Our practice has been instrumental in developing a novel approach to wet AMD monitoring and management. Patients previously under the hospital eye service (HES) for wet AMD who have not required injection for several months are selected by a consultant ophthalmologist and offered the opportunity to be reviewed in primary care.
When the patient was initially seen in the practice, this was with the ophthalmologist present who was able to review the OCT scans taken alongside copies of the hospital notes. In the early stages of the pilot, the consultant would attend all of the follow up appointments in our practice. As we gained more experience, and the ophthalmologist became more confident about our abilities, we simply reviewed the patient ourselves without direct observation and reported our findings using our local hospital intra-vitreal therapy (IVT) form.
Patient BB
BB is a sprightly 90-year-old+ who was diagnosed with a right occult choroidal neovascularisation (CNV) in August 2015. A short course of three Lucentis injections was given, the last in October 2015. This made BB eligible for our community follow up scheme.
April 2016
BB was commissioned into the pilot in April 2016 with presenting acuities of:
R 6/15
L 6/7.5-2
OCT scans record normal thickness with no evidence of leakage. Non-specific stable cysts and atrophic changes were noted. Retinal examination showed no haemorrhages (figures 1a and b). BB was reassured, and a standard 5/52 follow up was arranged. This examination occurred with the ophthalmologist present.
Figure 1: Retinal appearance at April 2016, (a) right and (b) left eye
June 2016
Acuities measured were:
RE 6/12-2
LE 6/6-2
OCT scans were recorded ISQ (‘in status quo’ or no change) with the same stable cystic and atrophic changes. A routine follow up was arranged for August. This examination occurred with the ophthalmologist present.
August 2016
Acuities measured were:
RE 6/12-2
LE 6/6-2
OCT scans were recorded again as ISQ. On this occasion, I reviewed the patient without the ophthalmologist being present. A 2/12 review was requested. Figure 2 shows the retinal 3D map for the right eye.
Figure 2: 3D OCT map of the right eye at August 2016
October 2016
Acuities measured were:
RE 6/12-2
LE 6/6-1
Again, no change noted – OCT as previous. Discharge advised. Retinal appearance was as shown in figure 3. Patient was issued home Amsler and given strict instructions about actions in the event of change. She was advised to return for routine eye examination in 6/12.
Figure 3: Retinal view in October 2016, (a) right eye and (b) left eye
January 2017
BB presented for a Band 1 Eye Health Wales Examination reporting a sudden change in right visual acuity and noting ‘blank patches’ present when viewing the television screen. Acuities at this presentation were:
RE 6/30; with a slight hypermetropic shift in refractive error
LE 6/6; stable refraction
There was a reported dimming of the Amsler grid, with a scotoma located inferior to fixation. Dilated fundus examination showed a small fresh haemorrhage just superior temporal to fovea (see figure 4).
OCT scans revealed new intra retinal fluid (IRF), with an increase in retinal thickness of about 30 microns when compared with results from October 2016 (figure 5). A moderate increase in RE posterior capsular opacification was also noted.
Figure 5: (a) OCT retina map showing intra retinal fluid, (b) 3D map showing thickness increase, (c) and (d) change analysis showing extent of change since previous appointment
Actions taken
I diagnosed new signs of wet AMD and needed to arrange a further injection of Lucentis to the RE. I completed a standard wet AMD referral as well as the HES IVT sheet which mirrors that used in the hospital IVT service. I spoke to the service co-ordinator and was able to book the patient directly into the hospital day surgery unit for a further injection.
At review five weeks post injection the new IRF had cleared, though BB also required an urgent YAG capsulotomy to deliver the previous perceived quality of vision prior to posterior capsular opacification. At a more recent hospital review clinic, BB was achieving a good 6/12 acuity and the wet AMD was again quiescent.
Discussion
This case shows how novel approaches to patient care can have unexpected benefits in their future management. Our novel pathway has already demonstrated that the regular follow up scans and assessment required in patients undergoing IVT can be delivered in a more flexible and accessible primary care environment. This allows easier scheduling of appointments around both a patient’s personal commitments and those of their carers, in a manner very similar to booking a routine eye examination.
It also highlights how a personal respect between secondary and primary care facilitated a really positive outcome for an elderly and not so mobile patient, saving them the extended travel demands in accessing the hospital service that would have been necessitated had they been treated as a new incidence of wet AMD.
In my ongoing work with macula disease patients, I am frequently struck by the potential opportunities for patient care that can be offered if we strive towards even closer links between primary and secondary care.
If data sharing and transfer is facilitated so that practices are able to upload scans and images directly to secondary care, for either initial assessment or comparison to existing data, the whole process of managing this cohort of patients could be simplified. Frequently I find myself speaking to our urgent access clinic, where a patient is required to attend hospital for a virtual repeat of the work completed in practice prior to having a second appointment in the actual injection clinic. Often the commencement and management of IVT occurs prior to or in the absence of a formal fundus fluorescein angiography, so it is likely that most management decisions could be made remotely.
In an ideal world, optometrists would have access to and be able to both review and build upon an electronic patient record (EPR), quickly identifying any drugs and therapy that are being delivered, and be able to both compare old scans and results with their own and, crucially, to upload new data for review. It is unfortunate that such attempts end up being slow, inefficient and sacrificed on the altar of patient confidentiality and data security, with Sisyphean protocols to gain access to the most rudimentary of interfaces.
With an increase in optometrists holding higher qualifications who are ready, willing and able to support our stretched secondary care service such collaborative working cannot help but to be beneficial for patients, hospital and practices alike as we move towards an increasingly medicalised role.
Andy Britton is an optometrist and co-director of Specsavers Haverfordwest in South Wales.