Since emerging in Sydney in the early 1970s, Australia’s Brien Holden Vision Institute has had a major influence on eye care, co-developing the first silicone hydrogel contact lenses along with several other market-leading products, advancing knowledge about contact lens infection and inflammation, and initiating a global campaign to eliminate vision impairment and blindness due to uncorrected refractive error.
The Brien Holden Vision Institute is now set to significantly impact myopia management, having recently announced a licensing agreement with independent manufacturer of premium monthly replacement contact lenses, mark’ennovy, which will bring the Institute’s novel soft contact lens designs for myopia, as well as presbyopia, to European markets in the near future. This, in addition to the myopia management program for practitioners, service development through the Our Children’s Vision campaign and advocacy efforts, are aimed at reversing the trends in myopia prevalence.
Early years
The organisation’s history reaches back to the seventies when its founder Brien Holden, a young academic who had earned his PhD in corneal and contact lens research at the City University London in 1971, moved to the University of New South Wales Sydney (UNSW). Here he took a position as a lecturer and began investigations into the properties of contact lenses required to maintain eye health.
Soon after, Holden established the Cornea and Contact Lens Research Unit (CCLRU) at UNSW which, by the mid-1980s, had become a world leader in multidisciplinary research encompassing basic and clinical contact lens research, as well as contract research for industry.
The CCLRU was the first of numerous organisations that Brien Holden helped establish, such as the Institute for Eye Research in the 1980s, an independent, university-affiliated, non-profit organisation, which eventually became the main vehicle for Holden’s vision correction activities (and was later to be renamed Brien Holden Vision Institute).
The royalties resulting from the invention of silicone hydrogel (the material which today accounts for around 50% of contact lenses prescribed globally),1 along with several sizeable government grants, enabled Holden to established a ‘social enterprise’ to pursue further vision correction breakthroughs and educate postgraduate research students, deliver optometry education programs around the world, and build sustainable eye care services in developing communities.
In addition to the co-development with Ciba Vision of silicone hydrogel lenses (first released as the Focus Night & Day lens in 1999), the organisation played a key role in the development of further market leading products, including the Biomedics soft toric lens for astigmatism and Air Optix Aqua multifocals for presbyopia. Previously, Brien Holden’s group had been instrumental in the development of daily wear hydrogel spherical and toric lens (Zero 6 Hydron), in co-designing Permalens and Permaflex extended wear soft contact lenses, and in helping to develop the first centre distance and centre near soft bifocal combination for treating presbyopia with concentric bifocal contact lenses (with CooperVision).
Research output
Important scientific contributions from Brien Holden include specifying the minimum oxygen transmissibility required to avoid excessive levels of corneal oedema during daily and extended contact lens wear. Conducted with colleague Dr George Mertz, this seminal work established what became known as the ‘Holden-Mertz criterion’, and laid much of the foundation for the silicone hydrogel invention. From this foundation flourished a strong postgraduate research program, which has now produced almost 200 PhD candidates.
The influence on contact lens research by the Holden group was endorsed in the journal Optometry & Vision Science in 2012, when four long-term staff were listed among the top 10 authors for contact lens articles (with Brien Holden as number one) and which featured several others who had worked collaboratively with Brien Holden’s group.2
Collaboration
A collaborative approach has defined the organisation, with the Institute having worked with all major contact lens manufacturers and leading lens research organisations around the globe. The Brien Holden Vision Institute was the lead partner in several ‘cooperative research centres’ between 1991 and 2015, an Australian Government initiative to drive innovation through collaborative partnerships between researchers and industry. A global outlook was personified by Brien Holden, who travelled the world engaging with industry and researchers and, later on, public health specialists.
Research collaborators in the Institute’s current myopia program alone include the University of Houston (US), the LV Prasad Eye Institute (India), and the Zhongshan Ophthalmic Centre along with the Shanghai Eye Disease Prevention and Treatment Centre (both in China).
Spreading knowledge
In addition to its research contribution, Brien Holden and his group also took leadership in the area of professional education, conducting contact lens education programs in the Asia-Pacific, India and China, having a major involvement in the International Association of Contact Lens Educators, as well as conducting training courses with Essilor in the use of speciality spectacle lenses for many years.
The Institute helped establish an international non-government organisation in 1998 to build sustainable eye care systems throughout the world, which has since helped train around 150,000 eye care personnel, established or supported 16 optometry schools in developing communities, and delivered glasses or eye care to more than four million people in more than 50 countries. The Brien Holden Vision Institute has been at the forefront of efforts to build sustainable eye care systems to provide services to the more than 600 million people who are blind or vision impaired because they lack access to an eye examination and appropriate spectacles.
This initiative includes helping drive global advocacy efforts to have uncorrected refractive error recognised as the leading cause of vision impairment worldwide, including hosting the inaugural World Congress on Refractive Error in 2007.
In 2010, the Institute for Eye Research was renamed the Brien Holden Vision Institute in recognition of Brien Holden’s lifetime of contributions. In July 2015, Brien Holden passed away suddenly at the age of 73.
The Brien Holden Vision Institute, the legacy he has left behind, continues to tackle some of the biggest challenges in eye care and, with a number of new licensing agreements in place, is set to remain one of the leading vision correction research, education and public health centres in the world.
The Brien Holden Vision Institute in Sydney, Australia
Myopia
In 2016, the organisation published a landmark study that estimated around half the world’s population would be myopic by the year 2050 (5 billion people) and that up to 1 billion of those affected would have high myopia (≤ –5.00 D).3
The Institute’s flagship myopia program, which began in 2003, has several projects aiming to help address what it sees as a major public health crisis in the coming years. Optical devices for myopia management, professional development programs in myopia management, studies into the mechanisms related to onset and progression of myopia, and development of novel instruments to aid diagnosis are all part of this program.
The Brien Holden Vision Institute recently announced a deal with mark’ennovy on the production of soft contact lenses for myopia management and for presbyopia, utilising the Institute’s patented extended depth of focus (EDOF) technology. The deal demonstrates the organisation’s current research and development strategy, focused on engaging with the right industry partner to convert its research ideas into products that will benefit patients.
With clinical research and trials centres in Sydney and Guangzhou, China, and in-house legal expertise, the organisation can fast-track novel ideas to proof-of-concept, produce the clinical data and prototypes and protect intellectual property, ready for industry to licence.
In addition to the prospect of its EDOF technology being on the market shortly, it has several more novel contact lens and spectacle lens designs in development, as well as intraocular lens technology that industry is currently evaluating.
In addition to optical products, Brien Holden Vision Institute has become a strong myopia advocate, including hosting the World Health Organization for a Global Scientific Meeting on Myopia in 2015, and helping establish the International Myopia Institute, a global think-tank of scientists, clinicians, policy makers, government and educators promoting further progress in myopia research.
The organisation’s education arm, Brien Holden Vision Institute Academy, has begun delivering online myopia management courses for eye care practitioners, conducted so far in Australia, US and India. Tools for practitioners include the recently released myopia ‘calculator’, a web-based resource that shows various myopia management options and scenarios to practitioners and their patients and demonstrates the possible benefits, over time, of treating myopia progression (see Optician 22.09.17).
The Brien Holden Vision Institute Academy also boasts a range of online teaching and learning resources for varying levels of eye care personnel, especially aimed at resource poor settings, including materials that make up the bulk of an optometry degree program. The ‘Virtual Refractor’ is an online learning tool that simulates a distance and near subjective optometric refraction, using a refractor head on virtual patients, developed to augment traditional learning and teaching approaches to refraction with the intention of increasing the speed and accuracy of clinical subjective refraction.
Presbyopia
The organisation has had a long interest in novel treatments for presbyopes, with a current focus on optimising its EDOF technology for contact lenses and intra-ocular lenses.
These lenses incorporate a design which exploits higher order aberrations to optimise retinal image quality over a wide range of distances from far to near while eliminating ghosting and haloes. The agreement with mark’ennovy will see these lenses released on European markets in the near future, and a deal with Japanese contact lens manufacturer SEED will see them made available in most worldwide markets.
The researchers have also turned their attention to delivering improved efficiencies at the manufacturing stage for contact lens companies. In particular, a focus has been on optimising contact lenses to reduce the number of designs needed to meet a company’s target market and thereby reduce production costs.
The Brien Holden Vision Institute has also been heavily involved in public health efforts to provide eye care and spectacles to the hundreds of millions of people (the majority living in developing communities) with uncorrected near vision impairment due to presbyopia. This includes driving advocacy efforts for the inclusion of uncorrected presbyopia in official global estimates of vision impairment, and producing important research studies (including a recently published Lancet study that estimates more than 1 billion people are vision impaired due to uncorrected presbyopia).4
Dry eye
Continuing the organisation’s long-time focus on contact lens related infection and inflammation, investigations are under way into a novel treatment for ‘dry eye’, one of the most common ocular complaints. Based on the belief that an imbalance of the ocular bacterial community contributes to an unstable tear film, researchers at the Brien Holden Vision Institute are exploring topical applications that will help rebalance the bacterial community.
In addition, they are investigating the possibility that subclinical inflammation caused by dysbiosis in the gut (imbalances in the gut flora) can lead to ocular sensitivity and contact lens intolerance, and cause or exacerbate signs and symptoms of dry eye disease. Methods to address the systemic aspect of ocular discomfort would involve the novel approach of using supplements targeting gut dysbiosis to treat dry eye.
Innovative technology
A long-time asset in the organisation’s contact lens research is a technology team with the capacity to design and custom-build instruments for research purposes. A recent innovation is the ‘Brien Holden Aesthesiometer’, developed to overcome a lack of suitable methods to quantify ocular sensitivity which has previously hindered efforts to treat and diagnose dry eye.
The instrument stimulates the ocular surface, for the purpose of determining its sensitivity, by propelling small droplets of sterile liquid through a micro-valve onto the surface of the eye. The developers hope it might one day enable practitioners to quickly measure discomfort levels and inform their diagnosis and treatment recommendations for conditions like dry eye.
Other novel instruments developed by the group include the EyeMapper (developed as a method for rapidly assessing the refractive state across the visual field of an eye, especially for myopia research) and which also may have potential application in practices.
The future
Today, Brien Holden Vision Institute is led by its CEO, Professor Kovin Naidoo, a former anti-apartheid activist, Fulbright Scholar and internationally celebrated optometrist, who established the organisation’s South Africa office in 1999 to help build sustainable eye care services across the African continent.
With executives Yvette Waddell and Amanda Davis, both with decades of experience in eye care, leading business development and public health activities respectively, and a blend of experienced and outstanding young researchers, the organisation is well equipped to build upon the remarkable legacy Brien Holden created.
Stephen Davis is Communications Manager at the Brien Holden Vision Institute.
References
1 International contact lens prescribing in 2016, Contact Lens Spectrum. Accessed on 31/08/2017 at: www.clspectrum.com/issues/2017/january/international-contact-lens-prescribing-in-2016.
2 Efron N, Brennan NA and Nichols JJ, Citation Analysis of the Contact Lens Field, Optometry & Vision Science, Vol 89, No 1, January 2012.
3 Holden BA, Fricke TR, Wilson DA, Jong M, Naidoo KS, Sankaridurg P, Wong TY, Naduvilath TJ, Resnikoff S, Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050, Ophthalmology, May 2016 Volume 123, Issue 5, Pages 1036-1042.
4 Bourne et al, Magnitude, temporal trends, and projections of the global prevalence of blindness and distance and near vision impairment: A systematic review and meta-analysis. The Lancet Global Health, August 2017.