Benjamin R LaHood MBChB, Derek SherwoodFRANZCO and Antony Suter FRANZCO

Nelson Public Hospital, Nelson Marlborough DistrictHealth Board, Nelson, New Zealand

Received 6 September 2010; accepted 7 September 2010.

REFERENCES

1. Gillies M. Bevacizumab in ophthalmology: the contro-versy moves forward. Clin Experiment Ophthalmol 2010;38: 333–4.

2. Fong K, Kirkpatrick N, Mohamed Q, Johnston R. Intra-vitreal bevacizumab (Avastin) for neovascular age-related macular degeneration using a variable frequencyregimen in eyes with no previous treatment. Clin Experi-ment Ophthalmol 2008; 36: 748–55.

3. Yeoh J, Williams C, Allen P et al. Avastin as an adjunctto vitrectomy in the management of severe proliferativediabetic retinopathy: a prospective case series. ClinExperiment Ophthalmol 2008; 36: 449–54.

4. Friedman S, Margo C. Topical gel vs subconjunctivallidocaine for intravitreous injection: a randomized clini-cal trial. Am J Ophthalmol 2006; 142: 887–8.

5. Cintra L, Lucena L, Da Silva J, Costa R, Scott I, Jorge R.comparative study of analgesic effectiveness using threedifferent anesthetic techniques for intravitreal injectionof bevacizumab. Ophthalmic Surg Lasers Imaging 2009; 40:13–8.

Diabetic retinopathy in AustralianAboriginal peopleceo_2430_1 185..195

It is with much interest that I read the paper by AntonyClark and co-workers that reports the findings of multiplevisits to the Eastern Goldfields in Western Australia anddocuments their findings over a 12-year period.1 This workis highly commendable although of course it does missmany of the Aboriginal communities in the north-easternpart of their area. Overall, they examined some 920 peopleover the age of 16 out of a population in excess of 4000 inthat age range. Nevertheless, their findings are useful andimportant.

One area that does need correction is the very clearstatement by the National Health and Medical ResearchCouncil Guidelines on diabetic retinopathy that Aboriginaland Torres Strait Islander people with diabetes need to havetheir eyes examined on an annual basis.2,3 In their paper,Clark and co-workers misquote this as recommendation tobe seen within 2 years. The biennial examination is therecommendation for mainstream Australia because of themuch better control of diabetes in mainstream.

Hugh Taylor AC MD FRANZCOCentre for Eye Research Australia, Melbourne School of

Population Health, University of Melbourne,Carlton, Victoria, Australia

Received 2 August 2010; accepted 2 August 2010.

REFERENCES

1. Clark A, Morgan WH, Kain S et al. Diabetic retinopathyand the major causes of vision loss in Aboriginals fromremote Western Australia. Clin Experiment Ophthalmol2010; 38: 475–82.

2. National Health and Medical Research Council. Manage-ment of Diabetic Retinopathy: Clinical Practice Guidelines. Can-berra: NHMRC, 1997.

3. National Health and Medical Research Council. Guide-lines for the Management of Diabetic Retinopathy. Canberra:NHMRC, 2008.

Diabetic retinopathy in AustralianAboriginal people: responseceo_2430_2 185..195

We thank Professor Taylor for his comments1 regard-ing our paper.2 We presented 12 years of data from theGoldfields Eye Health Survey which consisted of yearlyvisits to the Eastern Goldfields Aboriginal communitiesbetween 1995 and 2007. The survey represents one of thelongest running Aboriginal eye health initiatives in Aus-tralia and allows a unique insight into AustralianAboriginal eye health over time that cannot be gleanedfrom cross-sectional community surveys. Although wedid not examine all of the over 4000 Aboriginal peopleliving in the region, we do feel that the 920 seen com-prised at least the major proportion of those with visionproblems or who were diabetic.

Our yearly visits to Aboriginal communities in theEastern Goldfields region are in line with the frequencyof eye examination for Aboriginal people with diabetesrecommended in the National Health and MedicalResearch Council Guidelines on diabetic retinopathy.3,4

We should clarify that in commenting upon the poorfollow-up of those Aboriginals examined it was ourintention to emphasize this by comparing follow-upto the minimum standard for the general Australianpopulation (2 years). That only 47.9% of those withdiabetes were seen again within 2 years falls vastly shortof the minimum recommendation for even the generalAustralian population. We did not intend to imply thatthe recommended screening interval for Aboriginal andTorres Strait Islanders be 2 years and appreciate theopportunity to provide further clarification.

Our data were collected in consistent, low-costmanner over many years and demonstrates the utility ofcreating a prospective Aboriginal eye disease registry.This is particularly important for diabetes, whereretinal disease grades can be stored and retrieved. Anational or state-wide scheme storing retinal photographand/or clinical examination scores, dates and locationswould be a cost-effective way to check individualfollow-up status, disease severity as well as trends indisease.

Letters to the Editor 185

© 2011 The AuthorsClinical and Experimental Ophthalmology © 2011 Royal Australian and New Zealand College of Ophthalmologists

Antony Clark MBBS(Hons),1,2,3 William H MorganFRANZCO PhD,1,3,4,5 Sam Kain FRANZCO,5

Hussein Farah MBBS,6 Kiele Armstrong MIHGradDipPH,6 David Preen BSc(Hons) PhD,2,3 James

B Semmens MSc PhD1,3 and Dao-Yi Yu MD PhD4

1Centre for Population Health Research, Curtin HealthInnovation Research Institute, Curtin University of

Technology, 2Centre for Health Services Research, School ofPopulation Health, 3Eye and Vision Epidemiology

Research Group, 4Centre for Ophthalmology and VisualScience, The University of Western Australia, 5Department

of Ophthalmology, Royal Perth Hospital, Perth, and6Population Health, WA Country Health Service –

Goldfields, Kalgoorlie, Western Australia, AustraliaReceived 26 August 2010; accepted 17 September 2010.

REFERENCES

1. Taylor H. Diabetic retinopathy in Australian Aboriginalpeople. Clin Experiment Ophthalmol 2010; 39: 186.

2. Clark A, Morgan WH, Kain S et al. Diabetic retinopathyand the major causes of vision loss in Aboriginals fromremote Western Australia. Clin Experiment Ophthalmol2010; 38: 475–82.

3. National Health and Medical Research Council. Manage-ment of Diabetic Retinopathy: Clinical Practice Guidelines. Can-berra: NHMRC, 1997.

4. National Health and Medical Research Council. Guide-lines for the Management of Diabetic Retinopathy. Canberra:NHMRC, 2008.

Coordination is the key to theefficient delivery of eye careservices in indigenous communities

There are some shining examples of the effective deliveryof eye care in Australia. By studying these one can identifycomponents critical to their success and make sure thesecomponents are incorporated in other programmes toachieve similar high levels of efficiency.1 The key compo-nent is good coordination and this needs to occur at mul-tiple levels. Good coordination improves the experience ofthe patient, the community, the health-care provider andthe health system. It is also more efficient as everyoneworks together to ensure that the patients actually turn upand receive the care they need.ceo_2431 186..196

Coordination may mean different things to differentpeople and it can cover a range of activities such as man-agement, communication, facilitation, cooperation andintegration. The linkages and inclusive approach that goodcoordination provides makes the real impact.

The current model for the provision of eye careinvolves Regional Eye Health Coordinators (REHC) thatwere introduced after the 1997 Taylor Report.2 The

recommendation for establishing Aboriginal Eye HealthCoordinators was based on two successful models ofregional coordination, one in far north Queensland andthe other in the Pilbara. In each of these cases, there wasa senior, semi-retired nurse who acted as the coordinatorfor the surgical visits of patients, the visits of the oph-thalmologist, optometrist or eye team, and coordinatedthese with the Aboriginal Medical Services (AMS). Thesepeople worked at quite a high level and made sure thatthe visiting eye services actually worked. The 1997Report recommended that these regional coordinatorswould be jointly responsible to the AMS, the state-runhospital, the private ophthalmologist and the privateoptometrist and ideally, the coordinator would be anindigenous person. In its implementation this recommen-dation was modified to provide funding to AboriginalCommunity Controlled Health Services to fund Aborigi-nal Health Workers (AHW) who became REHC and werefirmly based in the AMS. Each of 37 or so regions was tohave an REHC, although some were never appointed andat times many positions were vacant.

The roles and expectations for REHC have expandedenormously and it has become impossible for any singleperson to manage all the tasks now encompassed in thisrole. In some areas particularly committed and persistentREHC have selected a limited number of functions fromwithin this large range and they have done that part of thejob very well and with great dedication. Others have justquit or have seen their position disestablished. The aboli-tion of these positions was made even easier when globalfunding for the AMS was introduced after a review in2003. Some REHC spend much of their time in the field asclerks just filling out Medicare forms and forms for glasses.

In looking at these issues again it becomes clear that theroles are too broad and they need to be reviewed andredefined.

The first step in trying sort out the requirements for thedelivery of eye care is to go back to the basics about whatcare should be provided where and by whom.

People skilled in primary eye care need to be availableat the community clinic level.

The staff in these clinics include General Practitioners,nurses, and in many areas AHW who have some clinicalresponsibilities. Each of these groups should have anappropriate understanding of the requirements and theirroles in providing primary eye care.

The second level is the provision of specialist eye care ina clinic setting. Secondary eye care may be provided by avisiting eye team or by an existing stationary service, clinicor practice depending on existing circumstances. Eye caremay be provided by optometrists and ophthalmologistsworking together or separately, with or without othersupport staff such as orthoptists.

The third level eye care would include cataract, laserand other surgery. Patients requiring more specialized eyecare would be expected to be referred to a capital city orregional centre for further management. This level of carewould be provided at the regional level, usually in a publichospital. Staff would include ophthalmologists, nursesand theatre staff, technical support staff and many others.

186 Letters to the Editor

© 2011 The AuthorsClinical and Experimental Ophthalmology © 2011 Royal Australian and New Zealand College of Ophthalmologists