Patient pathways for macular disease: what will the new optometrist with special interest achieve?

Abstract

Sir, Patient pathways for macular disease: what will the new optometrist with special interest achieve?In their article, Ellis et al 1 explore the economical and philosophical dilemma of screening for neovascular agerelated macular degeneration, or choroidal neovascular membranes (CNV). Although these may be important considerations for those implementing such screening programmes, the complexities of such considerations are of little importance to those who have the disease. Their scepticism regarding the cost effectiveness of such a programme centred purely around community optometrists is, however, valid. There are currently little published data on different CNV screening methods and clearly the ability to implement effective screening will depend on the local health care architecture. Current methods of detecting CNV include periodic fundal examination, Amsler chart distortion, the preferential hyperacuity perimeter, 2,3 and reporting of symptoms by the patient. Of these, fundal examination by a medical retina specialist þ /À fluorescein angiography is the most accurate, but there are huge time constraints on such highly trained individuals working within the NHS system. With a proven effective treatment already available, and promising new treatments on the horizon, it would seem that efficient, cost effective detection of the disease is appropriate.We recently carried out a prospective study in the Ophthalmology Department of St James's University hospital, Leeds, West Yorkshire, looking at a novel, fasttrack assessment service for the refinement of suspected CNV referrals. The primary aim of the study was to determine whether referrals of suspected CNV from community optometrists could be refined by a nurse and photographer team within the department so as to detect those patients needing urgent intervention by a medical retina specialist. Based on the ophthalmic history and stereoscopic fundus photography, fluorescein angiography was performed if CNV was suspected by the presence of exudation, haemorrhage, and/or elevation of the macula. All referrals and images were subsequently reviewed by a medical retina specialist. The outcome of this review was used as a gold standard, against which the accuracy of the initial referral and of the novel fast-track assessment and refinement service was determined. In the study, 50 consecutive patients referred with suspected CNV by their optometrist, mainly using Amsler chart distortion as the marker of disease, were assessed. Of these 21 patients (42%) had neovascular AMD of whom 19 patients had CNV and two patients had retinal angiomatous proliferations. This represented a very high false-positive referral rate, which clearly could have implications both in terms of health-care economics and the timely treatment for true positive cases. Where fundal abnormalities were seen by the optometrist the specificity rose from 0 to 41%, but the sensitivity fell to 71%. Information regarding the true false-negative rate among community optometrists was not available. In cont...

Improving care and increasing efficiency—challenges in the care of chronic eye diseases

“…25 Furthermore, there is a concern that moving care from secondary to primary settings may be at the expense of care quality and that costs for such services are often greater than expected. 26,27 While there are a number of successful community models of primary care ophthalmology that improve the quality of new referrals into secondary care, [28][29][30][31][32] there is a scarcity of evidence concerning the viability of community monitoring services for people with stable eye diseases. Furthermore, there is evidence to suggest that nonattendances to non-ophthalmologist-led community services are greater than those in NHS secondary care settings.…”