1. Eye care What really matters today? Simon Hardman Lea 2015

2. What really matters today? Same as yesterday plus…. Common things are common – Red eyes But rare things matter – The killers What’s new(ish) that affects everybody – Treatments – Systems

3. Conjunctivitis

4. Conjunctivitis?

7. Treatment for conjunctivitis? Why? Anything you like for 2 weeks Bacterial infections (if they exist) must respond to appropriate antibiotics. If not better, ?send to me

8. Blepharitis

9. Chalazion Management? - Warm pressure - Wait x 3/12 - Incision (from inside)

10. Simple guide to red eye What does it feel like? Is the cornea clear? Is the vision normal? Does the pupil look normal? Are both eyes affected? If all yes = innocuous.

11. Red eyes: beware HYPOPYON

12. Red eyes: beware Corneal opacity Hypopyon Contact lens wearers If you have flourescein dye, that helps sometimes

13. What are the most important cases? True eye emergencies The ones not to miss The conditions that make you go blind and/ or kill you overnight. There are 5 of them. Case histories to follow Let’s assume you have the normal kit in a GP surgery.

14. Case 1 79 year old lady Describes episode of sudden loss of vision last week Lasted only an hour She says mainly lower half of vision Now ok ? What next Other history features?

15. Only abnormality NOW WHAT?

16. Disc swelling: what to do The key issues are whether the vision is normal or not, and what colour the disc is Pink swollen disc with normal vision needs investigation. Pink swollen disc with reduced vision need emergency referral Pale swollen disc always needs emergency referral irrespective of vision

17. Case 1: GCA THMs Many patients with GCA do not have classical symptoms – Jaw claudication, malaise, PMR, scalp tenderness Sub-clinical presentation is common Altitudinal field loss, whether transient or permanent, must be caused by retinal or optic disc pathology

18. Case 2: 24 year old man Otherwise well Noticed visual disturbance last week Difficulty judging stairs Probably only right eye. THOUGHTS?

19. Case 2 What might be the cause?

20. Case 2

21. Case 2. Retinal embolus THMs Always need investigation for source High association with future CVA In young men, high and curable mortality from congenital cardiac valve disorder. Can produce total field loss or altitudinal

22. Case 3 48 year old lady Headaches for years But she’s puzzled that the vision in one eye went grey for a few seconds last week. The came back to normal Then the same again twice this week. ?what next

23. Case 3a First action?

24. Case 3: papilloedema THM Transient visual obscurations are classical Malignant hypertension can be undistinguishable from raised ICP If BP ok, patient needs soon referral rather than emergency (providing no other features)

25. Case 3b But if the disc was normal? Any other questions? REMEMBER ANGLE CLOSURE GLAUCOMA

26. Case 4: acquired Horner’s When to refer?

27. Case 4: carotid dissection THM Acquired unilateral facial pain is worrying (esp if after trauma) Horners often associated Needs urgent imaging Risk of CVA

28. Case 5: 12 year old boy Just back from holidays in Majorca Unwell. “Bit of a temperature” Eyelids swollen

30. Case 5: what to look for? Conjunctiva Eye movements Vision

31. Case 5:

32. Case 5: orbital cellulitis THMs Always think about it If no obvious skin focus, including HZO, it’s an emergency Needs admission and IV antibiotics to prevent extension into cavernous sinus.

33. The absolute eye emergencies are: GCA Disc swelling from malignant hypertension Retinal embolic disease Carotid dissection Orbital cellulitis

34. New issues AMD Diabetes Retinal vascular disease All revolve around intra-vitreal injections

35. AMD Loss of central vision Commonest cause of blind registration in UK 15,000 cases per year registered 2012-13

36. Dry AMD

37. Wet AMD

38. Anti VEGF injections Effective in preserving vision in wet AMD ¼ billion £ spend on Lucentis last year in UK Can double that on the cost to the CCG of actually providing the service Alternatives unlikely to be much cheaper Open ended! Challenge of triaging new patients and providing follow up for stable patients

39. New NICE approved anti-VEGF uses Diabetic macular oedema Possible role in proliferative diabetic retinopathy Macular oedema after retinal vein occlusion

40. OPHTHALMOLOGY DEMAND MANAGEMENT 2015 The issues Soaring demand Finite capacity Solutions Control demand Increase capacity Both in a cost effective way Both in a safe way

41. Control demand Requirements A single point of access into tertiary care Mostly already achieved. Many areas including East and West Suffolk have taken the majority of referrals direct from optometrists for the last 10 years **The ability to count and monitor those referrals***. Has not existed until 2012

42. Why the need to count and monitor referrals? To enable commissioners to know exactly what they are purchasing from the hospital, by providing independent figures rather than simply relying on the hospital IT department To start to identify whether all referrals actually require a hospital visit that is both expensive (for purchasers) and resource consuming (for hospitals)

43. Requirements A system via which all referrals come A method of scrutinising those referrals BUT also, logically, a way of looking at those referrals thought possibly not needing to be seen in hospital, but requiring a more informed opinion than the referring optometrist. (Sometimes, simply a second opinion)

44. Patient with problem GP Optometrist Hospital Discharge EYE PROBLEM PATHWAY: OLD STYLE ALL STEPS UNMONITORED Manage and discharge 1

45. Patient with problem GP Optometrist Hospital Discharge EYE PROBLEM PATHWAY: 2005 STYLE ALL REFERRALS VIA OPTOMS STILL UNMONITORED Manage and discharge 2

46. Patient with problem GP Optometrist Discharge EYE PROBLEM PATHWAY: 2012 STYLE ALL REFERRALS VIA OPTOMS - REFERRALS THEN MONITORED AND TRIAGED - SOME PATIENTS SEEN IN COMMUNITY Manage and discharge Triage of referrals by OPSI Hospital eye departments OPSI in community Manage & discharge 3

47. Patient with problem GP Optometrist Discharge EYE PROBLEM PATHWAY: 2012 STYLE ALL REFERRALS VIA OPTOMS - REFERRALS THEN MONITORED AND TRIAGED - SOME PATIENTS SEEN IN COMMUNITY Manage and discharge Triage of referrals by OPSI Hospital eye departments OPSI in community Manage & discharge Urgent cases by phone 3a

48. GP Optometrist Discharge EYE PROBLEM PATHWAY: 2012 STYLE ALL REFERRALS VIA OPTOMS - REFERRALS MONITORED AND TRIAGED - SOME PATIENTS SEEN IN COMMUNITY Manage and discharge Collation and triage of referrals by OPSI Hospital eye departments OPSI in community Manage & discharge EVOLUTIO ELEMENTS IN GREEN Urgent cases by phone

49. Strengths of 2012 system Single point of referral to hospital services Allows accurate counting for referrals. For the first time, accurate costings for the CCG Allows triage of referrals A group of patients is seen in community by an additional human resource (optometrists), making use of existing physical resource (optometry practices). More convenient for patients (parking etc) Possibly cheaper – depends on cost of triage and the % of patients sent on to hospital Politically appropriate (?because of above?)

50. Why an external body? Why not HES itself? HES could perform this for themselves ? ability to employ outside groups IT capability Time Credibility

51. Potential weaknesses of 2012 system Still depends on the accuracy of the original referral. (It does not change the original request for routine/urgent.) The triage phase could produce false negatives ie patients who should be sent to the hospital are sidetracked into the community OPSI service. The OPSIs work without specific recognised training or supervision (This is a national issue, not particular to the Evolutio model) The cost effectiveness depends on the numbers of patients who do not need to be seen in hospital

52. Improvements for 2015 1 Clinical governance introduced Medical scrutiny of the Triage stage Medical scrutiny of the OPSI activity Regular published reports on numbers of patients/referrals Regular meetings with Hospital Eye Services to identify issues with the community service – either clinical or administrative

53. Improvements for 2015 2 In addition to the OPSI stage of patients being seen in the community, there is an additional group of patients who can be safely seen by an ophthalmologist working in the community A 1000 patient pilot of this new element to be performed in 2015 Monitored for clinical and financial safety.

54. GP Optometrist Discharge 2015 EYE PROBLEM PATHWAY Note new element of ophthalmologist in the community setting Manage and discharge Collation and triage of referrals by OPSI Hospital eye departments 1)OPSI in community Or 2) Ophthalmologist in community Manage & discharge EVOLUTIO ELEMENTS IN GREEN 4 Urgent cases by phone

55. Notes The triage system is not set up to change the urgency of the original referral The triage system does not have responsibility for the findings of the referring optometrist. At present, the triage system is not tasked with feeding back to the individual referring optometrists re the accuracy of the referral