Transcript Eye care What really matters today?

Eye care
What really matters today?
Simon Hardman Lea
2015
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
Conjunctivitis
Conjunctivitis?
Conjunctivitis?
Conjunctivitis?
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
Blepharitis
Chalazion
Management?
- Warm pressure
- Wait x 3/12
- Incision (from inside)
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.
Red eyes: beware
HYPOPYON
Red eyes: beware
•
•
•
•
Corneal opacity
Hypopyon
Contact lens wearers
If you have flourescein dye, that helps
sometimes
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.
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?
Only abnormality
NOW WHAT?
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
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
Case 2:
•
•
•
•
•
•
24 year old man
Otherwise well
Noticed visual disturbance last week
Difficulty judging stairs
Probably only right eye.
THOUGHTS?
Case 2
What might be the
cause?
Case 2
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
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
Case 3a
First action?
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)
Case 3b
• But if the disc was normal?
• Any other questions?
REMEMBER ANGLE
CLOSURE GLAUCOMA
Case 4: acquired Horner’s
• When to refer?
Case 4: carotid dissection
THM
• Acquired unilateral facial pain is worrying (esp
if after trauma)
• Horners often associated
• Needs urgent imaging
• Risk of CVA
Case 5:
•
•
•
•
•
12 year old boy
Just back from holidays in Majorca
Unwell.
“Bit of a temperature”
Eyelids swollen
Case 5: what to look for?
• Conjunctiva
• Eye movements
• Vision
Case 5:
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.
The absolute eye emergencies are:
•
•
•
•
•
GCA
Disc swelling from malignant hypertension
Retinal embolic disease
Carotid dissection
Orbital cellulitis
New issues
• AMD
• Diabetes
• Retinal vascular disease
• All revolve around intra-vitreal injections
AMD
• Loss of central vision
• Commonest cause of blind registration in UK
• 15,000 cases per year registered 2012-13
Dry AMD
Wet AMD
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
New NICE approved anti-VEGF uses
• Diabetic macular oedema
• Possible role in proliferative diabetic
retinopathy
• Macular oedema after retinal vein occlusion
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
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
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)
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)
1
Patient with problem
GP
Manage
and
discharge
Optometrist
Hospital
Discharge
EYE PROBLEM PATHWAY: OLD STYLE
ALL STEPS UNMONITORED
2
Patient with problem
GP
Manage
and
discharge
Optometrist
Hospital
Discharge
EYE PROBLEM PATHWAY: 2005 STYLE
ALL REFERRALS VIA OPTOMS
STILL UNMONITORED
3
Patient with problem
GP
Manage
and
discharge
Optometrist
Discharge
Triage of referrals
by OPSI
Hospital eye
departments
Manage &
discharge
OPSI in community
EYE PROBLEM PATHWAY: 2012 STYLE
ALL REFERRALS VIA OPTOMS
- REFERRALS THEN MONITORED AND TRIAGED
- SOME PATIENTS SEEN IN COMMUNITY
Patient with problem
3a
GP
Manage
and
discharge
Optometrist
Urgent cases by
phone
Discharge
Triage of referrals
by OPSI
Hospital eye
departments
Manage &
discharge
OPSI in community
EYE PROBLEM PATHWAY: 2012 STYLE
ALL REFERRALS VIA OPTOMS
- REFERRALS THEN MONITORED AND TRIAGED
- SOME PATIENTS SEEN IN COMMUNITY
GP
Manage
and
discharge
EVOLUTIO ELEMENTS
IN
GREEN
Optometrist
Discharge
Urgent cases by
phone
Collation and triage
of referrals by OPSI
Hospital eye
departments
Manage &
discharge
OPSI in community
EYE PROBLEM PATHWAY: 2012 STYLE
ALL REFERRALS VIA OPTOMS
- REFERRALS MONITORED AND TRIAGED
- SOME PATIENTS SEEN IN COMMUNITY
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?)
Why an external body?
Why not HES itself?
•
•
•
•
•
HES could perform this for themselves
? ability to employ outside groups
IT capability
Time
Credibility
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
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
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.
4
GP
Manage
and
discharge
EVOLUTIO ELEMENTS
IN
GREEN
Optometrist
Discharge
Urgent cases by
phone
Manage &
discharge
Collation and triage
of referrals by OPSI
Hospital eye
departments
1) OPSI in community
Or
2) Ophthalmologist in community
2015 EYE PROBLEM PATHWAY
Note new element of ophthalmologist in the
community setting
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