef.com.au There are some other links, but they'll be on the website as well. Don't forget to fill in your evaluation forms to register for CPD points. I'm Norman Swan, and I'll see you next time�