Schemes for the optometric management of acute eye disease in Wales have been running since 2001, with the Primary Eyecare Acute Referral Service (PEARS) scheme in the Bro Taf health authority area being the first. This was helped along by devolution and the transfer of health care powers to the Welsh Assembly, and also by the small scale of Welsh health authorities at the time. Prior to the introduction of the service, the frontline for acute eye care in Wales involved general practitioners. It has been reported that approximately 2% of GP consultations are eye related,1 and these consultations are largely conducted by the use of history taking and examination with non-specialist equipment. It has also been noted that, in the main, GPs receive inadequate ophthalmology training.2 The aims of the initial service were to reduce unnecessary referrals to secondary care, provide good quality care close to home, to improve the accuracy of referrals and to improve relationships within primary care and between primary and secondary care. The initial scheme proved successful with a reported 76% reduction in the number of acute referrals.3 This led to the scheme being rolled out across Wales in 2003.
The scheme developed over the following decade to today’s incarnation, the Eye Health Examinations Wales (EHEW) scheme, which was introduced in 2013, and which continues to evolve. This comprises the PEARS examination element, as well as the long-established Wales Eye Health Examination (WEHE) – a Welsh government funded extended examination for those at higher risk of ocular disease (for example parents of Black African ethnicity) or those that would find sight loss a particular burden (such as those with hearing impairment).
In order to provide these services, optometrists currently complete online lectures with multiple choice questions, and attend an objective structured clinical examination. To maintain registration, they must attend ongoing reaccreditation events in a three-year cycle.
Patients with acute eye problems usually self-refer (84%5) or are referred by their GP to accredited optometric practitioners. They must be offered an appointment within 24 hours, or arrangements should be made by the practice for the patient to be seen by another EHEW accredited optometrist within this timeframe. Professional judgement is exercised by the optometrist as to the extent of the examination, and is determined by the patient’s reason for visit. Anterior examination should be by slit lamp and posterior examination by binocular indirect ophthalmoscopy (slit lamp BIO) where possible. Tonometry should always be by a contact applanation method unless contraindicated. Practitioners may choose to recall the patient at a later date for follow-up examinations (for example to monitor how conditions are responding to the treatment advised). Payment for this service has a banded structure. For acute presentations, practices are currently awarded £60 (Band 1), while for follow-up examinations practices receive £20 (Band 3). Only one of each of these examination payments may be claimed for a particular clinical issue each year. If further investigations, such as repeat IOPs and visual fields for suspect glaucoma, or dilation for referral into the HES for cataract surgery are required, this is classed as a Band 2 (£40).
Recent guidelines by the College of Optometrists and Royal College of Ophthalmologists have recommended to commissioners of eye care that those diagnosing acute eye conditions have access to and can use a slit lamp, and must ensure there is adequate scope to provide same or next day primary care appointments to take the burden from secondary care.6 This scheme fits nicely with these recommendations.
The scheme has been a great success overall in meeting its initial aims. A recent study by McAlinden and colleagues looked at the service and found that 75% of patients are managed by the optometrist, with only 18% referred to secondary care.5 87% of patients are less than five miles away from a practice offering the service, and even in more remote locations the distance is generally short. For example, Powys is the most sparsely populated county in Wales and the average distance travelled from was six miles (though it is worth noting that this is from a service evaluation from 2006 and the proportion of accredited optometrists has since increased).7 The scheme is popular with patients with a survey finding all patients to be satisfied, 95% being very satisfied.2
While there appears to be good public awareness of the service in Wales, it is interesting to note that, according to the GOC’s Public Perceptions Survey 2016, only 26% of Welsh patients would choose an optometrist if they ‘woke up tomorrow with an eye problem’, while almost twice as many (48%) would think of seeing their GP.8 While the first figure is the second highest in the UK after Scotland (31% of the Scottish public would see an optometrist) there is no doubt this situation could and should be improved. Also, there still seems to be a lower than expected use of the service by GPs. Ideally patients should be directed to optometry practices by their GP surgery in the first instance, but often patients are having a consultation with their GP then being advised an examination at an optometry practice resulting in a duplication of patient and chair time. This has been highlighted as an area of improvement.5 Other problems include the relatively low uptake of therapeutic optometrist qualifications in Wales (approximately 1% of the workforce as compared to 3% in Northern Ireland, 9% in England and 14% in Scotland),9,10 no access to prescribing pads for independent prescriber optometrists (and limitations on the availability of free prescriptions. Practitioners often find themselves having to refer back to the patient’s GP or secondary care for problems which could be managed in-practice. Despite the ability to write a signed order for certain medicines, it is not unheard of for patients to ask to be referred to their GP for a NHS prescription for chloramphenicol or some other medication. It is hoped more optometrists in Wales will be encouraged to take up therapeutic qualifications, with local health boards funding a number of places. Optometry Wales (the representative body for Welsh optometrists and dispensing opticians) have also released a position statement encouraging the provision of prescribing pads to optometrists.
The following case studies are based on real examples of when this service has worked well:
Case study 1
A 55-year-old female office worker was booked in for an acute EHEW examination after ringing her GP for an appointment and being advised to contact us. She had a two-day history of irritable eyes and itchy eyelids, which were particularly bad on waking, with no other symptoms, general health complaints, ocular history nor family history. She had recently moved to the area and had been told by her last optometrist some years ago that she had blepharitis and was using Blephaclean occasionally and Celluvisc 0.5% tid. Examination revealed bilateral blepharitis (Efron scale grade 3.5 right and left with crusting and lid margin hyperaemia) and meibomian gland dysfunction (grade 3 right and left). Corneas showed mild inferior punctate epithelial erosions. Break up times using sodium fluorescein were low at three seconds in each eye. None of the practitioners in the practice were independent prescribers.
It was decided the patient should be more persistent and regular with her lid hygiene. She was recommended warm compresses using an Eyebag twice a day for 10 minutes and to continue with lid hygiene measures. She liked the convenience of the commercially available product she was already intermittently using for her blepharitis so was advised to use that twice a day, and to use her carmellose sodium four times a day. Environmental factors affecting dry eye, such as taking regular breaks from the computer, staying hydrated and ensuring a good intake of omega 3 (either through diet or supplementation) were also discussed. Written material was given and the patient was signposted to reliable online resources.
She was followed up a month later and found to have a slight improvement in her symptoms but still reported slightly dry and itchy eyelids. Examination revealed an improved clinical picture but still significant anterior and posterior blepharitis. The patient was keen to try anything to improve her symptoms so oral antibiotics were suggested. The patient’s GP was telephoned that afternoon and she agreed to prescribe doxycycline 100mg od for one month. She was further followed up a month later and signs and symptoms had almost completely resolved. Reinforcement of the importance of compliance to the management regimen described above (minus the systemic tetracycline) was given.
Comment: While it would have been more convenient for the patient to have been given a prescription at the time of the consultation, this case shows that good relationships built with local general practitioners aid good patient care, and allow examination of a problem using specialist equipment close to home, preventing the patient from needing to be seen in costlier secondary care clinics and duplication of appointments in optometry and general practice settings.
Case study 2
A farmer presented to a rural practice with a sore right eye. He had been working on a piece of machinery without safety goggles in the morning and felt something enter his eye. He tried washing it under the tap but the pain had progressively worsened throughout the day. Slit lamp examination revealed a 2mm metal foreign body penetrating the cornea to the level of the anterior stroma. Despite this, acuity was 6/7.5 right and left, with no evidence of anterior chamber inflammation. The foreign body was removed using a 23-gauge hypodermic needle but a rust ring remained which was removed using an Alger Brush. The wound was assessed and patient advised gutt. chloramphenicol 0.5% qds for five days as a prophylactic measure along with oral analgesics. A signed order was written for the chloramphenicol and the patient obtained this from the pharmacy next door. The patient was followed up twice over the following week until resolution, all that remained was a small scar. A report of the outcome was sent to his GP after each visit.
Comment: This case highlights the benefits of providing such a service in more rural areas, delivering good quality care close to the patient’s home. This patient lived more than 40 minutes’ drive from the nearest eye casualty service but he lived five minutes from the optometry practice, so found access to care most convenient. The scheme provided the funding to keep the patient within primary care, eliminating one unnecessary referral, and also helped strengthen relationships between pharmacy and GP.
While there is always room for improvement, over the past 13 years the EHEW service has no doubt improved patient care in many ways and helped develop the status of the optometric profession in Wales. It will be interesting to see what the next decades bring in improving the care of acute eye conditions in Wales and across the rest of the UK.
Ceri Probert is an optometrist who practises in south Wales.
Reference
1 Sheldrick JH, Vernon SA, Wilson A. Study of diagnostic accord between general-practitioners and an ophthalmologist. British Medical Journal 1992;304(6834):1,096-1,098.
2 Sheen NJL, Fone D, Phillips CJ, Sparrow JM, Pointer JS, Wild JM. Novel optometrist-led all Wales primary eye-care services: evaluation of a prospective case series. British Journal of Ophthalmology 2009;93(4):435-438.
3 Arbuthnot T. Practical experience of a shared care acute referral scheme. Optician 25 February 2002:22-25.
4 Welsh Government. Eye Health Examination Wales (EHEW) service. A clinical manual with protocols. 10th ed 2016. p 54.
5 McAlinden C, Corson H, Sheen NJL, Garwood P. Demogra-phics, referral patterns and management of patients accessing the Welsh Eye Care Service. Eye and Vision 2016;3(14).
6 College of Optometrists, Royal College of Ophthalmologists. Commissioning better eye care: urgent eye care. 2013.
7 Sheen NJL. Evaluation of the Primary Eyecare Acute Referral Scheme (PEARS) and the Welsh Eye Health Examination (WEHE). Welsh Government; 2006.
8 General Optical Council. Public Perceptions Survey June 2016. General Optical Council; 2016.
9 College of Optometrists. Optical Workforce Survey – full report. College of Optometrists; 2016.
10 Personal communication with Robert Mannall, GOC Information Governance (email 23 September 2016).