Brien Holden is director of the Cooperative Research Centre for Eye Research and Technology in Sydney, a collaborative effort between industry and academia that develops new ways of correcting sight. He is also the founding chairman of the International Centre for Eyecare Education, which aims to provide glasses to the more than 100 million people worldwide who need them. Though he failed his first attempt to graduate from high school, Holden took a degree in optometry and a PhD in eye physiology. His interest in the developing world was sparked by a trip to Sri Lanka nearly 40 years ago.
What are the most pressing problems in eye care today?
Onchocerciasis or river blindness, and vitamin A deficiency, which used to be the major cause of childhood blindness, are being wiped out virtually as we speak. In many parts of the world that leaves cataract and trachoma as the major causes of blindness. Since 1998 we have also started waking up to the fact that uncorrected refractive error – that’s people who need glasses and don’t have them – is a major issue.
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How major?
The numbers are staggering. A pair of glasses costs just five Australian dollars [US$3], but they would be lifeblood to perhaps as many as 100 million people worldwide who don’t currently have them. In India, 12 per cent of the blind and 55 per cent of the visually impaired are that way because of a lack of spectacles. In Africa, half the kids in blind institutes aren’t blind. They just need glasses. Some read Braille not by touching it but by holding it up close to their eyes so they can “re ad” the dots.
How does this affect their quality of life?
If you need glasses and don’t have them it’s hard to get around. Elderly people are more likely to suffer depression and to fall over and break a hip. Kids don’t learn because they can’t see the blackboard. You can’t see the leaves on the trees. If you can’t see close up, you can’t cook well because you can’t separate the weevils from the rice. You can’t read instructions. You can’t sew.
What are you doing to address the problem?
We created the International Centre for Eyecare Education (ICEE) in 1998, which is a spin-off from the Cooperative Research Centre for Eye Research and Technology (CRCERT). It’s funded partly by donations, partly from royalties from our contact lens development, and partly by running full-cost education programmes. Say an industry partner such as a lens manufacturer wants to train all the opticians, ophthalmologists and optometrists in Thailand to fit glasses properly and do proper eye examinations. They pay the full costs for doing that and we use part of the funds to finance our humanitarian activities.
What have you achieved so far?
In some places in Africa there are 6 to 10 million people with no optometrists, no ophthalmologists, no eye doctors, no eye nurses and no optometry schools. We have set up training programmes for optometrists and eye-care workers at the Kilimanjaro Christian Medical Centre in Tanzania, and established a programme at the University of Durban-Westville in South Africa that trains 60 teachers each year. Each of those teachers can train 30 eye-care personnel a year, and each of those eye-care personnel can see about 3000 patients a year. That’s over 5 million patients a year in total. We have also helped establish a fantastic eye hospital in Hyderabad, and we’ve delivered eye care and spectacles to 18,000 East Timorese.
We have also arranged for local optometrists to provide eye care to about 5000 Aboriginal people each year in New South Wales and the Northern Territory. In New South Wales is through the Aboriginal Medical Services clinics, which are run by Aboriginal people for Aboriginal people.
Where do the glasses come from for developing countries in Africa and Asia?
The vast majority of ready-made glasses are produced in China. They are cheap, have the same power lens in both eyes and have no correction for astigmatism, a defect that results in distorted images. They can be used for about half the people who are in need. The ICEE has started setting up warehouses in South Africa and India to deliver these spectacles, but the eventual aim is have them manufactured locally. At the moment, it costs about A$20,000 to set up a small laboratory to make 5000 pairs of glasses a year. But we need smarter ways to produce prescription glasses so that we can provide more glasses at lower costs.
Do you find that children in developing countries, like children in rich countries, won’t wear their glasses?
It varies. In some parts of Africa the kids will wear a frame without lenses because it gives them status. The last thing you want to do is give people glasses that make them look stupid, and in the past there’s been a tendency to do that. For example, you can use circular lenses that you rotate to correct different types of astigmatism, but they are big and stupid-looking and people won’t wear them. We have tested the cosmetic acceptability of different types of frames among poor and rich people, and there are some that are pretty good for most countries – something modern, oblong, not dissimilar to the shapes used in the film Men in Black, although there they tended to stick to sunglasses.
You mentioned that you are helping provide eye care to Aboriginal people. Is eye care a particular problem for them?
Australia is the only developed country in the world with active trachoma in significant segments of the population, the indigenous population. In trachoma, you get an infection of the conjunctiva, on the outside of the eye, the cornea and the inner eyelids, which causes scarring and eventually blindness. Running water and face-washing clears up the problem, which is why it’s so tragic we still have it here in Australia. Aboriginal people have a life expectancy something like 20 years less than white Australians. It’s an indictment of Australia’s inability to tackle the politically unpopular issues of Aboriginal health, housing and education – it’s so much bullshit that Aboriginal people are getting too much and wasting money. The ICEE recently decided to help establish six new Aboriginal Medical Services clinics in New South Wales, and it cost incredibly little – A$10,000 – for each centre.
You have spent most of your career developing expensive, high-tech solutions to vision problems, such as the 30-day contact lens. How did you get interested in providing low-cost eye care to poor people?
In the mid-1960s I visited Colombo in Sri Lanka. It was like Dante’s inferno: there were lepers, there were blind people. I decided that one day I would do something useful for people in need. Then five years ago, one of my collaborators, Gullapalli Rao, an ophthalmologist who runs the LV Prasad Eye Institute in Hyderabad, India, told me I should be doing optometry instead of all this research and product development. The world needs optometry, he said. At first I said no, optometry’s boring. But it was my opportunity. The world has suddenly discovered that uncorrected refractive error – needing glasses – is a big deal. With the Aboriginal stuff, initially I said it was too political, too hard, too many conflicting interests. But one of our ICEE project officers said, “We have to do something for the Aboriginal people.”
You made your name warning of the dangers of wearing lenses that are not permeable to oxygen. How did that happen?
I initially made my name in a bad way, in the 1970s. One of our patients got a serious infection and sued me and the University of New South Wales for compensation for their loss of vision. It was settled out of court, but it was a very, very bad experience. The only thing we had done wrong was to use the lenses that were on the market in the prescribed way. We were trying to find out whether they provided enough oxygen to the cornea. As it turned out they didn’t. We campaigned against using those products, and spent the next 30 years telling people not to sleep while wearing that type of lens.
Why is oxygen permeability an issue?
The cornea has to be clear. So it has no blood vessels and gets its oxygen directly from the atmosphere while your eyes are open, or from blood vessels on the inside of your eyelid when you sleep. If you sleep in a normal contact lens, the oxygen can’t diffuse into the cornea. You get swelling, and it becomes susceptible to infection. If you get infection, you can get scarring and lose vision or even become blind. The CRCERT developed a lens that is highly oxygen-permeable. You can wear it 24 hours a day for 30 days. The technology is licensed to CIBA Vision and will generate about A$278 million in royalties by 2020.
The Australian government has just agreed to fund CRCERT for a further seven years. What do you intend to tackle next?
There is going to be an explosion in the need for eye care. Some 70 per cent of the world’s population is going to require vision correction as a result of myopia and presbyopia – that’s when people in their 40s lose the ability to focus their eyes. In Asia, it’s myopia, myopia, myopia. China has a population of about 1200 million people, and probably 600 million of them have myopia severe enough to warrant spectacles and 50 per cent of those don’t have spectacles. In Taiwan, 93 per cent of girls aged 18 are myopic. It’s absolutely astronomical. We are talking about almost all Asians being myopic in future. For ageing populations, the main problem is presbyopia. In Japan, over two-thirds of the population will be over 45 by the year 2020 and they will need reading glasses. Our aim is to stop or correct myopia and presbyopia.
Why is myopia on the rise?
Because of hereditary factors and because people’s lives have changed. We spend hours staring at computer screens and books rather than scanning the horizon for prey. If you are Chinese, have two myopic parents and read 8 hours a day, you have an 80 per cent chance of being myopic. If you are Caucasian, if neither parent is myopic and you don’t read, you have a 10 per cent chance.
How do you intend to treat the two conditions?
The reason you get short-sighted is because your eyes grow too long, so one idea is to use contact lenses to alter the growth of the eye in young children who are likely to develop myopia. We will use a lens that prevents part of the image being projected behind the retina and so stops the eye elongating. At least that’s the theory. With presbyopia, we are going to use a needle to tear a little hole in the capsule that holds the lens, suck out the old lens which is too hard, and then inject a mini contact lens to correct the refractive error and some gel to restore the ability of the eye to change focus. We have been working for two-and-a-half years on this project, and we’ve got a gel that is unbelievable.