With the NHS under strain and an ageing population meaning this is only going in one direction, the optometric profession is well placed to help ensure ophthalmology is seeing the patients most at need. This was one message of Thea Pharmaceuticals’ Eye Health Conference, a one-day event held at the Royal College of Physicians in early October.
Lids
Teifi James, consultant ophthalmic surgeon gave the keynote lecture on ‘Blinking eyelids’ which drew heavily on case studies of patients attending his clinic, with conditions including thyroid eye disease, where male patients could be mistaken for being aggressive, exposure keratitis and lid margin conditions.
James also showed a case of demodex infestation, presenting with the characteristic cylindrical ‘ruffs’ at the lash bases. He also questioned whether demodex was a causal agent in acne rosacea, something that would be investigated in the next five years.
Lessons from Wales
The challenge of delivering eye care at a time of austerity was covered by Dr Barbara Ryan, chief optometric adviser, Wales. In her lecture, ‘Too many eyes and not enough time – delivering eye care to the nation’, she described the impact of sight loss as major, with 43 per cent experiencing clinical depression, similar to that for people diagnosed with cancer set to undergo chemotherapy. (Optician is publishing CET articles on this study, starting next week.)
There were direct healthcare costs of £3bn associated with impaired vision, and indirect costs of £25bn. ‘We want to prevent sight loss and help the health of the nation too,’ she said. ‘You judge society on the way it treats its most vulnerable.’
The incidence of sight loss was actually falling in Wales, as a result of treatments for wet AMD and diabetic retinal screening. However, there was an increase in the numbers of low vision and lower levels of impairment.
‘Demand is rocketing and there isn’t enough money now, so how will we cope? We want to save patients but can only stretch the finances so far. We are facing a big problem – there are more and better treatments but services are not coping.’
One solution recommended by Professor Mark Drakeford, Welsh Government minister for health and social services, was moving people away from tertiary and secondary care to be seen by primary care.
Dr Barbara Ryan, chief optometric adviser, Wales, and ‘friend’
Another option was to see whether patients could do something for themselves. ‘The NHS is trying to give that message – go to see your pharmacist or optometrist,’ said Ryan. ‘There is a recognition that you need to use primary care to do more complex work than they have been doing and that’s part of the solution in Europe too.’ In Wales there had been an effort to educate the public that high street practices were part of the NHS as well as private businesses.
Among pilot schemes, AMD patients in Brecon, instead of travelling to England, were being injected with Lucentis by optometrists, with an ophthalmologist next door. In another scheme optometrists were assessing and a nurse injecting, while in Newport all AMD patients were seen in community practice with follow up OCT scans.
Ryan recommended practitioners embrace change and technology, be clear they are part of the NHS and part of the solution by getting involved in shared-care schemes and practising at the top of their licence.
Primary care role
Consultant ophthalmic surgeon Laura Crawley gave guidance on suitable referrals in her lecture: ‘Life at the receiving end – referrals into ophthalmology’, using cases at Imperial College. She referenced the work being carried out in Wales, that was not being done in London, and gave practitioners pointers in working to help each other do better.
Crawley said that large numbers who attended walk-in clinics, and were prepared to wait for four hours to be seen, could have been dealt with in optometry. Seventy-seven per cent were self-referrals and had not seen anyone else. Yet community optometry was a good place to see patients with red eye and the public needed to be re-educated.
Thea’s head of medical affairs, Professor Christine Purslow, spoke about communication, and how to get patients to follow advice. ‘Communication is key but in reality patients don’t take an awful lot in,’ she said. ‘Medical and prescribing literature shows that after a short time many people aren’t doing what we ask them to do.’
Purslow said practitioners needed to find their own way to communicate and diet, lifestyle and nutrition played a part in prudent self-care. Highlighting the case of a solicitor who sued when he discovered he had not been recommended the latest silicone hydrogel contact lenses, she suggested that not giving smoking and lifestyle advice could have similar consequences.
‘If more of us tackled smoking, we would have a big impact on eye disease and eye health. With cataract we don’t wait to see lens changes before we recommend sunglasses. We wait to see drusen and then we talk about lifestyle. We should talk to younger people with healthy eyes about lifestyle and nutrition. There is a lot of evidence and no one will contradict the idea that smoking is bad for your eyes,’ she said. ‘The big message is tackle smoking.’
Nutrition
Dietitian Helen Bond covered ‘Vitamin D, deficiency and its relevance to eye health’, explaining that it was a major issue. ‘Sugar is the public enemy at the moment, with added sugar equating to 15 teaspoons a day, leading to excess calories and weight gain, which could have a detrimental effect on eye health,’ she said.
Another concern is vitamin D deficiency. The Scientific Advisory Committee on Nutrition (SCAN) report (July 2016) examined vitamin D and concluded that vitamin D levels were simply not enough in the summer months to carry over to the winter months. Important for muscles and bones, the level should not be allowed to drop below 25nmol/L at any time of the year.
Supplementation improved muscle strength and function in young people and adults and reduced fall risks in community-dwelling adults over 50. While it did not reduce fracture risk, vitamin D was important during pregnancy. There was also a need for more evidence to draw conclusions about non-musculoskeletal health outcomes, including AMD.
In one recent study, vitamin D deficiency was described as ‘pandemic’ across Europe, with prevalence rates that were a matter of concern – 13 per cent of 55,844 European citizens had low serum concentrations, rising to 17.7 per cent in winter. Rates were not as high in the more northerly latitude countries such as Norway, Iceland, and Finland, despite fewer hours of sunlight. The Finns eat more oily fish and fortification of fat spreads and milk is mandatory, she said.
Other at-risk groups included the overweight and obese, including post-bariatric surgery patients. ‘There is also an issue with statins. Seven million people take them but you need cholesterol to manufacture vitamin D and people taking statins report muscle weakness and leg pains,’ she added.
Looking at AMD prevention, she pointed out that, post AREDS, European research on the opinion and use of micronutrition for AMD placed lutein top of the list of importance, with vitamin D at the bottom, ranked a lowly three per cent in Britain.
Observational studies suggested vitamin D may have inhibitory actions on angiogenesis and immunological changes and anti-inflammatory effects. A 2011 report revealed a genetic link between vitamin D metabolism and AMD risk. However, intervention studies were required.
With 13 per cent of European adults and 20 per cent in the UK having vitamin D deficiency, prevention was a public health priority.
Glaucoma
James Tildsey, an ophthalmologist at Royal Derby Hospital highlighted the role of optometric involvement in glaucoma care in his lecture: ‘Glaucoma treatment – what you need to know in primary care’. The condition was responsible for 15 per cent of blindness in the UK and constituted a major part of the workload of ophthalmologists, with 25 per cent follow up and 15 per cent of new referrals.
In terms of the UK population, up to three per cent of over-40s were estimated to have glaucoma – 715,500 people, however, only one per cent were diagnosed, a figure of 238,500.
‘There are just 500 consultants, so only seeing these patients we still would struggle. The impact is huge,’ he said.
He described glaucoma as a disease of the optic nerve, not raised intraocular pressure. The fixation on IOP was because it was the only thing they could manipulate. ‘From our patient’s point of view we need to stop them losing vision rather than achieve a specific pressure,’ he said, adding that patients lost heart if they could not achieve a certain pressure.
The technique that could differentiate between the different glaucomas was gonioscopy. ‘It tells you a lot and is preferential to Van Herrick and Redmond Smith techniques for assessing angles. Start using gonio – it’s difficult to begin with but the more you use it the better.’
Tildsey gave a detailed session on treatment options, highlighting recent developments such as Tiopex gel and the Triggerfish contact lens, fitted with sensors to monitor pressure through the day and pick up spikes that indicate the need for surgery.