 fabulous to work with and to be involved in he is a person a long time ago when international ophthalmology had a lot fewer people interested was seriously looking at what could be done and how we could affect different areas of the world and so he's worked very closely with the World Health Organization he's worked very closely in regards to the International Council of Ophthalmology you can't find anything in any of those areas besides that one of the preeminent programs in the world the University of Melbourne and continues to be there does a lot of traveling I found out that those of you who've made the trip it's not a short trip from here to Melbourne that's a good long trip and he made it all the way here he's going to be in the United States four and a half days and head on back so well he hasn't learned any better than Nick Mamelis of the end a lot of us who do a lot of traveling or Jeff Tabin but it's an honor to have him and before he comes and talks to us I would like to have Jeff Tabin has a few announcements he'd like to make. I'd like to welcome we have actually three new international fellows we have Claudia Andrea Lozano-Arvey and she's right here she's from La Paz, Bolivia and she'll be with us on the cornea service for a while and then we have Rochana Singlana and also Rojita Parajuli and they both just right they're both in the Telganga training program in Nepal and they'll be with us for a month each of them will be two weeks on the neuroophthalmology or medical redness service and then they'll be switching and then I'll turn it over to Professor Taylor as many of you know I did my fellowship under Professor Taylor he's been any small amount that I've learned anything whether it's international ophthalmology or life I learned from Professor Taylor which I forgot more than he taught me but it's a great pleasure to have you here. Well thank you Randy and thank you Jeff and it really is a pleasure here let me just wire myself up. As Randy said it's a bit of a flying visitor then if I still have my straight and accent it's because I only left my office at 10 30 yesterday morning. What I wanted to do today as this as you've seen on this slide for the last 15 minutes is talk a little bit about the impact of vision loss and I'm going to talk about that in a range of things I know why to talk about what's the dimension of the problem of vision loss what can we do about it what are we doing about it and what should we be doing about it and talking in a sort of a broad issue but looking at if you know ophthalmology is our profession then blindness and vision loss is really our business and we need to be concerned about that impact of vision loss and blindness and this shows the age specific rate of blindness and vision loss in Australia and which is representative of basically all the developed countries and you can see the amount of blindness or vision loss and visual impairment here is less than 2040 or driving vision and blindness is less than 660 which is slightly different from the American definition of blindness which is 660 or less but you can see the amount of vision loss increases almost three fold with each decade over the age of 40 so that almost half the people in their 90s have visual impairment and one person in five is legally blind now people think you know 80s and 90s are actually sort of too old to really worry about but the average life expectancy is about 80 and once you've had your 40th birthday you've got a two out of three chance of having a 90th birthday so we're not actually talking about very rare people there's a lot of people who are going to be 80 and 90 and if you look at 10 or 20 percent of them being blind it gives a magnitude of the problem we're facing and we look at the cause of blindness again about half the blindness is caused by AMD about 14% from cataract and unoperated cataract and glaucoma and diabetic retinopathy but also refractive error is an important measurable cause of blindness people walking around who are functionally blind who all they need is a pair of glasses and if you look at visual impairment it's the same five conditions AMD cataract glaucoma diabetic retinopathy and refractive error are the five conditions that cause three quarters of the vision impairment of course the proportions and ratios are different and refractive error become much more important and this is the way people function in their day-to-day lives it's not what's their best correct security as we measure it in a lane this is the way they're actually operating and so it's very important for us to remember refractive error as a cause of vision loss in addition to AMD glaucoma cataract and diabetic retinopathy and if you look at the prevalence of blindness and vision impairment in the US the data are actually a little bit flaky because they have to use the Australian data and data from a variety of studies to put together the best estimate and this is the work done through the NEI some years ago now but giving the projected rates of blindness and vision loss in the US and again the causes are similar this is again published in archives but showing those same five conditions AMD cataract glaucoma diabetic retinopathy and in addition refractive error now low vision has a very marked impact even relatively small decreases in acuity have a marked impact a lot of the definition had been used of less than 2060 but in fact most of the work now is focusing on vision of less than 2040 and it's been shown that acuity of less than 2040 presenting acuity of less than 2040 impacts both on the quality and length of life and prevents healthy and independent aging and the break point is really at less than 2040 rather than less than 2060 and it's the the impact on the tasks of daily life whether it's your work or leisure being able to read a newspaper being safe and being able to get around safely outdoors particularly in old people and how people feel about their vision so that's 2040 is not only important as driving vision it's actually a very important functional vision and for people whose vision is less than 2040 they are twice as likely to have a fall four to eight times as likely to have a hip fracture have three times as much depression will be admitted to a nursing home or supported care three years earlier than people match for other health and age just on the basis of having this in 2040 have a doubling in their requirement for social support twice as likely to visit a doctor and factor twice as likely to die so even small amounts of vision impairment are important and looking at those other figures two out of three people will lose vision before they die so it's actually a huge problem in social terms but it's also a huge problem in economic terms and looking at the economic impact of low vision one has to look at and vision loss one has to look at not only the provision of services the curative services I care that we provide but also the personal or out-of-pocket expenses the people with low vision suffer loss of income the cost of a carer that somebody's got a daughter or daughter-in-law he's got to take off time from work to drive somebody to their doctor's appointment or help them with their shopping money that spent on low vision age and equipment around the house or how to make things safe and also transport because they can't drive themselves they may not be able to take a bus and so forth and the amount that people with low vision spend varies tremendously depending on their economic status study we did in Australia is that on average people with low vision are spending about three or four thousand dollars per atom on their various low vision costs and these other out-of-pocket expenses but obviously that's very related to their ability to pay to pay and what they can do we also in Australia looked at how what's the impact of vision loss on on the life that on disability and the impact in the community and how does it relate to other things and we found that vision disorders are actually the seventh leading cause of disability less important than things like depression or dementia but far more important than breast cancer prostate cancer or even HIV AIDS so as a as a sector it has a very big impact in terms of disability within the community and we also looked at the costs of vision loss in Australia and the total cost there's these are figures now some years ago were 10 billion dollars and the estimates that were done last year have increased that number to about 16 billion dollars per atom and Australia's got a population of 22 million about a 1 14th the size of the US half of that cost or impact of vision loss is due to the impact on well-being the loss of well-being or the burden of disease another third of that is on the indirect costs the the loss of income the cost of carers and agents and that sort of thing these indirect cost listed here and about a quarter of the cost is the direct care given to either now as I mentioned if you the average life expectancy now is close to 80 but there's been a big change in life expectancy over the last century or so and basically for every year that we've lived we've got four months for free and the life expectancy has increased dramatically in Australia the US Japan in fact globally although the starting point is different and with that change in life expectancy there's going to be a doubling in the number of people over the age of 60 or over the age of 65 over the next 20 years and with that doubling there's going to be a doubling in the number of people with vision loss and blinders just because of the increasing age distribution in the population and so that the cost of blindness and vision loss is going to become much greater over the next 10 or 20 years than it is today so what can we do about vision loss having shown that it's not it's important not only to the individuals but also it's important to the community and there are actually three simple things we can do it's susceptibly simple we can prevent the things that we can prevent we should treat the things that we can treat we need to solve the remaining problems that's doing research on the things we don't know how to treat or prevent it present and I just like to run through some of the simple things that one can do in terms of preventing the diseases we can prevent what we need is appropriately resourced and long-term high health promotion initiatives to reduce avoidable vision loss what we need to do is make sure that people who need an eye exam get an eye exam is one thing and so we had a show in a moment had a series of public health promotions about the need for eye exams there although many people about 40 percent of people will have an eye exam every year in Australia at least where we've got universal coverage and access to services we still have 15 percent of people who do not have an eye exam in a five-year period and so there are people there who need to be seen the other is preventing diseases and things like and the link between smoking and AMD and cataract is very important and so we've also done quite a lot of work in that and so working with the Australian government we've got compulsory anti-smoking ads on lung cancer heart disease stroke and stuff on cigarette packets we also got eye disease included with this you know very graphic labels on all the packs of cigarettes but to talk the government into doing this as a government program is actually you know quite terrific it's similar things have been picked up in the UK but this is a this is trying to do something about particularly AMD where smokers have three times the risk of AMD and 30% of AMD is probably attributable to cigarette smoking and very interestingly that recent Haines data that have just been published in the last month they're showing a decrease in the amount of AMD maybe a decrease in the amount of AMD in the US that may be due to changing in smoking rates which is which is interesting to think about the other thing we've been working on is getting these community messages out that people over 40 should have an eye exam at least once every five years unless they're in a high-risk group and the high-risk groups are obviously people who've noticed a change in vision should be looked at right away people have diabetes need their annual eye exam in Australia it's actually every two years because in general the level of care and control of diabetes across the community is better than the US and so the two yearly exams what's recommended there people with a family history of glaucoma need to be assessed those over the age of 70 probably need to be looked at every year or two and obviously if you're under the care of a practitioner you need to follow their advice so if Jeff Tavern says you've got to come back tomorrow for your Cornell also you need to do that don't wait five years but interestingly this this is a another ad or campaign that we had the talk the government into running increasing the awareness of the need for our exams and this is what a healthy eye looks like and this is what an unhealthy eye looks like you can't spot the difference meaning you know that you do need to have these regular exams and what you don't need is if you've had a normal eye exam and otherwise normal you don't need to be examined every year you do not need to be examined every two years those are a whole lot of unnecessary exams that are filling up our chairs and offices with the worried well and we're not getting to the people who need to be looked at who are not being examined and refractive error I mean even though it's it's something we don't spend a lot of time thinking about is actually very important in the community and this shows just in Australia the number of people who have a vision of presenting vision of less than 2040 who just need a pair of glasses to bring it back to 20 or it's a better than 2040 and see there's a large number particularly as you get into the older age groups all right we talked briefly about diabetes but people with diabetes have 25 times the risk of vision loss 98% of that the severe vision loss is can be prevented by timely laser treatment people need their regular eye exams every one year in the US every two years in Australia to be able to find those who need treatment but only half of the people with diabetes are getting those regular exams and a third of the people with diabetes have never had an eye exam and these figures are for Australia but they're exactly the same in the US so we are clearly failing to reach all those people with diabetes who need to be looked at and so there's a message there for us to talk to the internist to the family practitioners to the diabetologist to make sure we have those links so that all the patients they're treating with diabetes are getting the examinations they need we need to treat the diseases we can treat obviously there's we need adequate funding and resources to be able to provide services to the whole community that needs them counteract surgery on the one hand is a classic case where what we need to do that and also providing low vision services for those who we cannot reverse the low vision and in general only a third of the people who are blind are actually using low vision services and only about 10% of people who have low vision less than 2060 are using low vision services and their quality of life and ability can be improved dramatically with even simple low vision aids but with counteract everybody will develop cataract if they live long enough basically a hundred percent of people in their 90s will have lens capacities although half of them have already been operated on cigarette smoking and UV exposure the only two modifiable risk factors I mean other than sort of ionizing radiation or high-dose steroid but but cigarette smoking UV are the only thing that we can address and cataract is by far the most common of all the elective surgical procedures and by far the largest cost in eye care but counteract surgery is also extraordinarily cost-effective and costs 2020-2020 dollars per quality adjusted life year treating hypertension is about $20,000 per quality treating diabetes is about $40,000 per quality and our heart transplant is close to half a million dollars per quality cataract surgery is so cost-effective we cannot afford to have people sitting around in our community with unoperated cataract the community just cannot afford that loss so we need to make sure the cataract surgery is available for everybody in the community not just those with private health insurance and then we need to do more research to solve the present problems particularly looking at AMD and glaucoma and AMD increases dramatically in the older age groups so that two out of three people will have at least early AMD in their 90s and a quarter of people will have vision loss from it there's not a lot you can do to change your family history and there's been a huge amount of work done on the the genes associated particularly with neovascular AMD cigarette smoking is the only modifiable risk factor that we've got and there've been a whole lot of other risk factors listed there that really are not consistently shown but if we could just slow the progression of AMD by only 10% just a small change in the rate of progression of vision loss from AMD it would have huge savings and again you can multiply that figure by 14 fold to bring it up to a US number so that there is a huge impact and cost from even a slow reduction let alone being able to prevent or reverse AMD but glaucoma is has a different sort of appearance through the community about one person in 11 or now about 10% of people will ultimately develop glaucoma if they live long enough glaucoma doesn't keep rising the way cataract and AMD tend to glaucoma seems to plateau off so there are people clearly at risk and a family history is the most important factor by far increasing the risk of glaucoma 3 to 4 fold any of the other risk factors might increase it by 20 or 30 percent but a family history increases it by 3 or 400 percent orders of magnitude difference the most important thing about glaucoma is sort of early diagnosis they can have appropriate treatment and control of the IOP and stuff but half the people with glaucoma are undiagnosed and are therefore untreated and half of those people who are undiagnosed have had an eye exam in the last 12 months and have been missed so somebody's checked their pressure or taken it flashed to some sort of light over their disc and just not actually looked at them properly and so we're actually having walking through our going sitting on our chairs in our in our examination lanes all these people with undiagnosed glaucoma and the reason they're not being diagnosed is people are not doing visual fields on them and the one of the biggest reasons that people are not doing visual fields and not thinking about glaucoma is they don't know that they have a family history that puts them at high risk of developing glaucoma so the single most important thing that we can do is to make sure that our patients who have glaucoma tell their relatives their first-degree relatives that there is a family risk of glaucoma so we see all the patients who are known with glaucoma that's our easy link into everybody who's got a first-degree relative with glaucoma so what we need to do is we need to each patient you see with glaucoma you need to ask them or tell them instruct them inform them encourage them to tell their first-degree relatives their brothers and sisters their sons and daughters hey I've got glaucoma and you will be at risk of having glaucoma too so when their family member comes for an eye exam like you say hey my mother brother whatever has glaucoma please check me out to make sure I don't have it and that will be enough of a cue for us to actually look further than just as a routine exam so that's a very important thing that we can do to pick up those half the people with glaucoma who are undiagnosed and we looked at some of the economic health economic impact of glaucoma and what you can do when we know where things are with drugs and I know there's I've been a whole lot of correspondence recently about all the prostagland inhibitors going generic and what that's going to do for costing but a change in treatment to have initial laser trabeculoplasty would be tremendously cost savings in terms of preventing vision loss from glaucoma you get 24 hour a day seven day a week compliance after your ALT you don't have to worry about the person remaining to put in drops you don't have to worry about whether they can afford to refill the prescription and if it lasts one year or ten years they've gone that long with good control without the need of drops and so there's and you know occasionally having to take pills and med case myself I know if I get to have it fixed up by having one bit of surgery and it lasted for a year or ten years there is absolutely no question in my mind my very first stop would be an ALT or an SLT but that's not what we're doing most people don't do that most people put them on zalatown or something and that and we know that a third of it are probably only a third of the people are fully compliant a third of them well the date even you know not using the prescriptions at the end of a year so our compliance with glaucoma medication is just atrocious so that the really the thinking more about that SLT or ALT as your first line in glaucoma will make a huge difference into that overall management we looked at if we did those three simple things that we were talking about if we prevented the diseases that we could prevent if we had adequate resources to treat the diseases we can treat particularly cataracts and if we provided some additional funds for research now what would that cost what they were saved and in Australia when we model this out it costs about just under two hundred million dollars additional funds per annum not a big amount but in the first year it would return almost a billion dollars so there's a five-fold return on investment and a lot of this is just getting people their glasses getting people getting you know examined picking up some of the diabetics and stuff and the same thing over the lifetime of the people was again over five-fold return so for each dollar invested in I care there is a five dollar return to the community so that's a very good investment for a community to make and if you look at the costs of vision loss in the US and this is you know prevent blindness America data and their estimate there was fifty one billion I think that's wrong by about a factor of three-fold and because there's a lot of stuff that's been left out and there's an article that we had in investigative off the apology about a year back with a consensus panel about the factors that you need to put in and I think people would agree that that figure should probably be in about three-fold larger than that we've also done work on the cost of vision loss in Canada and the UK and Japan looking at and the figures are remarkably similar there may be differences in the distribution of disease there may be differences in the health care system but relative to health care revision that impact of vision loss is remarkably consistent now what's happening globally where is we sort of worldwide and in 1995 the estimate was that there were 45 million people blind and the disease is a little bit different here we've cataract causes half the blindness globally glaucoma still is about 14% and glaucoma is very interesting if you look at data going back to the 1880s and through the early 1900s through today glaucoma stays at around 10 to 12% year after year after year in one country after another and it doesn't matter if you're looking at Germany or the UK or the US or Australia or the developing countries glaucoma has remained while the other causes of blindness who have gone from being infectious disease of family in the in the Torum syphilis smallpox through cataract and diabetes in the developed countries and now we're looking at AMD but globally cataract causes half the blindness and glaucoma still important but anyway trachoma and corneal capacities are still important but the big thing that happened between 95 and 2004 was there is for the first time ever globally there was a decrease in the number of people with blindness and that's been a lot of work done with vision 2020 programs like the Himalaya cataract program the international ophthalmology work that Jeff's doing and others getting these services out to these areas and just in the last month W.A. Joe has released new data to show that now include those with refractive error but again showing a further decrease to just under 40 million when you add in those people with which about five or six percent who have got uncorrected refractive error and this is despite a very significant increase in the population in the global population and a particular increase in the older people in the global population so that progress is being made globally on reducing the amount of blindness and vision loss and these are some data that came out last year that show that the total impact of blindness globally is about four thousand billion dollars per atom I mean it's a huge cost on the world and it's interesting that about one and a half trillion dollars of impact is due to refractive error and then the two and a half trillion dollars is the other causes of vision loss and you don't have to worry necessarily about all these different categories about the direct cost and dead weight cost and stuff there's some of the health economic mumbo jumbo that goes to give you these sort of global figures which shows the huge impact of vision loss and globally not only does blinders lead as I've talked about to that individual impact but it's a major contribution to contribute to poverty both for the individual who loses their economic livelihood to the family who's got to look after somebody who's not generating income or helping grow food and in some of these countries are blind person can be referred to as a mouse without hands it's somebody who and actually you have to have a child often look after the blind relative so you're actually losing two people from the economic system of the subsistence farmers and of course it contributes to community poverty globally 80% of this blindness and vision loss is preventable and some of the interventions are extraordinarily inexpensive we talked about cataract surgery at 2020 or 20000 dollars per quality distributing vitamin A capsules is about the most cost-effective thing you can do in the world it's even more cost-effective than immunization at $2 quality adjusted life year and screening for diabetic retinopathy much more complicated much more difficult is still only $15,000 per quality and there's some some work done recently by Pollock and Cooper from London looking at the impact of cataract surgery in these developing countries and looking at the change in economic benefit in the community and in the households of people who've had cataract surgery showing that those people have been operated on vastly improved compared to how they were before surgery and this is a measurement of quality of life again showing huge changes not only not only in the economic area but also in the rating of ability all right so what can we do about about vision loss I mean one a little bit like climate change one needs to think globally but you need to also act locally and locally each of you here can work somewhere along a spectrum at least you need to be aware of the problem of vision loss in your own community in your own country in your own hemisphere in our own world be aware of it the next step of engagement would be supportive or become an advocate see what you can do to help it may be you change your research you start to focus on some of these issues or diseases to see how your research could contribute to doing something about vision loss you may go and work with Jeff Tabard and you know we spend three months a year overseas ready I didn't say that I don't want all your faculty to go overseas but you may do that or some people may say well I'll become an Albert Schweitzer and go and live in Africa and commit myself full-time there's a range of things you can do but even if you're just aware and an advocate and are supporting other people who are doing this work you're making a big difference but in our own practice in our own the patients you see this morning you need to think about the things we talked about you need to think about glaucoma you know what are you doing are you were learning all your patients with glaucoma about family history I actually checking relatives who have glaucoma well enough what are we doing to reach the the diabetics are we making sure that everyone with diabetes is actually getting their eyes examine what are we doing about the underserved people in our community are we actually providing care out there or are we just sitting there looking at the people who come into our clinic you know are we actually doing what we can in our own community to practice these things about trying to reduce or minimize vision loss and a lot of that is also advocacy you know talking to to people about the importance of vision and the importance of things that we can do about as I've been going through today and vision loss is difficult and I get a lot of inspiration from Helen Keller who is photographed here and the quote that she said because I can't do everything I will not refuse to do the something I can do and we can do something about vision loss and blindness it's very achievable to eliminate blindness and vision loss if we wanted to we could operate on everybody with vision loss from cataract by Christmas there's no way we could get rid of obesity by Christmas or alcoholism by Christmas or cardiac disease by Christmas but to eliminate cataract blindness would give everybody a pair of glasses is very finite we can actually do that the other thing I like about this photograph and it's actually you can see there's some writing here Helen Keller writing pencil and it's pressed into the photograph and then Polly Thompson who at this stage is this woman who was her eyes and ears and companion and it's written in thank you to my grandfather who was also an ophthalmologist there. So I'd like to end there and I'd be very happy to answer any questions thank you. So you're very good and obviously a great chance for us to get a good international look at the problem where it is. I'd like you to comment a little further on the hate study because I mean they're purring about it a lot to talk to you and they're giving figures as though that since 2004 and now that there's potentially a decrease in much of almost a third. I'm a little fearful of people so we've got a couple of low hanging fruit that right now seem to be stabilizing fairly well if indeed it is taking antioxidants and smoking sedatives but I worry we've got a really a sampling error problem and you're the one who's done a lot of this epidemiology. I'd love to hear your input about that because it's a big deal right now. The implication is we're looking at this problem. I don't believe the data. They had over 900 people that they excluded out of a sample of 7,000 about 7,000 so it's almost 20% of people they threw away and they threw away people they couldn't get a photograph on they threw away people who are blind. So if you if you're throwing I mean it's those people were not randomly distributed. The people who were excluded from the analysis are going to be your highest risk people and so those numbers are really flaky. Well I mean I think that with that high percentage of exclusion or you know failure of ascertainment those data are very suspect and what you really there is a sensitivity analysis and say if everybody we didn't look at had AMD what would be the number because what they've assumed is nobody they didn't look at had AMD or so you go from the they presented the very best case example you need to present the well if the rate in these other people was the same as those we examined what would it be and then you get a third estimate so that and that's the sort of sensitivity analysis that I think the reviewers or the editors should have insisted that paper had. Absolutely right and I don't believe the analysis was a secondary analysis and if you look at the breakdown of the average data those with neovascular did a little bit better than the average which means those with geographic atrophy did a reverse and those never properly teased out and we know that zinc on its own doesn't do anything we know that vitamin E on its own doesn't do anything we know that vitamin C on its own doesn't do anything we know that we can't use vitamin A in the high risk people because they're all smokers and that increases the risk of cancer so I think that that arid's bubble was not well evidence-based that's pretty controversial position it'll be really interesting to see what it comes up with and you know Israeli said there's lies and statistics and you can pull these analyses in different ways and you know they I had a hundred million dollars in arids the drug companies wanted to sell it people want to have good news stories you know you got to sell something to the Congress to get your funding and so there's lots of pressure to put and of course I'm always just want to do something I want to have patients come and say look you're going to go blind from AMD there's nothing I can do about it they say look you know you got early AMD but if you take this you might not go lose vision so I mean everybody wants it to work but I don't find those data convincing arid's too will be very interesting to see what they what they come up with yes and you'll see that by current position is I'm working on Aboriginal indigenous I health where we're not only working across a doctor patient barrier or divide but we're also working across a cultural divide as well and so it's extraordinarily important to understand what other if you like the patient perceptions there and you know it's you've got to sit down talk to people and it's sort of in a structured way you know you're not going to do research by sort of putting a drop by something on a 96 well played or strangling a cattle or something you go to do a properly designed study you're not going to get information about the community perceptions without doing properly designed studies and you know whether they focus groups whether they're different ways of consulting but it's to understand the patient barriers to utilisation and care is very important if you're planning those larger services absolutely agree with you yes sir yeah no that the the there are a couple of things that were interesting everybody except for I think one patient had measurable detectable field defect the range of pressures were were in the same range as those with diagnosed glaucoma the range of discupping were in the same range as those with diagnosed glaucoma so it wasn't as though they were all very early glaucoma there was actually some very advanced glaucoma that was missed but the thing that they all had or almost all had was the field loss so if somebody checked their field they would have been picked up but you're not going to do a field on everybody as part of a routine exam which is why that alert of say hey you know somebody my family's got glaucoma can you make sure I don't have it is so important and the only way we'll get that is by us telling our patients with glaucoma you've got to tell your first-degree relatives does that help I mean I'm a cordial surgeon so I'm a trachea ground I'm talking about AMD and antioxidants or glaucoma or low vision but I think yeah glaucoma is important as a disease in its impact on visual function that's what's important you know the number of nerve fibres you've got or don't have don't matter what matters is what you can see or what you can't see so so to my mind the siniquanon glaucoma is field loss now of course if you pick it up early you can treat it before it gets worse and and you know I'm not saying that you should forget about the disc and nerve fibres all together but to my mind the key the thing I mean if I lost you know 40% of my nerve fibres and still had complete field who cares and if that's the day before I die who cares so the fear the loss of nerve fibres themselves in the absence of demonstrable field loss is on the self not important the so so I put a lot of value into field but I'm not suggest and I also think that the FDT is terrific and when we did you know examination a whole lot of Aboriginal people who know you've got all the cultural barriers and language barriers and stuff I mean they will all do FDT in a snap you just tell them to push the button when they see the lightning flashing you know it's nothing about grids or patterns it's just you know the lightning flashes and they are being why they go so one could do that very quickly and easily if you want it to as a routine test and and I'm suggest it's actually a lot easier to do than OCT on everybody but but I think that the easier thing for us to do when there's something we can do immediately today with almost no change in our practice every patient we see with glaucoma you should put that message is please tell your relatives first-degree relatives that they are at risk to and to get checked out now that's very simple thank you yeah we're one more sorry I I think that to have a non-mediatic retinal photograph and a visual acuity test because you're not going to pick up all the early macular edema and necessarily on a retinal photograph and not a non-mediatic retinal is a single retinal photograph so that and you're not necessarily going to pick up their cataract either on the retinal photo photograph so you need a visual acuity and a retinal photograph and I think that the best way to do that is actually put the retinal cameras in the local pathology labs where people go to have their blood taken and they go to have their ECG or their urine down or what have you put cameras there so the family docs can sign EC EKG you know electrolytes hemoglobin A1C whatever and retinal photography that's where I see is that's a one-stop shop I mean people with diabetes have to go to the the pharmacy every month to get their prescriptions they got to go to the family practitioner every two or three months to get their blood pressure or the blood sugar or something else sort of out you know they don't want to spend half a day sitting outside somebody's office in an eye center and then come away not being able to work for another five hours because they're dilated I mean there's not enough hours in their year to do that so you'd need to make it easy and I think that non-mediatic photography plus an acuity check somewhere where they go and you're not going to be able to put those cameras in every family practitioner's office you can put them in every diabetic clinic so that'll be another place to do it but the place all the diabetics go to sort of at least well at least once a year sometimes a lot more often is that local path lab and so to my mind that'll be a very smart place to put it yeah I've got my sorry ready yeah I've just been reading some interesting papers written by Pelly you know who did the Pelly Robson charts and stuff looking and also from the people in the fight in Alabama where they're doing in Birmingham where they're doing a lot of work on sort of driving and stuff and the field defects I have a variable impact on driving and a very individual specific which is interesting the other thing is if you just do field checks without anything else you're going to pick up all those people who've had strokes and or got cataract or something else and so you need to if you're just doing a field screening this is something else we sort of tested out in a population people aged in their 70s that you need to do a couple of questions before you do the field test and a measure of visual acuity because if there are visual acuities down they need an automatic referral but but it's built you know the idea of building some sort of automatic system makes it's got a lot to explore it's a good idea the idea of the United States I mean everybody has to drive almost if you can that's one time you can catch everybody every five years yeah and it as a screen if there's a problem as they do now I mean if they have a visual acuity problem they say you've got to go have this check yeah and to throw a put an FDT you know push the button when you see the light link would work well too