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GLOuCestershire Gloucestershire Local Optometric Committee Resource Pack www.glosloc.co.uk Version 3 April 2010 GLOuCestershire Gloucestershire Local Optometric Committee www.glosloc.co.uk Welcome to Gloucestershire Dear Practice Manager/Optometrist Please find enclosed a copy of the revised Gloucestershire LOC Resource Pack detailing the optometric and ophthalmology services available in Gloucestershire. This pack is primarily designed to inform all optometrists moving into the Gloucestershire area about the locally negotiated protocols, support services and help available within the county. It is designed to provide important and up-to-date information which we felt would be useful for all existing practices in the county. This pack can be downloaded from our website and it is also available on a CD for transfer to your computer system if required. If you have any questions or require any further information please feel free to contact Frances Reilly our LOC Administrator or any one of the committee members and we would be very happy to help where we can. The LOC website is used as the main means of providing relevant information for all optometrists in the county. It contains up-to-date information on the activities of the LOC, information about committee members and contact details, and both essential and general information on practising within Gloucestershire. All of the forms contained within the pack are on the website in a format which enables them to be downloaded as required. We hope you will find this pack interesting and informative. We suggest it is made available as a resource to all the optometrists working in your practice by placing it in an accessible location. If there are any aspects of optometric practice that you feel could be included in future editions or you would like any further information, please do not hesitate to contact Frances or one of the committee. Yours sincerely David Adams Chairman Gloucestershire Local Optometric Committee Email: [email protected] Tel: 01594 823690 GLOC Resource Pack-Version 3-April 2010 2 PACK CONTENTS Page Chairman’s Letter 2 Committee Members 4 GOS Matters 5 Ophthalmology in Gloucestershire 6 Cataract Guidelines for Cataract Direct Referral Guidelines for referring patients with age-related macula disease who are likely to benefit from cataract surgery Copy of Cataract Referral Form Copy of Cataract Claim Form Cataract Choice Management of wet age-related macular disease (AMD) Management of wet age-related macular disease (AMD) in Gloucestershire Copy of Wet AMD referral form 9 11 13 15 16 17 18 20 Ophthalmology Referrals in Gloucestershire 21 GOS Sight Test – Early retest Codes 22 Low Vision 23 The Gloucestershire Glaucoma Referral Refinement Scheme 25 Hospital Optometry Services 26 Diabetic Screening Service 26 NHS Gloucestershire and Gloucestershire Care Services 27 The Three Counties Optometry Society 29 GLOC Resource Pack-Version 3-April 2010 3 GLOuCestershire Gloucestershire Local Optometric Committee COMMITTEE MEMBERS David Adams Chairman [email protected] 01594 823690 Jeff Poole Secretary [email protected] 01453 885534 Steve Guilford Treasurer [email protected] Michael Bailey [email protected] Lisa Collins [email protected] Laura Wilkin [email protected] Keith Holland [email protected] Dermot Keogh [email protected] Kevin Tait [email protected] Nigel Harris [email protected] Ankur Trivedi [email protected] Adrian Street Dispensing Optician [email protected] Frances Reilly Administrator [email protected] GLOC Resource Pack-Version 3-April 2010 4 GOS MATTERS To apply to join the PCT Ophthalmic Performers List in Gloucestershire please contact Kate Barnes at the address below. Applicants will be required to provide ORIGINAL qualification certificates, 2 recent clinical references, proof of identity and an ophthalmic indemnity certificate. A Criminal Record Bureau (CRB) check will also have to be carried out if the applicant has not obtained an enhanced CRB disclosure within the last six months. Kate Barnes Primary Care Administration Support (Dental and Ophthalmic) Primary Care Commissioning and Development Gloucestershire PCT Sanger House 5220 Valiant Court Gloucester Business Park Brockworth Gloucester GL3 4FE Tel : 08454 221588 Fax: 08454 221863 For other queries regarding GOS sight tests and to obtain copies of all other relevant NHS forms contact: Jacky Higgins The Optical Payments Team Sanger House 5220 Valiant Court Gloucester Business Park Brockworth Gloucester GL3 4FE Tel: 08454 22 1666 As a reminder, please find listed here the GOS-NHS CLAIM FORMS that you may need – GOS1 Application for an NHS funded sight test GOS2 Patient’s optical prescription or statement GOS3 NHS optical voucher and patient’s statement GOS4 NHS optical repair/replacement voucher application form GOS5 Help with the cost of a private sight test GOS6 Application for a mobile NHS funded sight test HC1 Claim for help with health costs HC11 Help with health cost GLOC Resource Pack-Version 3-April 2010 4 OPHTHALMOLOGY IN GLOUCESTERSHIRE The main provider of NHS ophthalmology services is Gloucestershire Hospitals NHS Foundation Trust. The ophthalmology department consists of Sixteen Consultant Ophthalmologists, a number of Associate Specialists, Fellows, Staff grades and Senior House Officers and a large associated support team of nurses, optometrists and orthoptists. This team provides a variety of different services at sites across the county. Outpatient services are concentrated at the two main hospital sites - Gloucestershire Royal and Cheltenham General with general and specialist clinics being held at both sites. Other general outpatient services are provided at peripheral sites throughout the county with clinics being held on a less frequent basis. Inpatient services are provided on Montpellier ward at Cheltenham General Hospital along with day case surgery in the Eyford Day Unit also at Cheltenham. There are 3 operating theatres equipped for eye surgery. In addition, day case cataract surgery is also available at Tewkesbury and Tetbury Hospitals. Contact details for all hospitals in the county that provide ophthalmology services are listed below: Cheltenham General Hospital (CGH) Sandford Rd, Cheltenham, Gloucestershire GL53 7AN Main Switchboard: 08454 222222 Fax: 01242 272105 Cheltenham Eye Clinic: 08454 223200 Eye Appointments: 08454 225975/6878 (Fax: 08454 226749) Gloucestershire Royal Hospital (GRH) Great Western Road, Gloucester, Gloucestershire GL1 3NN Main Switchboard: 08454 222222 Fax: 01452 310737 Gloucester Eye Clinic: 08454 228468 Eye Appointments: 08454 226871/5973 (Fax: 08454 226749) Ophthalmology Casualty phone line: 08454 22 3578 9.00 – 5.30 Monday – Thursday 9.00 – 1.00 Friday This phone line is set up to improve access to the department for GPs and Optometrists. It will be manned by Nurse Practitioners and senior outpatient Nurses who will triage calls. Optometrists are encouraged to phone this number for advice. At weekends/bank holidays and outside these hours the number will go to the switchboard and will be dealt with by the on-call doctor GLOC Resource Pack-Version 3-April 2010 5 HOSPITAL Address Contact Details Berkeley Hospital Marybrook Street, Berkeley, Glos GL13 9GL Tel: 01453 562000 Cirencester Hospital Tetbury Road, Cirencester, Glos GL7 1UX Tel: 01285 884694 Dilke Hospital Cinderford, Gloucestershire GL14 3HX Grove Road, Lydney, Gloucestershire GL15 5JF Tel: 01594 598100 Moore Cottage Hospital Moore Road, Bourton on the Water, GL54 2AZ Tel: 01451 820228 Moreton District Hospital Hospital Road, Moreton- Tel: 01608 650456 in-Marsh, GL56 0BS Stroud General Hospital Trinity Road, Stroud, Glos, GL5 2HY Tel: 01453 562200 Tetbury Hospital Malmesbury Road, Tetbury, Glos GL8 8XB Tel: 01666 502336 Tewkesbury Hospital Barton Road, Tewkesbury, Gloucestershire GL20 5QN Tel: 01684 293303 Fax: 01684 295887 Lydney & District General Hospital GLOC Resource Pack-Version 3-April 2010 6 Tel: 01594 598220 Whilst all consultants are general ophthalmologists each has an area of specific clinical interest. When recently asked, the consultants listed the following as their areas of special interest: Mr Glynn Baker PhD, FRCOphth, FRCS Ed (Ophth) Orbital, lacrimal and oculoplastic surgery. Small incision cataract surgery Mr Richard Caesar MA MB BChir FRCOphth Small incision cataract surgery, Oculoplastic reconstructive Surgery, Oculoplastic cosmetic surgery, Lacrimal surgery Mr John Ferris FRCOphth Small-incision cataract surgery, Paediatric Ophthalmology, Ocular Motility Mrs Barbara Harney PhD FRCOphth Medical retina including diabetic retinopathy and age-related macular disease Mr Rob Johnston FRCOphth Vitreoretinal surgery, Medical retina, Small incision cataract surgery Mr Nigel Kirkpatrick MD FRCOphth Medical and Surgical Retina Mr Graeme Mackintosh DO FRCS FRCOphth Cataract lenses: Accommodative, multifocal, aspheric, Refractive Surgery: Lasik, Lasek Phakic Implants (ICL, Artisan/Artiflex), Corneal Transplantation/Intacs. Ferrara rings Oculoplastics and cosmetic surgery Prof Andrew McNaught MD FRCOphth Glaucoma Mr Quresh Mohamed BM, BSc(hons), FRCOphth Medical retina including age related macular disease and diabetic retinopathy, Ocular inflammation & uveitis, Small incision cataract surgery. Mr James H Nairne MA MB BChir FRCOphth FRANZCO FRACS Glaucoma Mr Nicholas C Price FRCOphth (current Clinical Director of Ophthalmology) Cataract, Corneal Surgery Ms Sandra A Rayner MA PhD FRCOphth Primary Care, Oculoplastics and External Eye Disease Dr Peter Scanlon MD FRCP DCH DRCOG DO MRCOphth Medical retina, Diabetic retinopathy Our newer Consultants include: Miss Sujata Rao, Ms Helena Cilliers and Mr Ahmed Sallam. Further information about the ophthalmology department and its staff can be found on the ophthalmology page within the Gloucestershire Hospitals website (www.gloshospitals.nhs.uk) GLOC Resource Pack-Version 3-April 2010 7 Private Options: For patients that would rather see an ophthalmologist privately there are a number of different options available within Gloucestershire. Contact details for the various hospitals/organisations are listed below: CESP (Consultant Eye Surgeons Partnership) Lansdown Lodge Lansdown Road Cheltenham GL51 6QL Tel: 01242 521919 Fax: 01242 253816 or visit their website at www.cesp.co.uk Email: [email protected] Nuffield Hospital -Cheltenham The Cheltenham and Gloucester Nuffield Hospital Hatherley Lane Cheltenham Gloucestershire GL51 6SY Tel: 01242 246500 Fax: 01242 246501 or visit the Nuffield hospital website (www.nuffieldhospital.org.uk) Winfield Hospital - Gloucester Tewkesbury Road, Longford Gloucester GL2 9WH Tel: 01452 331111 Fax: 01452 331200 or visit the Winfield hospital website (www.winfieldhospital.co.uk) GLOC Resource Pack-Version 3-April 2010 8 GUIDELINES FOR CATARACT DIRECT REFERRAL May 2005 In Gloucestershire we have been fortunate over the years to have developed excellent relationships between the healthcare professionals and administrators involved in the provision of eyecare. This has enabled Gloucestershire to be one of the leading areas in the country for pioneering the development of eye care services. Optometrists have also been developing their role as Primary Eyecare Providers. June 2005 marked another step in that process as we widened the Direct Referral Scheme for Cataract to cover all referrals where cataract is the major or significant reason for the loss of vision. Criteria for Referral Patients will be monitored in the community as their cataracts develop until they reach the point where their vision is significantly affected. The referral criteria are: 1. 6/12 or worse in either eye. 2. Where the acuity is better than 6/12 but is seriously affecting the visual performance of the patient then referral is permissible, so long as clear reasons for the referral are stated (e.g. Driving). Responsible referral is key to the success of the scheme. The Gloucestershire Referral Procedure 1. Fast track Referral The Fast Track Referral Scheme will continue to offer an efficient user-friendly pathway for all patients with simple cataract. Patients must agree to proceeding with surgery should it be offered. Fast track referral is available at Gloucester (GRH) or Cheltenham (CGH) hospitals only. A referral fee will be paid. Optometrists must be registered with the PCT to be able to refer directly. 2. Referral to a general clinic Patients with significant cataract but with ocular co-morbidity or significant secondary issues will also be referred directly but into a general clinic rather than the cataract fast track clinic. Referral is to Gloucester or Cheltenham or any community hospital clinic as requested. However where the appointment is offered is ultimately the decision of the ophthalmologists. A referral fee will be paid. 3. Conventional GLOS1 Referrals Patients who need to be assessed by an ophthalmologist but where the primary reason for referral is not cataract, please continue to refer via the GP on a GLOS1 or referral letter. No fee will be paid. All Direct referral forms are to be sent to Gloucestershire Royal Hospital, Central booking office, The Old Chapel, Horton Road, Gloucester GL1 3PR. A fee will be paid for all direct referrals and claimed in the normal way on the relevant claim form. An audit trail must be kept within the practice. No fee will be paid for non-direct referrals via the GP. Referrals will be audited to ensure that the present high quality of referral is maintained. GLOC Resource Pack-Version 3-April 2010 9 For your information ophthalmology consultants have clinics at the following hospitals Mr G Baker Mr R Caesar Ms H Cilliers Mr J Ferris Mrs B Harney Mr R Johnston Mr N Kirkpatrick Mr G Mackintosh Mr A McNaught Mr Q Mohamed Mr J Nairne Mr N Price Miss S Rao Ms S Rayner Mr A Sallam Dr P Scanlon CGH, GRH, Stroud, Tetbury CGH, GRH, Tewkesbury CGH, Delancey GRH, Stroud, Tetbury GRH, Berkeley CGH, GRH, Stroud CGH, GRH, Cirencester, Bourton-on-the Water CGH, GRH, Stroud CGH, Evesham, Tewkesbury GRH, CGH GRH, Lydney CGH, GRH, Cirencester, Evesham, Moreton-in-Marsh CGH, Berkeley, Tetbury CGH, GRH, Tetbury CGH, GRH CGH All Cataract Referral is to be via the Community Optometrist. It is intended that all referral for cataract will be by the community optometrist. If a patient goes to see their GP having noticed a reduction in their vision and their GP suspects that this is due to cataracts, then the patient will be given a letter of referral and advised to see their optometrist/OMP. Each patient will have the referral procedure explained to them and be given a copy of either the “Patient Advice “ booklet produced by the hospital or the RNIB publication “Understanding Cataracts” Copies of the Hospital booklet can be obtained via Frances Reilly at a nominal fee and the RNIB booklet can be purchased via onlineshop.rnib.org.uk. The New Referral Forms The cataract form is available on disc at optometry practices or can be downloaded from the LOC website (www.glosloc.co.uk). The GP is sent a copy of the referral for reference and information only. No response from the GP is required. Two copies go to the hospital; one for the ophthalmologist and one for audit. One copy is kept by the optometrist. Fee Claim The Direct Referral Claim form is completed for each referral and submitted to Jacky Higgins at Sangar House 08454 221666. Again, claim forms may be downloaded from the LOC website or from Jacky Higgins direct. The fee per claim is £38.74 (April 2010). Registration for Cataract Scheme All optometrists need to be registered to refer directly. This can be done by contacting Kate Barnes on 08454 221588. No additional training for registration is required but knowledge of and adherence to the referral guidelines is essential. GLOC Resource Pack-Version 3-April 2010 10 Guidelines for referring patients with age-related macula disease who are likely to benefit from cataract surgery It is recognised that there will be a significant number of patients who develop cataract who also have a degree of age related macular changes. These guidelines relate to the co-morbidity of cataract and AMD without the presence of any other ocular co-morbidity and are designed to help optometrists make accurate and appropriate referrals. The guidelines are based on the recommendations from a prospective study (Armbrecht et al. 2000, 2003) of 187 patients with and without AMD undergoing cataract surgery. The results of the study showed that, for certain combinations of cataract and AMD, there were improvements either in specific aspects of visual function and/or vision related quality of life. Cataract extraction in this group of patients improves both visual acuity and contrast detection. Referral recommendations Referral is recommended even if there is better vision in the fellow eye so that the potential for preserving binocular vision can be assessed. Cataract Mild Moderate Severe Age related macular degeneration Mild Moderate Severe Yes 1 No 2 No 3 Yes 4 Yes 5 Yes 6 Yes 7 Yes 7 Yes 7 The table below relates to the super-scripts in the above table and is a summary of the improvements likely to occur in visual function and vision related quality of life following cataract surgery. 1 2 3 4 5 6 7 Visual function Dist VA; Near VA; CS with glare None likely None likely Dist VA; Near VA; CS with and without glare Quality of life Reading small print & newspapers/books Reading small print None likely Trouble with vision, reading small print, doing fine handwork Dist VA; Near VA; CS with and without Trouble with vision, reading small print, glare doing fine handwork Insufficient data Possible improvement in CS Cataract surgery is indicated when the opacity precludes adequate fundal examination and treatment of retinal lesions that are likely to progress and cause progressive vision loss if untreated. If there is moderate cataract or greater, with symmetrical maculopathy and a poor outcome of previous cataract surgery, cataract surgery may not be advisable. GLOC Resource Pack-Version 3-April 2010 11 Definitions of AMD severity (derived from the International Classification of ARMD) “Mild” Any number of only hard drusen, fewer than 20 intermediate or soft distinct drusen, or fewer than 10 large soft indistinct drusen involving less than 25% of the macular region and/or granular pigmentary changes. “Moderate” 20 or more intermediate or soft distinct drusen, or more than 10 soft indistinct drusen involving more than 25% of the macular region and/or pigmentary changes larger than 63µm. “Severe” Geographic atrophy (severe “dry”) or neovascular maculopathy (severe “wet”). References Armbrecht AM, Findlay C, Kaushal S, Aspinall P, Hill AR, Dhillon B.Is cataract surgery justified in patients with age related macular degeneration? A visual function and quality of life assessment.Br J Ophthalmol., 2000;84:1343-1348 Armbrecht, AM, Aspinall PA, Dhillon B. Cataract surgery in the patient with age-related maculopathy and degeneration.Comp Ophthalmol Update. 2003;4(1):17-24 Armbrecht AM, Findlay C, Aspinall P, Dhillon B, Hill AR.Cataract surgery in patients with age-related macular degeneration. One-year outcomes.J Cataract & Refractive Surgery. 2003;29(4):686-693 GLOC Resource Pack-Version 3-April 2010 12 Gloucestershire Ophthalmology Service: Cataract Referral Form The form is divided into three sections: Part A: White To be completed by the referring optician (Four copies) Two for Ophthalmologist, One for GP, One for Optometrist Part B: Yellow To be handed to the patient. Please send referrals to: Gloucestershire Royal Hospital Central Booking Office The Old Chapel Horton Road, GLOUCESTER GL1 3PR Guidelines for Direct Referral of Cataract Patients Aim To provide an efficient service to patients who have visual impairment resulting primarily from cataract. We hope that the use of this cataract referral form will improve the cataract service and reduce the total number of steps that most patients need to go through between initial recognition of cataract by the optometrist and discharge following surgery. Patients will be allocated to either a cataract clinic or a general ophthalmology clinic depending on the information provided on this form. Which Patients are Suitable for the Direct Optometrist Referral into the Fast Track Clinic? Patients with visual impairment which is principally due to uncomplicated cataract. If they have ocular hypertension or mild stable glaucoma, diabetes with no retinopathy, or trivial macular degenerative change. The patient should have expressed a willingness to proceed with surgery, if it is offered. Which Patients need to be referred to a General Clinic? Patients who are unsure about surgery or who have other significant ocular or other problems where there is a lower chance of immediate listing should be referred to an ophthalmologist on the same form but specifying that they are to be seen in a general clinic. Referral Criteria Any patient whose corrected VA is 6/12 or below in either eye should be referred to an ophthalmologist. Patients who have vision better than 6/12 but with significant visual impairment resulting from cataract and are experiencing a degree of difficulty with normal day to day activities (including driving) should be referred. Any patient whose VA has dropped dramatically or prescription has changed rapidly in the last 6-12 months as a result of cataract should be referred. Referral Procedure All patients are to be offered “Patient Choice” of where they wish to be referred and their decision indicated on the referral form. Optometrist should complete form A (white, four copies), ask the patient to sign it, and forward two copies (one for audit) to the appropriate Hospital. An appointment within Gloucestershire will be issued on the basis of the optometrist referral either for a Fast Track Clinic or a Routine Clinic according to that specified on the referral form. When requesting a routine appointment, please indicate patient preference for a general appointment at CGH/GRH or a general clinic appointment in a community hospital. The Optometrist should send a copy of the completed form to the GP for information only. The Optometrist keeps one copy of the form for their own records. Optometrist should sign and give the patient a copy of the Cataract Information Sheet C (yellow) and the RNIB Cataract booklet. The Fast Track Cataract Clinic An ophthalmologist will assess the patient and if surgery is recommended they will receive information and counselling. Biometry will also be performed at the first visit. The patient will be given an indication of when they are likely to have surgery. Following the patient’s first clinic appointment some will be considered for a telephone pre-assessment prior to surgery, whereas others may be required to attend a pre-assessment clinic at the hospital. General Clinic Where there is significant co-morbidity then patients will be fully assessed and counselled before surgery is offered. GLOC Resource Pack-Version 3-April 2010 13 Gloucestershire Ophthalmology Service: Cataract Referral Form Optometrist/OMP Copy Part A: For completion by optometrist Patient details Name: ___________________________________ Male D.O.B: __/__/__ Female Address: _______________________________________________________________________________________ ______________________________________________________________ Postcode: ________________ Telephone: Home: _________________ Work: _________________ Occupation: _________________ Referring Optometrist General Practitioner: Name: ________________________________________ Practice Name: __________________________________ Address: _______________________________________ _______________________________________ Postcode: _____________________ Telephone: ____________________ Patients Visual Status Right Eye Current Corrected V/A 6/4 6/5 6/6 6/9 6/12 6/18 6/24 6/4 6/5 6/6 6/9 6/12 6/18 6/24 6/36 6/60 3/60 2/60 1/60 PoL NPL 6/36 6/60 3/60 2/60 1/60 PoL NPL sph Current Refraction Left Eye axis cyl axis Prism Previous V/A Previous Prescription sph Base Date cyl axis Prism Base 6/4 6/5 6/6 6/9 6/12 6/18 6/24 6/4 6/5 6/6 6/9 6/12 6/18 6/24 6/36 6/60 3/60 2/60 1/60 PoL NPL 6/36 6/60 3/60 2/60 1/60 PoL NPL sph cyl axis sph cyl axis Cataract Present Yes / No Yes / No Previous cataract Surgery Yes / No Yes / No Name of Hospital Medical History Diabetes Hypertension Heart Disease Lung Disease Stroke Other Ophthalmic History Eye Drops-specify: Cataract surgery Other surgery-specify: ………………………… Significant Ocular Pathology Glaucoma Age Related Macular Changes Retinal Detachment Diabetic Retinopathy Traumatic Injury Amblyopia/Squint/Phoria Other Further Comment Patient definitely wants surgery Patient appointment for: General Clinic Yes Patient’s Preferred Choice Cataract Fast Track Clinic CGH GRH CGH GRH ____________________ (Within Gloucestershire) General clinic at _______________________________ Patient Signature:__________________________Optometrist Signature:_________________________Date: ____/___/____ Sept2007-Version2-copyright © Glos. Hospitals NHS Foundation Trust GLOC Resource Pack-Version 3-April 2010 14 ACTION ON CATARACTS: CLAIM FORM Name of Optometrist: Practice Stamp: Contact telephone number: Please indicate whether you are working at this location as a locum: YES / NO Date of assessment: Referral form number: Patient's full name: Patient's date of birth: Please indicate to which Cataract Clinic the patient was referred: Cheltenham General Hospital Gloucestershire Royal Hospital Declaration: I declare that: I am registered to take part in the Action on Cataract Project I have examined and referred the above named patient in accordance with all guidelines and referral protocols established by the Gloucestershire Ophthalmology Service. the information provided is accurate to the best of my knowledge and belief Signed………………………………… Date………………………………. ……………………………………………………………………………………………………………………… Notes: 1. Claim forms to be returned to:- Optical Payments Team Sanger House 5220 Valiant Court Gloucester Business Park Brockworth Gloucester GL3 4FE 2. Payments will only be made to normal contract accounts. 3. Claims for the proceeding six month period (i.e. April to September or October to April) must be received within 10 working days of the end of that period FOR OFFICE USE ONLY: Claimant registered for Action on Cataract Project? YES/NO Service provided within previous six month period? YES/NO Claim received within 10 working days of the end of the relevant six month period? YES/NO Fee of £38.74 authorised? GLOC Resource Pack-Version 3-April 2010 YES/NO 15 Initials……………. Date…………… Cataract Choice In order to adhere to current Government policy, when making an NHS referral, optometrists are required to offer patients a choice of referral centres from an approved list. As optometrists we have worked closely with our PCT to adhere to Government policy and extend the choice of approved providers for patients with cataracts. We wish to do this in such a way that it enables patients to make an informed choice without adding greatly to the workload of the optometrist. To this end the following guidelines are set out to facilitate the referral process 1. 2. The criteria for referral, the referral form and the ‘Advice to Patient’s’ booklet remain the same. Patients should be informed of the six providers to whom they can be referred and general information given. However, where patients are already being treated within the ophthalmology department in Gloucestershire it is strongly recommended they stay with their consultant within the county. 3. If patients want more information with regard to the service provided by the different locations before making a choice, then they should be given the telephone number of the Gloucestershire Choice Support Service on 01285 884597. It is then their responsibility to find out the information they require and to make their choice. It is also their responsibility to inform their optometrist of the choice they have made in order that the referral can be processed. 4. The referral form is completed in the normal way but specifying the patients preferred choice. It is then forwarded to the address shown on the table below. 5. A claim for the referral fee is made in the normal way. Trust name Gloucestershire Hospitals NHSFT Address for referrals Gloucestershire Royal Hospital Central Booking Office The Old Chapel, Horton Road GLOUCESTER GL1 3PR Tel number 08454 222 222 United Bristol Healthcare NHST Medical Records Department Bristol Eye Hospital Lower Maudlin Street Bristol BS1 2LX 0117 928 4746 Oxford Radcliffe Hospital Patient Appointments Bureau John Radcliffe Hospital Headley Way, Headington Oxford OX3 9DU 0845 330 8888 Swindon & Marlborough NHST Ophthalmology Dept Great Western Hospital Marlborough Road Swindon Wiltshire SN3 6BB 01793 604 853 Hereford Hospitals NHST Booking Centre Hereford Hospitals NHS Trust County Hospital Union Walk Hereford HR1 2ER 01432 355 4444 and ask for the Booking Centre Worcester Acute Hospital Ophthalmology Dept Aconbury West Worcester Royal Hospital Charles Hastings Way Worcester WR5 1DD 01905 760006 (automated number) Extn 33391 UK Specialist Hospitals (UKSH) Patient Bookings Team Emersons Green NHS Treatment Centre The Brooms Emersons Green Bristol BS16 7FH Tel. 0117 906 1800 An information leaflet has been produced that can be given to patients. This can be downloaded from the LOC website www.glosloc.co.uk. GLOC Resource Pack-Version 3-April 2010 16 Management of Wet Age-related Macular Disease (AMD) and Rapid Access Referral (updated July 2009) Patients with exudative AMD have a more rapid onset of symptoms than those with the dry form. They notice central visual loss often accompanied by distortion developing over the course of a few days or weeks. Distortion may be the earliest sign. Patients may not notice early symptoms when only one eye is affected and it is not unusual for them to present at a late stage with their first eye. Treatment with ranibizumab (Lucentis) is now available in Gloucestershire according to NICE guidance. Most patients with wet AMD who have experienced recent progression of symptoms and whose vision falls within the guidelines are now eligible for treatment for first and second eyes. In a proportion of patients, treatment leads to an improvement in vision but in the majority it stabilizes vision so it remains very important that patients should be seen as early as possible in the course of the disease process and ideally within a few days of onset of symptoms. In order not to overload the service and to prevent disappointment, it is also important that only those patients with any hope of benefiting from the treatment should be referred urgently. As most patients are referred via their optometrists, a rapid access referral system is now well established to allow optometrists to refer directly. A copy of the wet AMD referral form can be downloaded from the 'Forms and Leaflets' link; it also details the referral criteria. It is preferable to refer by fax to the number on the form. Please ensure you retain a copy of the referral for your own records and send a copy to the patient’s GP. On receipt of the referral, the patient will be contacted directly and then assessed by a retinal specialist. If the diagnosis is confirmed using optical coherence tomography (oct) and fluorescein angiography and if the patient falls within NICE guidance (see below), they will be offered treatment with ranibizumab. Treatment is offered in Cheltenham General Hospital and in Gloucestershire Royal Hospital. Copies of our patient information leaflet are available from the Hospital website: www.gloshospitals.org.uk. GLOC Resource Pack-Version 3-April 2010 17 Management of wet age-related macular disease (AMD) in Gloucestershire NICE GUIDANCE Ranibizumab, within its marketing authorisation, is recommended as an option for the treatment of wet age-related macular degeneration if all of the following circumstances apply in the eye to be treated: the best-corrected visual acuity is between 6/12 and 6/96 there is no permanent structural damage to the central fovea the lesion size is less than or equal to 12 disc areas in greatest linear dimension there is evidence of recent presumed disease progression (blood vessel growth, as indicated by fluorescein angiography, or recent visual acuity changes) Lucentis has been shown to improve vision in approximately 30% of patients and to maintain vision in over 90%. It remains vitally important that eligible patients should be referred as quickly as possible. Routes of referral Patients usually present to their optometrist. Only those with recent symptoms of wet AMD should be referred using the fast track system. The existing guidelines should be followed and the existing form completed and faxed as before. Patients presenting with symptoms in their first or second eye should be referred Patients presenting to their GP should be referred urgently to the retinal team. If there is some uncertainty, local optometrists are usually happy to advise at short notice and to make the appropriate referral. At risk patients under the care of the Eye department or who have been discharged on an open appointment and who are aware of symptoms to look out for can contact the eye department directly. Assessment Patients will be assessed in the retinal clinic. Investigations will usually include optical coherence tomography and fluorescein angiography. Those falling within the guidelines for treatment with Lucentis will then be seen in a designated assessment clinic. Those eligible for treatment will usually start their injections the same day. Patients with occult wet AMD but no evidence of recent progression will be monitored. OCT (optical coherence tomography) is a non invasive investigations which is an essential tool in monitoring change. It allows quantification of macular thickness and demonstrates intraretinal and subretinal fluid GLOC Resource Pack-Version 3-April 2010 18 Treatment Treatment consists of 3 intra vitreal injections at monthly intervals. Further injections are given according to findings at subsequent assessment visits Patients should expect to attend monthly for assessment and/or injection – it is very important that retreatment should not be delayed if it is necessary. It is not certain how long monitoring and treatment needs to continue, but it will be for at least 2 years. Generally, treatment is well tolerated and adverse events are rare, however patients need to be aware of the risks. Information and counselling are provided. Trust based information booklets are available. Rehabilitation Low visual aid assessment and referral to social services (with or without registration) will be offered where appropriate. Copies of the referral form can be downloaded from this site - please see the link at the top of this page or our forms and leaflets to download page Other useful information can be found on the LOC website www.glosloc.co.uk : Nutritional supplementation in ARMD - advice written by Mrs Barbara Harney Appendix to nutritional supplementation information GLOC Resource Pack-Version 3-April 2010 19 WET AMD RAPID ACCESS REFERRAL FORM Gloucestershire Ophthalmology Service: For completion by Optometrist Patient details Name: ______________________________ _______ Date of Birth: ___/___/___ Male Female Hospital No (if known) _________________________ Address: ____________________________________________________________________________________ __________________________________________________________ Postcode: _________________________ Telephone: Home: ______________________ Work: __________________ Occupation: ____________________ Referring Optometrist General Practitioner Name: ____________________________________________ Practice Name: _____________________________________ Address: __________________________________________ _________________________Postcode: ________________ GOC No: ________________________ Telephone: ________________________________________ AFFECTED EYE: PREVIOUS HISTORY IN EITHER EYE Previous AMD Myopic Other: RIGHT LEFT Right Right Right Left Left Left Referral Guidelines PRESENTING SYMPTOMS IN AFFECTED EYE (one answer must be ‘yes’) Less than 3 month history of: 1. Visual Loss Yes 2. Spontaneously reported distortion Yes 3. Onset missing patch / blurring in central vision Yes FINDINGS Corrected VA (must be 6/96 or better in affected eye) 1. Distance VA Right 2. Near VA Right 3. Macular drusen (either eye) Right In the affected eye ONLY, presence of macular: 4. Haemorrhage Yes 5. Subretinal fluid Yes 6. Exudate Yes No No No Left Left Left No No No CURRENT REFRACTION: Distance: R …………………………… L ……………………..……… Date: ……..………… Near: R …………………..…….…. L …….…..……………..…... OTHER COMMENTS: FAX TO: 08454 226749 I request that my referring optometrist receives a report from the Hospital Eye Department: Yes No Patient’s signature: Print name: Optometrist’s signature: Print name: Date: / / Central Booking Office: Gloucestershire Royal Hospital, The Old Chapel, Horton Road, Glos GL1 3PR Patients will be contacted within 48 hours of receipt of this Copy sent to GP: Yes No referral, Monday to Friday and an appointment will be sent. AMD Rapid Access REFERRAL FORM – VERSION 3 – Jan 2008 GLOUCESTERSHIRE HOSIPITALS NHS FOUNDATION TRUST GLOC Resource Pack-Version 3-April 2010 20 OPHTHALMOLOGY REFERRALS IN GLOUCESTERSHIRE Copies: General Ophthalmology Referrals Send to: Form: Patient’s GP GLOS1 or by letter. CATARACT Direct Referral * registration required see below 2 to Ophthalmology 1 to GP 1 for your own records Central Booking Office The Old Chapel Gloucestershire Royal Hospital Horton Road GLOUCESTER GL1 3PR Download from www.glosloc.co.uk. and photocopy GLAUCOMA Referral Refinement * registration required see below 1 to Ophthalmology with copies of two Visual Fields plots Central Booking Office The Old Chapel Gloucestershire Royal Hospital Horton Road GLOUCESTER GL1 3PR Glaucoma Office Gloucestershire Hospitals NHS Foundation Trust Cheltenham General Hospital Ground Floor Annexe Riverside House College Baths Road Cheltenham GL53 7QB Download from www.glosloc.co.uk. Or carbonated copies can be obtained from the Glaucoma Office. FAX to: 08454 226749 Fax operates Mon-Fri 8.30am – 4.00pm Download from www.glosloc.co.uk. 1 to Glaucoma office 1 to GP 1 for your own records Wet AMD Rapid Access Referral 1 fax to Ophthalmology 1 to GP 1 for your own records CATARACT Direct Referral To register contact: GLAUCOMA Referral Refinement To register contact: Kate Barnes Primary Care Administration Support (Dental and Ophthalmic) Primary Care Commissioning and Development Gloucestershire PCT Sanger House,220 Valiant Court Gloucester Business Park Brockworth, Gloucester GL3 4FE Tel : 08454 221588 Fax : 08454 221863 Frances Reilly Glaucoma Office Gloucestershire Hospitals NHS Foundation Trust Cheltenham General Hospital Ground Floor Annexe, Riverside House College Baths Road Cheltenham GL53 7QB Tel: 08454 224736 GLOC Resource Pack-Version 3-April 2010 21 GOS SIGHT TEST - Early Retest Codes 1.0 Risk of frequent Rx change not requiring referral/already known to GP 2.0 Pathology likely to worsen e.g ARMD, cataract, corneal dystrophy, or congenital anomalies. 3.1 Px presented and required referral 3.2 Px presented and change in Rx found 3.3 Px presented with symptoms but no Rx change or referral required 4.1 Complex lenses required 4.2 Corrected vision less than 6/60 in one eye 5.1 GP requested ST 5.2 Management under GOC referral criteria, e.g suspect visual field not confirmed on repeat, or abnormal IOP without other glaucoma indications 5.3 Risk factors require more frequent exams 6.0 Other unusual circumstances requiring clinical investigation June 2009 GLOC Resource Pack-Version 3-April 2010 22 LOW VISION LVL, RVI and CVI There are many different organisations throughout the county providing help and support to visually impaired people. Recent changes in the way in which visually impaired people are identified should make it easier to access help from the appropriate agencies and referrals can now be made by optometrists. The Letter of Visual Impairment or LVI has now been superseded by the Low Vision Leaflet or LVL. The LVL can be given by optometrists to any patient they feel would benefit from contact with the Sensory Impairment Team at Social Services. The patient can then complete the leaflet and send it to the Sensory Impairment Team themselves. Social services will not be providing copies of the low vision leaflets but it can be downloaded from the LOC website www.glosloc.co.uk. Optometrists in both community and hospital practice can also make a referral to Social Services using an RVI (Referral of Visual Impairment). This may be useful for patients that are either not eligible or have declined registration at the present time or who have not seen an ophthalmologist that are struggling with day to day life due to a sight impairment. The BD8 form for partial sight and blind registration has been replaced by the Certificate of Visual Impairment (CVI) which as before can only be completed by an Ophthalmologist. The terms partial sight and blind have been changed to sight impaired and severely sight impaired Further information on the new terminology and all aspects of registration of sight impairment can be found on the Department of Health website www.dh.gov.uk. Sensory impairment team - Gloucestershire Social Services Social Services Helpdesk: 01452 426868 Fax: 01452 427359 The Sensory Impairment Team hold “drop-in sessions” for people with a visual impairment and their relatives. The drop-in sessions are usually once a month in the Optometry departments at CGH and GRH. To find out the next dates planned, please phone the sensory services team on 01452 426868. Low vision clinics - hospital service Low vision clinics are held at Cheltenham General, Gloucestershire Royal, Cirencester and Stroud Hospitals. These clinics are run by the hospital optometry department and provide an assessment of visual needs, offer advice on ways to cope with sight loss and issue magnifying aids where appropriate. Most optical magnifying aids are provided to patients on a loan basis. In order to access these low vision clinics patients need to be referred by their GP or community optometrist, or must already be a patient within the ophthalmology department. GLOC Resource Pack-Version 3-April 2010 23 GCAB - Gloucestershire County Association for the Blind This is a local charitable organisation that provides various means of support for the people with sight loss in the local community. Their services include a resource centre open 9am to 4pm Monday to Friday, a visiting service for registered visually impaired people, newsletters and members information groups. For more information contact the GCAB on 01242 221170 visit the resource centre at 81 Albion Street Cheltenham GL52 2RZ or visit the GCAB website: www.geecab.org Forge Centre The FORGE Centre is an independent local charity which has established a resource centre for visually impaired people in the Forest of Dean. As well as offering advice and support on coping with visual impairment they also offer a range of activities for the visually impaired including craft classes and gardening club. For more information contact Jenny Green at the Forge Centre on 01594 827711 Forge Centre, Foxes Bridge Centre, Valley Road, Cinderford, Glos, GL14 2LJ. www.forgecentre.org.uk RNIB There are around two million people in the UK with sight problems and RNIB (Royal National Institute of the Blind) is the leading charity offering practical support and information to anyone with a sight problem. Our pioneering work helps - not just with braille, Talking Books and computer training but with imaginative and practical solutions to everyday challenges. For further information visit the RNIB website: www.rnib.org.uk , helpline 08457 669999 GLOC Resource Pack-Version 3-April 2010 24 The Gloucestershire Glaucoma Referral Refinement Scheme In 2003 a pilot glaucoma pathway, funded by West Glos. PCT was introduced in the Forest of Dean for the refinement of glaucoma referrals by community optometrists. The principal aim of the scheme was to reduce the number of false-positive referrals to secondary-care. The award-winning pilot scheme has proven to be highly successful and has received a great deal of national attention with many of its principles being adopted by groups around the country. In September 2008, NHS Gloucestershire agreed the countywide roll-out of the scheme with all community optometrists invited and encouraged to participate. The scheme requires contact tonometry (Goldmann or Perkins) to be undertaken on two separate occasions and visual fields to be repeated, prior to referral. Accredited community optometrists are remunerated for providing a detailed, structured and high quality clinical examination prior to making a direct referral to an ophthalmologist. Anyone interested in participating in the scheme or wanting further information is advised to contact the LOC Administrator, Mrs Frances Reilly at [email protected]. GLOC Resource Pack-Version 3-April 2010 25 Hospital Optometry Services The Optometry service within Gloucestershire Hospitals NHSF Trust is a countywide service headed by Miss Lisa Collins. The majority of the clinical services are provided at Cheltenham General and Gloucestershire Royal Hospitals but optometry clinics are also held at a number of peripheral sites across the county including Tewkesbury, Cirencester, Stroud, Berkeley and Tetbury. Much of the clinical work of the Hospital Optometry Department is investigative and diagnostic to support and supplement the ophthalmology services. These include performing post-operative cataract examinations, the monitoring of stable and suspect glaucoma and retinal/macular patients, diagnostic and paediatric refractions. We also provide a number of specialist services including low vision rehabilitation, diagnostic ocular ultrasound and complex contact lens fitting, including scleral contact lenses. The department consists of a team of sixteen Optometrists, five Optometry Tecnhcians and a Contact Lens Optician. A small number of the clinical team work on a part-time basis between hospital and community practice. If you have any queries relating to hospital optometry please contact the department on 08454 223203. Diabetic Screening in Gloucestershire The Diabetic screening service in Gloucestershire started screening in October 1998 and is spear-headed by Dr Peter Scanlon. The service is currently based at Cheltenham General Hospital and has 6 mobile units travelling out to GP surgeries across the county to screen patients suffering from diabetes, for any signs of diabetic retinopathy. The service currently has 22,000 diabetic patients on its register. All patients are dilated, unless there is evidence of contraindications, their vision is tested using LogMar charts and then high resolution digital retinal images are taken. Patients will be given some basic education on how diabetes can affect their eyes and they will be shown their own images. The images and patient data are then transferred to the diabetic eye screening central server within Cheltenham General Hospital, for analysis by a team of specialist graders. All grading is subject to a full and nationally recognised QA process, this helps reduce mistakes and un-necessary referrals. Patients with sight threatening diabetic retinopathy or other referable ocular pathology identified on the photographs are referred on to the ophthalmology clinics within the hospital eye service. The service aims to screen all diabetics on an annual basis. ‘Mop up’ clinics are held at both Cheltenham General and Gloucestershire Royal Hospital on an occasional basis to which patients who missed the session at their GP surgery are invited. Further details of the service can be found on the hospital website www.gloshospitals.nhs.uk GLOC Resource Pack-Version 3-April 2010 26 NHS Gloucestershire and Gloucestershire Care Services NHS Gloucestershire Sanger House 5220 Valiant Court Gloucester Business Park Brockworth Gloucester GL3 4FE Tel: 08454 221500 E-mail: [email protected] Chief Executive: Jan Stubbings Gloucestershire Care Services Unit 43, Central Way Arle Road Cheltenham GL51 8LX Tel: 01242 548800 E-mail: [email protected] Chief Executive: Jan Stubbings Gloucestershire Primary Care Trust was formed on 1st October 2006 and replaced the three former Primary Care Trusts in Gloucestershire (Cheltenham and Tewkesbury, Cotswold and Vale and West Gloucestershire). Since January 2009 the PCT has been known as NHS Gloucestershire. The organisation serves a population of approximately 602,000 and covers the following district council areas: Cotswold, Cheltenham, Forest of Dean, Gloucester, Tewkesbury Borough and Stroud. GLOC Resource Pack-Version 3-April 2010 27 NHS Gloucestershire is responsible for commissioning healthcare for its population. It has contracts with 83 GP Practices and through its Arms Length Organisation, Gloucestershire Care Services runs 9 community hospitals and a maternity hospital. Gloucestershire Care Services also provides a range of community services such as podiatry, speech and language therapy, occupational therapy, district nursing and health visiting. The main roles of NHS Gloucestershire are to: engage with the local population to improve health and well being commission a comprehensive and equitable range of high quality, responsive and efficient services and; through Gloucestershire Care Services directly provide services where this gives best value. As a countywide organisation, NHS Gloucestershire recognises how important it is to retain a local focus so that the valuable working relationships that have been built with primary care, local councils and a wide range of committed community and voluntary groups continue to be strengthened. NHS Gloucestershire believes that its future success will depend on this co-operation and joint working. For the latest information on NHS Gloucestershire and Gloucestershire Care Services please www.nhsglos.nhs.uk. GLOC Resource Pack-Version 3-April 2010 28 Three Counties Optometry Society Herefordshire Worcestershire Gloucestershire Background As an LOC we have appreciated the valuable input of the Three Counties Optometric Society in providing high quality continuing education in a local context and also a forum for communication between Gloucestershire optometrists. Three Counties Optometry Society has been established for over 30 years and has provided academic lectures and a meeting forum for its members every year. The Society has previously arranged 5 or 6 lectures each year between September and March. This year (2009/2010) however, we intend to concentrate on a reduced number of more focussed sessions to target local clinical or educational issues. We will keep you posted with plans as they come to light. It is essential therefore, if you wish to be notified of our plans to ensure that you can be contacted by e.mail. The most effective way is via Frances Reilly, the LOC administrator at [email protected] Would you please advise Frances of your e.mail address if you have not already done so. The Society is registered with Vantage Technology as a CET provider and most lectures are awarded CET credits. We also feel that it is vital for a Society such as ours to bring new people and ideas into the committee and we would be delighted to hear from any members (current or potential) who would like to join us in this capacity. Please be in touch with Graeme or Mary - details below The Society is open to all Optometrists, Dispensing and Contact Lens Opticians. Lecture fees and start times will be arranged as details of speakers become available. Venue We have previously met at Sandford Education Centre at Cheltenham General Hospital and hope to continue with this excellent venue. The centre has up-to-date multi media presentation equipment and there is ample free parking on site. Programme of lectures Please check the LOC website www.glosloc.co.uk for lecture information. Contacts Committee members are: Graeme Lowcock Mary Russell [email protected] tel.01684 850212 [email protected] GLOC Resource Pack-Version 3-April 2010 29
