Niall O’Kane is a therapeutic optometrist with a private practice in Strood, Kent. Optician readers may already be familiar with his activities as he has been a major advocate in developing services to support the resource-constrained hospital eye service in areas such as AMD and macular oedema management. His practice was one of the first optometry centres to incorporate the Heidelberg Spectralis OCT and this has proved instrumental in his ability to liaise with ophthalmology. His enthusiasm in establishing optometry support services has been widely reported and led to his winning and award a few years back for his excellence in ophthalmology.
The challenge
Conditions such as AMD and cystoid macular oedema (CMO) and the introduction of new treatments are ‘swamping’ eye departments with their finite resource and capacity, O’Kane explained. ‘Departments need to be more creative in their planning if they are to meet treatment times.’ To address this, O’Kane underlines the importance of a mind shift for consultant ophthalmologists, such that they may embrace the value of allied professionals and be willing to train and accredit them. Despite there being no national criteria or training for community AMD clinics, non-medical decision-makers and medical injectors, working in clinics outside the hospital or GP practice, developed in liaison with willing community optometrists, provide the necessary required resource. And as O’Kane has shown, this can be a very successful solution.
Required skills
‘It is important to show a suitable level of competence and not to refer everything you see,’ O’Kane continued. ‘You need a desire to learn more, show an ability and willingness to monitor things, make appropriate decisions and accept the consequences. I am not a data recorder but a clinical decision-maker,’ he clarified.
Niall O’Kane Optometrists was instrumental in the development of a Community Age-Related Macula Scheme (CAMS), training for which began in June 2010 and the pilot for which ran between October that year through to April 2011.
Training involved undertaking eight sessions in the hospital clinic, each covering all aspects from the initial greeting, assessments, through to discussion of results and scheduling next assessment. For the final assessment, 40 OCT images were interpreted as either inactive or reactivated and my results were compared with those of two consultant ophthalmologists to confirm consenting views.’
Hypo reflective voids in the inner nuclear layer and the outer nuclear layer, consistent with CMO
A working scheme
Once training is sufficiently complete, patient data entered into Excel in the hospital along with OCT images can be sent to the practice via NHS.net. O’Kane completes the spreadsheet records and returns them to the hospital along with relevant OCT images in cases of reactivation of retinal lesions.
Patients are scheduled for three monthly appointments, then three bimonthly and then three separated by three months. With no further active disease, patients are then returned to the hospital for their final discharge from the scheme.
Important elements of assessment include subjective acuity, intraocular pressure, OCT and digital photography and binocular indirect fundoscopy. A follow-up appointment may then be confirmed.
‘I have 47 patients currently under my care, and in June 2014 patients started attending at a second practice.’ A third practice came on board in September 2014.
As well as the 47 under review, from October 2010 there were 76 who had been returned to hospital, 22 discharged, and 11 deceased (‘unfortunately, patients do die when under community care systems’). In all, 156 patients have been cared for via a total of 748 appointments.
Macular cross section showing hypo reflective voids in the inner nuclear layer and the outer nuclear layer, consistent with CMO
‘Reactivation is not a failure,’ O’Kane is keen to point out. ‘Each community appointment frees one in the hospital better used for essential treatment.’ Such a scheme makes much more effective use of resources (so allowing better and easier access to patient care), is an excellent use of optometrist practice equipment and skillset, and offers a challenging, rewarding and practice profile building opportunity. ‘It does,’ O’Kane concludes, ‘take time to build both your own confidence and patient numbers.’
Read more
Technology in community practice - part 1
Technology in community practice - part 2
Technology in community practice part 3
Further information on OCT at heidelbergengineering.com.