The long-term impact of the pandemic on eye health is unknown and avoidable sight loss has emerged as the biggest concern for eye care professionals (ECPs) and their patients, according to the College of Optometrists (CoO) and the Royal College of Ophthalmologists (RCOphth).
‘It will be some time before we can see how existing patients and people at risk of developing conditions have been affected,’ Sarah Cant, director of policy and strategy at the CoO, told Optician.
Cant explained that the main challenge the pandemic has created for ECPs has been providing eye care services safely and effectively while adapting to changes in the way it is delivered.
‘Optometrists have risen to this challenge and adapted to a fast-evolving evidence base in tough economic conditions. They have done this by providing care remotely, embracing the use of technology, developing new clinical and infection control practices, and adapting to changing patient needs. In primary care, with the support of the College’s guidance for adapted practice, every aspect of how the sight test is conducted has been revised,’ she said.
Dr Sarah Cant
Cant added that patients have been affected differently, depending on their condition, but throughout lockdown the optometric sector across the UK has worked to ensure that any person with an eye problem could access eye care safely.
‘Many patients will have experienced delays in accessing secondary eye care, although we know that patients at greatest
risk of sight loss were still able to have face-to-face or remote appointments.
‘In some parts of the UK, services have been commissioned so that some secondary eye care patients can be managed by their local optometrist, working collaboratively with the local hospital eye service. These patients will have been able to access care closer to home,’ Cant explained.
Cant highlighted that patients who developed significant eye problems may have been worried about travelling to an eye care appointment during the pandemic. A CoO national survey found that 20% of those questioned felt that their sight had deteriorated during lockdown. ‘We provided information on www.lookafter youreyes.org and ran a national media campaign to encourage people to contact their optometrist if they had any concerns about their eyes or vision,’ she said.
Alleviating pressure
Bernand Chang, president of the RCOphth, told Optician that when lockdown first occurred, routine eye care services in hospital stopped. ‘We were only able to get emergency urgent eye cases seen. Patients were anxious and worried about whether attending hospital, where they may have a higher concentration of Covid-19 cases, was safe. Patients didn’t feel safe turning up to hospital or seeing their optometrist in order to get a referral.
Bernard Chang
‘The biggest concern that we have is whether there have been episodes of avoidable sight loss. For example, patients with potential wet macular degeneration. We know that the referral rates to the macular service fell by perhaps as much as 50% or so. These patients may not have been getting prompt treatment with anti-VEGF injections and there’s a risk that by the time they do turn up to clinic that they may have irreversible sight loss. Likewise, with patients with retinal detachment, they may be presenting late as well and therefore the outcome from their surgery may not be as good as it could have been.’
Chang added that before Covid-19 occurred, hospital eye services experienced pressure. The demand for eye care services increased and the capacity in secondary care was not sufficient. ‘We know that there was a backlog and now the backlog is even larger. It’s important for both optometrists and ophthalmologists to step up. I think we have to increase the amount of multi-disciplinary working that’s going on.’
Cant also said that demand on hospital eye services has been exacerbated by the pandemic. ‘Optometrists should be recognised as key to solving this problem as they have the skills and infrastructure to provide collaborative and effective patient care, often closer to home. Many also have independent prescribing and other higher qualifications, which should allow them to work with a greater degree of autonomy to provide advanced practice and peer support,’ she added.
Allaying fears
In order for new ways of working to be implemented effectively,
Cant said that collaborative, multidisciplinary working across primary and secondary eye care that is underpinned with good clinical governance, will be key to delivering effective services.
The two professional bodies have partnered in order to allay the fears patients may have about attending appointments and have been working with hospital eye units, charities and NHS England to achieve this. A joint vision for delivering patient eye care services during and beyond Covid-19 was launched by the CoO and RCOphth in August as pandemic measures continued to impact eye care services.
‘This will build on the new ways of working that have been developed during the pandemic, so that we can better prevent avoidable sight loss and improve outcomes for patients. The vision for England is the first joint vision to be published and we are working to develop similar frameworks for Scotland, Wales and Northern Ireland,’ Cant explained.
The joint vision has been developed to support workforces in meeting the needs of all patients, improving patient care and outcomes during and beyond the pandemic. It outlined that current measures in place to protect people from acquiring Covid-19 will undoubtedly lead to vision loss that in normal circumstances, would have been preventable, as additional safety measures will further reduce capacity.
Principles of care
Crucially, the joint vision focuses on multidisciplinary working and integrated eye care between hospital eye services, community settings and primary care optometry. It is designed to pave
the way for a safer and more sustainable eye care service for
the long term.
Cant said that the joint vision is based on three principles in order to ensure that patients are prioritised based on their clinical need and can receive accessible, appropriate care. ‘This should be provided by a multidisciplinary team of professionals across primary, community and secondary eye care,’ she added.
Chang said that the first principle is to balance the risk of sight loss with the risk of catching Covid-19. ‘It’s very important to ensure that patients with urgent conditions that absolutely need to be seen in hospital or in the optometry service, are seen. So, part of this work would be to risk stratifying referrals in order to prioritise and make sure that patients with urgent eye conditions are seen in a timely manner,’ he explained.
The second principle outlined that patients should have direct contact with a clinician capable of making appropriate management decisions, supported by a senior clinician where needed. The third principle said that all pathways should be underpinned by the highest standards of optometry and ophthalmology clinical governance, applied equitably.
Chang added that it is not just about seeing patients in hospital, and that optometrists have a major role to play in the community. ‘It’s important that the patients are seen in the appropriate setting by the appropriately trained professional. The other important aspect is to agree pathways, so that patients and professionals know where and by whom a patient should be seen, so their condition can be managed in the most effective way,’ Chang added.
A fresh start
The joint vision created by the two Colleges was designed to build on schemes such as Covid-19 Urgent and Eye Care Services (Cues) and to develop similar co-ordinated services for more eye conditions.
Cues, Chang said, was an important step to increase capacity in order to see patients with conditions that might not wait until the pandemic was safer to be seen. ‘I think we have started to embrace more joint working and the collaboration and integration of community and secondary eye care services is something that we need to pursue so that we get better integration and collaboration becomes the norm in the near future,’ he added.
In hospital eye clinics and community optometry practices, virtual consultations have been used more, which means patients feel safer as they do not have to go to a hospital where Covid-19 infection rates might be higher. ‘It seems to work well for certain conditions using this virtual technology,’ Chang said.
‘The one positive out of Covid-19 is the fact that it allowed eye care services to reset and make a fresh start by looking at collaborative working and how we can design pathways that better suit the patient. It is all about transforming the way we work and increasing capacity through multidisciplinary team working,’ he concluded.
