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A visionary President

Ms Marie Hickey Dwyer, Consultant Ophthalmic Surgeon at University Hospital Limerick, finishes up her two-year term as President of the ICO this week at the Annual Conference in Westport, Co Mayo, and says she has really enjoyed her time in the role.

“It has been a fantastic opportunity. I feel privileged to have been President at a time when we have created a very good cohesion in the ophthalmology community, having been a bit more fragmented in the past. I’m not saying I was instrumental in that but I have made my contribution to it. The ophthalmic community have truly rowed in behind me and given up their time, and committed themselves over and above to put ophthalmology more in the public eye and take it out of that sort of ‘Cinderella specialty’ it has been seen as before,” she tells the Medical Independent (MI).

Ms Hickey Dwyer adds that the timing of her Presidency has also been positive, in that it coincided with the launch of the long-awaited national diabetic screening programme, Diabetic RetinaScreen, which began its phased roll-out in 2013.

“It started off in Mary Harney’s time, was pushed forward by Dr James Reilly and was carried through. It is fantastic to see it up and running finally. We haven’t fully got to the point of seeing the fruits from it; that will probably take two or three years. But people are getting their invites for screening, coming in to be screened and treated if necessary; it is such a good service,” she explains, adding that she and many of her colleagues have attended meetings aimed at trying to get the programme off the ground for over 15 years and successfully launched a local pilot scheme during that time.

HSE review

In addition, the eagerly-awaited HSE review of primary care ophthalmology services is due to be published shortly and Mr Brian Murphy, Head of Planning, Performance and Programme Management, Primary Care Division, HSE, will give an update on the review during the Conference.


“That is something very close to my heart as I felt the community ophthalmologists and the ophthalmic surgeons in the hospital, we’d always been trying to link-up and I think this might be the first time that things might be improved, between that and the HSE’s Clinical Care Programme for Ophthalmology as led by Mr Paul Moriarty, and tying it all together.”

Some people are very nervous about using unlicensed treatments but I take a stand that, as a moral citizen, I have no problem in giving what is a very good treatment

Ms Hickey Dwyer hopes that the review will lead to a number of changes in how ophthalmology is delivered through primary care in Ireland: “Hopefully it will lead to where we will have the ophthalmologist as a key person supported in a multidisciplinary way by orthoptists and opticians, which we have been trying to achieve for a long time and we might just now be on the cusp of that happening. That really is where we hope primary care will transform things — we will enhance the community service and then be able to feed-in appropriately to the hospitals and work back and forth. I think it will be fantastic.”

She says this would mean an efficient, cost effective, close-to-the-patient service, with strong links to tertiary services.

Exciting

Ophthalmology currently is a “fantastically exciting specialty” because so many treatments have come on board which weren’t previously available, Ms Hickey Dwyer maintains.

“For corneal disease, you have interventions with crosslinking, which can prevent someone from needing a full corneal graft in many cases. That didn’t exist 10 years ago… Also, with the treatment of diabetic retinopathy, we have gone from a scenario where we had no treatment, to unlicensed treatment, to licensed treatments. In the midst of that, however, is the moral dilemma of the costs,” she says.

Ms Hickey Dwyer reveals that she has used bevacizumab in Limerick since 2005, so has 10 years of long-term follow-up. “I have some of those patients still driving and living enjoyable lives, which is fantastic.”

She also confirms that she treats the majority of her diabetic retinopathy patients with anti-VEGF injections, which she says are efficacious and safe. “Most importantly, patients whom you see, patients you have carefully lasered, 10 years later when you look at their retinas, the burn is double the size. The degeneration that that caused is significant.”

The cost of licensed anti-VEGF treatments is a challenge, however, and usage of the bevacizumab is widespread in Ireland.

Qualified staff

“Some people are very nervous about using unlicensed treatments but I take a stand that, as a moral citizen, I have no problem in giving what is a very good treatment to much more people who can avail of that, rather than a select few if you have a limited budget,” Ms Hickey Dwyer maintains.

However, good-quality care costs and having sufficient properly qualified staff in place is key, she stresses. “I have always felt quite privileged to be an ophthalmologist. As I was reading the papers recently, with the radiology scandal in the HSE, I thought this is what we are always trying to explain to the HSE — that to deliver good care, you need a high level of expertise, and at the end of the day that is the cheapest delivery. Locums can cost double what a substantive post would cost and look at all the controversy and possible risk. There have been queries about what is the cheapest, most effective way to deliver care, and comments that doctors are very expensive but actually if you see a person who is qualified enough to make a good decision, that is the end of the consultation and people don’t have to come back. It is a better service, better for patients and there is proper continuity of care.”

Speaking at the recent Irish Association of Dermatologists Spring Meeting, Minister for Health Leo Varadkar stated he would like to hire an extra 100 consultants a year, “particularly targeted in areas where there is a huge deficit,” and named ophthalmology as one of these areas.

“We welcome his comments with open arms. I have been in Limerick myself since 1997 when there were three of us and I’ve been though the Hanly Report and other reports where it has been said that we need five people in this area to adequately serve the population, the increasing number of deliverables, and the demands created by an ageing population and here in 2015, there are still three of us and the workload has significantly expanded, particularly with the new treatments for age related macular degeneration (AMD).

“In 1997 when I came, at the cutting edge of treatment, only 10 per cent of AMD patients could be treated with photodynamic therapy, but now with wet AMD, unless someone comes in very late, everybody is treatable… We have recently got the preliminary go-ahead to hire a fourth person, which would be fantastic,” Ms Hickey Dwyer outlines, adding that waiting lists for routine and non-urgent ophthalmology appointments are very high across the country.

While more serious conditions like AMD are seen and treated as soon as possible due to risk of irreversible damage and blindness, conditions like cataracts have fallen down the waiting lists. Ms Hickey Dwyer points out the HSE has cut back in hospitals the number of nurses and theatre sessions, “which we had experience of in Limerick and that needs to be turned around”. This has significantly affected cataract operation waiting lists.

“In some instances, such as our own, two nurses in a theatre make the difference between doing four and five extra cataracts a day. It is very simple economics, really.

“I feel very strongly that patients of my parents’ age group and somewhat younger went through hard times in this country and got nothing for free really, and now they find themselves, following living in the time of the Celtic Tiger which went beyond them, are now in the time of cutbacks and I think they should get their cataracts [treated] in a timely fashion.”

Advocacy

Patient advocacy has been a strong feature of Ms Hickey Dwyer’s Presidency, alongside the ICO’s recent public information campaign on the risks of commercial eye procedures.

The ICO is concerned about the lack of regulatory oversight in relation to direct-to-patient advertising for medical or surgical procedures in Ireland and the impact this may have on patients’ access to unbiased information. Last year the College, in conjunction with colleagues from the specialties of surgery and dermatology, held a special meeting on the subject, and in February the ICO issued guidelines for refractive eye surgery as a reference for the public, patients and healthcare professionals.

“Advocacy for patients is key. It is pivotal at this time. You only have to turn on the TV and see the pressures there with advertising for various eye procedures…. I think it is vital that people do not make rash decisions about such procedures. Pressurised selling is not a good idea and it is banned in other walks of life, with cooling-off periods even for things like insurance. People don’t understand that while their vision may improve, it may also disimprove,” Ms Hickey Dwyer says.

As she prepares to hand over the Presidential chains to incoming President Mr William Power, Ms Hickey Dwyer says she is excited about the “excellent programme” for this week’s Annual Conference.

This year’s overseas speakers include Prof Simon Harding from the University of Liverpool’s Institute of Ageing and Chronic Disease, who will give the ICO Annual Mooney Lecture on Diabetic Retinopathy. Prof Harding has carried out significant research through the IVAN trials (Alternative Treatments to Inhibit Vascular Endothelial Growth Factor in Age-related Choroidal Neovascularisation), which investigated whether treatment as-needed is as effective as monthly treatment for AMD.

“Simon was my mentor in Liverpool and he is a terrific guy. He was involved in the setting up of the diabetic retinopathy screening programme in the UK, and has a lot of different angles,” Ms Hickey Dwyer comments.

There will also be a symposium at the Conference on the Ocular Complications of Acquired Brain Injury.

“Seeing is independence. So many people come into me and say they want to keep driving. What we do is so important,” she concludes.

The ICO Annual Conference 2015 takes place in the Knockranny House Hotel and Spa in Westport, Co Mayo, from Wednesday 13 to Friday 15 May. There will be extensive coverage from the conference in the next issue of the Medical Independent.

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