The Consulting Room: The evolution of macular management
Nigel Kirkpatrick considers the recovery of eye surgery services since the pandemic
Author: Nigel Kirkpatrick
I have been a retinal specialist for many years and there have been a few milestones along the way when seismic shifts in our approach to disease have taken place. As a fresh-faced young consultant, I remember talking to a colleague who had just returned from a European meeting in 2005. This is when I first heard that Bevacizumab (Avastin), an anti-cancer drug, had a beneficial effect on patients with wet age-related macular degeneration (AMD). Early reports showed reduced macular swelling and vision was often stabilised. In theory, the molecule was too large to have any effective retinal penetration, but the clinical results in AMD patients was profound. For the first time, we had seen a new treatment allow preservation of vision in AMD without the need for highly invasive surgery or use of destructive lasers. It was a total game-changer.
At almost the same time, the advent of optical coherence tomography (OCT) imaging came about. The grainy false colour images looking at macula slices were incredible and represented histological level detail of the retina and retinal pigment epithelium (RPE) in living patients. Usually a bit sceptical about new technology and its uses, I was blown away and could not wait to get my hands on such a brilliant machine.
Almost 20 years later, we have sophisticated machines using cutting-edge technology that provide images of our patients at 10-micron level detail and look at aspects of retinal physiology. The pharmaceutical world has stepped up too with many anti-VEGF drugs and other agents used in myriad ways to maximise patient benefit and stabilisation of the common ‘leaky’ macular diseases, such as wet AMD, retinal vein occlusion and diabetic macula oedema.
In my experience of retinal medicine and surgery practice, the new era allowed increased diagnostic precision, earlier intervention, better defined outcomes and resulted in scores of patients who did not have to deal with massive sight loss. It was completely transformational.
A new era
The consequences of the anti-VEGF era have also been notable in terms of healthcare provision and access to timely treatment. For wet AMD, we know that early intervention is key to keeping useful vision and a national standard of referral to treatment within 14 days remains very important. In current practice, patients always have investigation of their healthy fellow eyes as routine and from this we know that if AMD starts in these asymptomatic eyes, they are more likely to keep better long-term vision by preventing macular damage.
In optometry, the rollout of new technology has been impressive. Most optometrists have access to OCT scanning and have rapidly built up a skillset to recognise macular problems in their daily practice. Patients who do not achieve good visual acuity with refraction need investigation of any possible causes and OCT scanning is almost a reflex response in the work up to determine possible causes. In routine cataract pre-op clinics, we use 100% OCT screening to help us accurately predict visual outcomes for patients. We often find epi-retinal, intra-retinal or RPE problems that will allow us to tailor our conversations with patients to help manage their condition. The bar to provide an OCT image is very low indeed.
Across the country, the NHS has set up a variety of schemes to allow rapid access to macula services with the aim of providing timely treatment for wet AMD. It seems obvious that an early OCT scan alongside a colour fundus photo is the key step to making an accurate diagnosis in such cases. This allows rapid referral and immediate treatment. For those with less urgent problems, eg early epi-retinal membrane or dry RPE changes, a more routine referral pathway can be used, and this ensures that the rapid route remains uncluttered, solely focused on the neediest patients. This is a simple concept.
In the NHS, this idea of accurate diagnostics and rapid access to care can be derailed into an administrative jungle. How do we set up urgent care in optometry? Is this part of a sight test? Who funds an expensive machine? Who reads the images? Do we set up an intermediate staging clinic to ‘refine’ referrals? Shall we make it different in every region? At many levels, the situation becomes confused, drawn out, more expensive and more difficult to navigate. The result is delay, expense, postcode anomalies and reduced access for patients. As professionals, we must lead these discussions remembering we need to deliver more care despite limited resources.
The past 20 years of macular advances have been fascinating. When it all boils down to helping patients maintain their vision and independence, we have all been on the front line with them and I suspect it is why many of us carry on with such enthusiasm. It has been a fantastic journey but there will always be a long way to run.
- Nigel Kirkpatrick is a consultant ophthalmologist and medical director of Newmedica.