Download Ophthalmology Update - Heart of England NHS Foundation Trust

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
Service
Cataract
Macular degeneration
Diabetic retinopathy
Glaucoma
Cataract
One stop cataract clinic
listing and biometry
Day case surgery
Nurse Post op – Listing for other eye
Doctor clinic
Glaucoma
• Visual Fields & clinic
• Diagnosis & Management
• Follow up
– Doctor/glaucoma nurse
– GMU
Macular Diseases
Retinopathies which can affect the macular are
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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)
1.
2.
3.
Penfold P,, Prog Retin Eye Res. 2001 May;20(3):385-414.
RNIB 2012 Diabetes
Cavallerano AA et al, J Am Optom Assoc. 1994 Dec; 65(12):845-54
4.
5.
6.
Pournaras CJ et al, Semin Ophthalmol. 2000 Jun;15(2):100-7.
Schatz h et al Ophthalmology. 1992 Jan;99(1):63-7.
Silva R. Ophthalmologica. 2012;228(4):197-213.
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8.
9.
Cleasby GW, Am J Ophthalmol. 1976 May;81(5):590-9.
Ciardella AP, Surv Ophthalmol. 2004 Jan-Feb;49(1):25-37.
Bunce C, et al. Eye (Lond) 2010;24(11):1692-1699.
Exaggeration of the 'normal' ageing process
characterized by discrete yellow spots at the
macula (Drusen) and pigmentary changes of
the RPE
Pathology
Drusen – a hallmark of AMD
•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
1. Nowak JZ. Pharmacol Rep 2006;58(3):353–363
2. Jager RD et al. N Engl J Med 2008;358(24):2606–2617;
3. Fine SL, N Engl J Med. 2000 Feb 17;342(7):483-92.
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 blind 3
• 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
1.
2.
3.
Bunce C et al. Eye (Lond) 2010;24(11):1692-9.
RNIB AMD Campaign
http://www.rnib.org.uk/getinvolved/campaign/success/amdcampaign/Pages/amd_campaign.aspx
accessed March 2013
Owen CG et al. Br J Ophthalmol 2003, 87:312-317.
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Klein R et al Ophthalmol 1992, 99:933-943.
Klein R, Ophthalmology. 1992 Jun;99(6):933-43.
Minassian DC et al. Br J Ophthalmol. 2011 Oct;95(10):1433-6.
Campbel JP et al. Arch Ophthalmol. 2012 Jun;130(6):794-5.
Dry Dry vs Wet AMD
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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
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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
1. Mitchell J, Bradley C. http://www.hqlo.com/content/pdf/1477-7525-497.pdf. Accessed March 2013;
2. Penfold PL,. Prog Retin Eye Res. 2001 May;20(3):385-414.
3. Nowak JZ. Pharmacol Rep 2006; 58 (3):353 – 363;
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
1. Jager RD et al. N Engl J Med 2008;358(24):2606–
2617.
Decreased contrast sensitivity
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 2004 7% of global blindness
due to eye diseases was due to AMD5
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Jager RD et al. N Engl J Med 2008; 358 (24):2606 – 2617
NICE Technology Appraisal Guidance TA155. http://www.nice.org.uk/nicemedia/pdf/TA155guidance.pdf. Accessed April 2013
Owen CG, et al. Br J Ophthalmol doi:10.1136/bjophthalmol-2011-301109
Congdon N et al. Arch Ophthalmol 2004; 122 :477 – 485
Vision 2020 WHO public health initiative http://www.who.int/blindness/Vision2020_report.pdf Accessed April 2013
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
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TAP Report No. 2. Arch Ophthalmol 2001;119:198–2007
Rosenfeld PJ et al. N Engl J Med 2006;355:1419–1431
Gragoudas ES et al. N Engl J Med 2004;351(27):2805–2816
Bressler NM et al. Am J Ophthalmol 1982;93(2):157–163
5. Pieramici DJ, Bressler SB. Curr Opinion Ophthalmol 1998;9:38–46
6. MPS Group. Arch Ophthalmol 1997;115:741–747
7. Haddad WM et al. Br J Ophthalmol 2002;86:663–669.
Choroidal Neovascularisation and Vision Loss
Scar tissue (disciform scar)
1.
Nowak JZ. Pharmacol Rep 2006;58(3):353–363.
Decreased visual
acuity
Metamorphopsia
Decreased contrast
sensitivity
Central scotoma
Wet AMD and Quality of Life1-3
Charles Bonnet
Syndrome
More likely to fall
60% report
anxiety or
depression
QoL
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
60% reduction in
QOL, similar to
prostate cancer or
catastrophic stroke
Patients with advanced AMD:
4x more likely to need
assistance with activities of
daily living
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2.
3.
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. http://www.hqlo.com/content/pdf/1477-7525-4-97.pdf. Accessed April
2013
ARMD Pathway – Guidelines
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
INJECTIONSRanibizumab/
Aflibercept
MACULAR AND MEDICAL
RETINA CLINIC
ORAYA
Referral scanning
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
Loading dose
3 monthly injections
2 monthly injections
(Nos: 4 to 7) &
OCT Scan
TREAT/MONITOR
SHORTEN/ EXTEND
DURATION
VIRTUAL CLINIC
Clinician reviews OCT scans
and vision within 3 working
days. Medisoft data input
Diagnosis
History & Visual Acuity
Fundus Examination
OCT – Ocular Coherence Tomography
FFA – Fundus Fluorescein Angiogram
Treatment
Intravitreal ant-VEGF injections
Ranibizumab
Lucentis
Aflibercept
Eylea
Stereotactic Radio Therapy – SRT
Oraya -- STAR study
Visual Rehabilitation
Low Vision Assessment
Low Vision Aids – Magnifier, lighting, CCTV
Registration (CVI) – Sight Impaired & Blind
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
Diabetic Retinopathy
• Diabetic Retinopathy Screening Programme
• Retinopathy – R0 R1 R2 R3
• Maculopathy – M0 M1
Maculopathy – M1
• Close observation
• Focal Argon Laser – stop leakage
• Intravitreal injections
– Lucentis, Eylea, Ozurdex & Iluvien
Retinopathy
• R2 – Close observation
• R3 – Pan Retinal Photocoagulation – PRP
• Decrease/destroy the ischaemic stimulus
Retinal Vein Occlusion - RVO
• CMO
– Focal Argon laser
– Intravitreal injections
• Lucentis, Eylea & Ozurdex
• Rubeosis/Rubeotic Glaucoma
– Pan Retinal Laser Photocoagulation - PRP
Lids & Oculoplasty
• Lid lesion biopsy
• Lumps & bumps – Needs authorisation
• Blepharoplasty – affecting visual field (Proof)
Discharge Policy
• New patient – 1 DNA
• Follow up – 2 DNA
Future????
• 4 hospitals under one trust
• Sharing of good practice
• Improve efficiency, cost & patient experience
• Complex procedures – I site