Visus writes: Questioning OCT policy
I recently saw this interesting letter to an ex/potential returning patient.
‘My receptionist has passed on the contents of the phone call from this morning. You requested an optical coherence tomography (OCT) which was suggested by your consultant rheumatologist. You were unhappy that we would be unable to undertake an OCT alone and that there would be a charge for the examination we would need to conduct. It is easier if I answer this in a letter. I am aware that you have been on Hydroxychloroquine (HCQ) therapy for some years, which predates your visit here in 2014 where it was recorded in your history.
At that examination our optometrist conducted a sight test and extended dilated examination including colour vision, visual fields and OCT as was felt appropriate. At that time we reported to your GP and consultant. We recommended annual re-examination and you received several recall letters, but you have not been back to see us since. Of course, this is your free choice.
‘HCQ has been known to have potential toxic ocular side effects for many years. That is why visual acuity (VA), colour vision, visual fields (VF) and optical coherence tomography (OCT) was indicated and undertaken in 2014. Although open to clinical opinion, at that time we recommended such a battery of tests be undertaken annually as a standard procedure to safeguard eye health. These tests do not form part of the NHS Sight Test which is why there was a charge, as indeed there is for any non-NHS clinical service.
‘It is only recently, within the past two years, that medical opinion has changed and guidelines have emerged as the incidence of HCQ induced retinopathy now appears to be more common than was first thought. Therefore, it is only now that other medical guidance (from rheumatology) has caught up with the need for screening and physicians in rheumatology have been recommending testing. Prior to this we did the examinations on an ad hoc basis on patient request, reporting to GP and hospital accordingly. We are aware that this is not standard practice in community optometry and does not form part of a General Ophthalmic Services NHS Sight Test, nor indeed a private eye examination. On the basis of recent literature we feel these tests should include VA, colour vision, VF and OCT but also add fundus autofluoresence (FAF). There is ambiguity as to how often.
‘Since the original recommendation was made by the British Society of Rheumatology, guidelines have been produced by the Royal College of Ophthal-mologists. The NHS and clinical commissioning groups have been grappling with trying to establish a screening programme in each area. I can assure you that [redacted] Clinical Commissioning Group is indeed intending to establish such a programme under the leadership of the local medical retinal ophthalmologist. This is likely to involve optometry practices with medical retina qualified optometrists who have access to OCT and FAF. It will be entirely separate to NHS Sight Testing which can carry on with one’s own optometrist but not all optometrists (opticians) will be able to offer this. It is likely that the NHS will pay for this service but there is no timeframe.
‘Until then patients are likely to be asked to seek their own examination. This is because the risk is not deemed great enough to merit referral into outpatient ophthalmology given other pressures on this speciality. We are pleased to offer a suitable examination protocol for HCQ screening (including reporting to your consultant) entirely separate to NHS Sight Testing. We have no eternal source of funding for this service and the training and equipment levels exceed that which most optical practices are prepared to invest. As such there is a charge and at present that is £[redacted]. It will involve about 40 minutes of testing and the pupils will need to be dilated, which means that one should not drive for a couple of hours post testing.
‘Please let us know if you wish to avail yourself of this service or alternatively please ask your own optometrist. We are, for medico-legal reasons unable to offer an “OCT only” service.’
I suspect that the above is commonplace around the UK and there will be one or two patients miffed that their own optometrist is not offering such a service, or if they find one who is, that there is a charge. Optometry has a clear potential to be capable of delivering such a service, with over 1,000 OCTs in primary care and well-established medical retina courses oversubscribed. Despite this, the Royal College of Ophthalmologists determined its guidelines via a committee bereft of any community optometric input.
Further, despite a public consultation it is clear that neither the professional body for optometry (College of Optometrists), nor the indemnity bodies (AOP, FODO) provided any response, still fewer insisted on being part of the process. The guidelines, like others produced in this manner, demand that it be ophthalmology led. While the guidance does not shut the door on optometric involvement and is open to a data collection and virtual clinic management, optometry is once again systematically excluded from planning and our professional bodies seem uninterested in stating our case. Given the envisaged role is to detect departure from normality and the only treatment is ceasing the medication I would suggest that imposing the necessity of an ophthalmology lead is unnecessary.