1. Ophthalmology Update 2017 Mr. S. Sivakumar
FRCS, MS, DO, PG Certificate in Medical Education, MBA
Associate Specialist & SAS Lead in Ophthalmology
SAS Clinical Tutor
Heart of England NHS Foundation Trust
Honorary Senior Lecturer
School of Life & Health Sciences
Aston University, Birmingham

2. Service
Cataract Macular degeneration Diabetic retinopathy Glaucoma

3. Cataract
One stop cataract clinic listing and biometry Day case surgery Nurse Post op – Listing for other eye Doctor clinic

4. Glaucoma Visual Fields & clinic Diagnosis & Management Follow up
Doctor/glaucoma nurse
GMU

5. Macular Diseases Retinopathies which can affect the macular are
Age-related macular degeneration (wet and dry type)1
Diabetic macular oedema2
Macular hole3
Epiretinal membrane4
Central serous chorioretinopathy5
High myopia macular degeneration6
Idiopathic CNV7
Idiopathic polypoidal choroidal vasculopathy8
Of these retinopathies, AMD is the leading cause of certified visual loss in England and Wales.9
Two subgroups of AMD are classically distinguished, atrophic or geographic atrophy (dry AMD) and Exudative or neovascular (Wet AMD)
Macular Diseases
There are many retinopathies which affect the macula. However of these AMD is the leading cause of certified visual loss in England and Wales
Penfold P,, Prog Retin Eye Res May;20(3):
Pournaras CJ et al, Semin Ophthalmol Jun;15(2):100-7.
Cleasby GW, Am J Ophthalmol May;81(5):590-9.
RNIB 2012 Diabetes
Schatz h et al Ophthalmology Jan;99(1):63-7.
Ciardella AP, Surv Ophthalmol Jan-Feb;49(1):25-37.
Cavallerano AA et al, J Am Optom Assoc Dec; 65(12):845-54
Silva R. Ophthalmologica. 2012;228(4):
Bunce C, et al. Eye (Lond) 2010;24(11):

6. Exaggeration of the 'normal' ageing process characterized by discrete yellow spots at the macula (Drusen) and pigmentary changes of the RPE

7. Pathology Drusen – a hallmark of AMD Hard drusen: Soft drusen:
Undigested cellular debris from degeneration of RPE cells as part of normal ageing process accumulates as ‘drusen’1,2
Yellow/white material that builds up between the RPE and Bruch’s membrane1,2
Hard drusen:
Small, hard, solid deposits, more closely associated with dry AMD2,3
Soft drusen:
Larger soft deposits, more closely associated with wet AMD2,3
Drusen may remain unchanged for years without causing sight loss2
95% of elderly patients have a small number of drusen1
Nowak JZ. Pharmacol Rep 2006;58(3):353–363
Jager RD et al. N Engl J Med 2008;358(24):2606–2617;
Fine SL, N Engl J Med Feb 17;342(7):

8. AMD Prevalence / Incidence
Age-related macular degeneration (AMD) is the leading cause of certified visual loss in England and Wales.1
The RNIB estimates that 500,000 people in the UK suffer from the condition, 40% of whom are over the age of 75.2
214,000 have sufficient visual impairment for registration as partially sighted or blind3
Prevalence rises with age4
Early AMD: 8% of people aged 43 to 54 years vs. 30% of those 75 years+5
Advanced AMD: 0.1% of people aged 43 to 54 years vs. 7.1% of those 75 years+5
The recent improvements in therapy have had a positive impact on visual impairment and blindness due to AMD 6,7
AMD Prevalence / Incidence
Age-related macular degeneration (AMD) is the leading cause of irreversible blindness among people over 55 years of age in the developed world.
In the UK, AMD is a growing concern. Nearly half a million people suffer from some form of the disease and half of these have experienced visual impairment severe enough to be registered as partially sighted or legally blind.
The prevalence of AMD rises with age.
Bunce C et al. Eye (Lond) 2010;24(11):
Klein R et al Ophthalmol 1992, 99:
RNIB AMD Campaign accessed March 2013
Klein R, Ophthalmology Jun;99(6):
Minassian DC et al. Br J Ophthalmol Oct;95(10):
Campbel JP et al. Arch Ophthalmol Jun;130(6):794-5.
Owen CG et al. Br J Ophthalmol 2003, 87:

9. Dry Dry vs Wet AMD Dry AMD Also known as non-exudative, geographic1
Pathophysiology: drusen related; end stage geographic atrophy1
More common form (80%)2
Slow insidious disease progression (20% of severe AMD related vision loss)1
Treatments: Limited - lifestyle advice or ocular vitamins
Wet AMD
Also known as neovascular, exudative1
Pathophysiology: VEGF mediated choroidal neovascularisation; end stage disciform scar
Less common form (20%)2
Rapid, severe vision loss (80% of severe AMD related vision loss)1
Treatments: Available
Dry AMD vs. Wet AMD
Two subgroups of AMD are classically distinguished - Dry AMD, known as non-exudative, geographic and Wet AMD, known as neovascular, exudative. These two forms of the disease can be distinguished from each other on a number of factors
Mitchell J, Bradley C. Accessed March 2013;
Penfold PL,. Prog Retin Eye Res May;20(3):
Nowak JZ. Pharmacol Rep 2006; 58 (3):353 – 363;

10. Decreased visual acuity
Symptoms of Dry AMD
Decreased visual acuity
Early AMD vision loss is generally mild and often asymptomatic
Symptoms may include1
Distorted vision
Loss of visual acuity
Loss of contrast sensitivity
Abnormal dark adaptation
Progression of dry AMD1
Mild occasional metamorphopsia
Gradual vision loss over months/years
Central/ paracentral scotomas
Decreased contrast sensitivity
Symptoms of Dry AMD
Vision loss in early AMD is not common but if it does occur, it is generally mild. Symptoms may include a loss of visual acuity and contrast sensitivity and an abnormal dark adaptation.
Progression of dry AMD can produce symptoms that are more severe. These include metamorphopsia (visual distortion) and central/paracentral scotomas (blind spots). Patients normally maintain enough vision to be ambulatory as the peripheral visual field around the central scotoma remains intact.
Progression of dry AMD generally causes vision loss over months or years.
Jager RD et al. N Engl J Med 2008;358(24):2606–2617. 10

12. Wet AMD
10-15% of cases, but is responsible for around 80% of severe vision loss in AMD1 26,000 to 40,000 new cases a year2,3 Prevalence is increasing with the ageing population4 The WHO has estimated that in % of global blindness due to eye diseases was due to AMD5
Wet AMD Overview
Wet AMD accounts for between 10–15% of cases, but is responsible for around 80% of the severe vision loss associated with AMD. Approximately 26,000 new cases of wet AMD are diagnosed in the UK every year, and its prevalence is increasing as the aged population increases.
Jager RD et al. N Engl J Med 2008; 358 (24):2606 – 2617
NICE Technology Appraisal Guidance TA Accessed April 2013
Owen CG, et al. Br J Ophthalmol doi: /bjophthalmol
Congdon N et al. Arch Ophthalmol 2004; 122 :477 – 485
Vision 2020 WHO public health initiative Accessed April 2013

13. Wet AMD
Can progress rapidly and cause significant visual loss in as little as 3 months1
Untreated, a high proportion of eyes affected will become functionally blind within 2 years2–4
Wet AMD in one eye is associated with an increased probability of development in the other eye5
Early detection and treatment may prevent unnecessary vision loss7
Wet AMD is a treatable disease2,7
Wet AMD
If wet AMD is diagnosed in one eye, the patient will be at increased risk of wet AMD in the second eye. Rapidity of disease progression varies among individuals, from a few months to 3 years, but if left untreated, the majority of eyes affected with wet AMD will become functionally blind within approximately 2 years. Early detection of wet AMD can allow prompt treatment, reducing potential vision loss in these patients.
TAP Report No. 2. Arch Ophthalmol 2001;119:198–2007
Pieramici DJ, Bressler SB. Curr Opinion Ophthalmol 1998;9:38–46
Rosenfeld PJ et al. N Engl J Med 2006;355:1419–1431
MPS Group. Arch Ophthalmol 1997;115:741–747
Gragoudas ES et al. N Engl J Med 2004;351(27):2805–2816
Haddad WM et al. Br J Ophthalmol 2002;86:663–669.
Bressler NM et al. Am J Ophthalmol 1982;93(2):157–163 13

14. Choroidal Neovascularisation and Vision Loss
The term “wet” is a reference to the development of choroidal neovascularisation through the Bruch’s membrane. This is mainly as a result of VEGF-A-stimulated angiogenesis. These abnormal vessels leak fluid and blood into the tissue at the back of the eye, causing damage to the retina. This in turn leads to scar tissue and a large blind spot, which impairs central vision.
Scar tissue (disciform scar)
Nowak JZ. Pharmacol Rep 2006;58(3):353–363. 14

15. Decreased visual acuity
Metamorphopsia
Decreased contrast sensitivity
Central scotoma

18. Wet AMD and Quality of Life1-3
More likely to fall
Charles Bonnet Syndrome
60% reduction in QOL, similar to prostate cancer or catastrophic stroke
60% report anxiety or depression
QoL
Wet AMD and Quality of Life:
AMD predominantly affects central vision, which can have a huge impact on the quality of life of a person with AMD.
The loss of quality of life for patients with wet AMD can be severe. Loss of visual function can produce a decrement in quality of life.
It can severely restrict daily activities and many people with AMD have to rely on someone else to help them. Patients with AMD are significantly more likely to fall and significantly more patients report anxiety and symptoms of depression compared with age-matched controls.
Loss of vision means a loss of independence for many sufferers, leading to residential care. Visually impaired patients make up the majority of people in care homes.
33% of patients report that they are unable or struggle to dress or wash themselves, compared with 24% of people who have suffered stroke or brain injury
Patients with advanced AMD: 4x more likely to need assistance with activities of daily living
Lotery A et al. Br J Ophthalmol 2007;91:1303–1307
Soubrane G et al. Arch Ophthalmol 2007;125:1249–1254;
Mitchell J, Bradley C. Accessed April 2013

19. Anti-VEGF Pathway ORAYA Non-medical retina clinics & VMC
ARMD Pathway – Guidelines
Anti-VEGF Pathway
Optician Referral
Discharge
GP/ Optician
Non-medical retina clinics & VMC
Rapid Access Macular Clinic (RAM)
Nurse does logMAR vision and dilates pupils with Trop1%/PE 2.5%. both eyes. Data input in Medisoft.
OCT scan of both eyes
Doctor consultation - FFA
ANTI-VEGF INJECTIONS-
Ranibizumab/ Aflibercept
MACULAR AND MEDICAL RETINA CLINIC
ORAYA
Referral scanning

20. V M C Pathway Treat/Monitor & Extend/shorten
Lucentis Pathway
Loading dose
3 monthly injections
V M C Pathway Treat/Monitor & Extend/shorten
VIRTUAL CLINIC
Clinician reviews OCT scans and vision within 3 working days. Medisoft data input

21. 1st Year 2nd Year Eylea Pathway TREAT/MONITOR SHORTEN/ EXTEND DURATION
Loading dose
3 monthly injections
2 monthly injections
(Nos: 4 to 7) &
OCT Scan
2nd Year
TREAT/MONITOR
SHORTEN/ EXTEND
DURATION
VIRTUAL CLINIC
Clinician reviews OCT scans and vision within 3 working days. Medisoft data input

22. Diagnosis
History & Visual Acuity Fundus Examination OCT – Ocular Coherence Tomography FFA – Fundus Fluorescein Angiogram

23. Treatment
Intravitreal ant-VEGF injections Ranibizumab Lucentis Aflibercept Eylea Stereotactic Radio Therapy – SRT Oraya -- STAR study

25. Visual Rehabilitation
Low Vision Assessment Low Vision Aids – Magnifier, lighting, CCTV Registration (CVI) – Sight Impaired & Blind

26. Summary
ARMD is the most prevalent maculopathy and the leading cause of certified visual loss in England and Wales
AMD causes significant burden to the economy and the patient/carer
Many pathogenetic risk factors underlie AMD
Severity and progression of wet AMD is dependent on the individual patient
CNV pathology and vision loss mediated through VEGF stimulated angiogenesis
Summary
To summarise the main take home messages from todays presentation
AMD is the most prevalent maculopathy and the leading cause of certified visual loss in England and Wales1
This disease causes significant burden both to the economy and the patient/carer
There are many pathogenetic risk factors which underlie AMD and consequently the severity and progression of wet AMD is very much dependent on the individual patient.
CNV pathology and vision loss mediated through VEGF stimulated angiogenesis
This is a call to action for eye care – AMD needs to be caught early and the disease progression needs to be monitored carefully – can you spot the signs of AMD?

27. Diabetic Retinopathy Diabetic Retinopathy Screening Programme
Retinopathy – R0 R1 R2 R3
Maculopathy – M0 M1

28. Maculopathy – M1 Close observation Focal Argon Laser – stop leakage
Intravitreal injections
Lucentis, Eylea, Ozurdex & Iluvien

29. Retinopathy R2 – Close observation
R3 – Pan Retinal Photocoagulation – PRP
Decrease/destroy the ischaemic stimulus

30. Retinal Vein Occlusion - RVO
CMO
Focal Argon laser
Intravitreal injections
Lucentis, Eylea & Ozurdex
Rubeosis/Rubeotic Glaucoma
Pan Retinal Laser Photocoagulation - PRP

31. Lids & Oculoplasty Lid lesion biopsy
Lumps & bumps – Needs authorisation
Blepharoplasty – affecting visual field (Proof)

32. Discharge Policy
New patient – 1 DNA
Follow up – 2 DNA

33. Future???? 4 hospitals under one trust Sharing of good practice
Improve efficiency, cost & patient experience
Complex procedures – I site

34. Thank you for listening