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Eyesight is the sense people fear losing the most, yet the vast majority of blindness is preventable with early diagnosis and treatment.
The goal of the Irish College of Ophthalmologists (ICO), the official training and professional body for medical and surgical ophthalmologists in Ireland, is to work towards eliminating the 75 per cent of cases that result in preventable blindness by 2020, in line with the World Health Organisation’s objectives of Vision 2020.
Established in 1991, the ICO came about from the merging of the Irish Ophthalmological Society (IOS) and the Faculty of Ophthalmology in the RCSI.
There are 220,000 Irish people living with vision loss or blindness and five people go blind in Ireland every week, approximately 260 people per annum.
It is estimated that 50,000 more people will have impaired vision and 5,000 more people will lose their sight within the next five years. AMD, diabetic retinopathy, cataracts and glaucoma are the main causes of sight loss in Ireland.
Since its establishment, the College has overseen the professionalism of ophthalmology training in Ireland and kept pace with the huge medical and surgical advances in effective treatments for eye conditions in the past 25 years.
“Since 1991, the role of the College has expanded enormously. Not only does it run the scientific meetings the IOS used to run and look after the political side of things, which the Faculty used to run, it now has an enormous amount of activity in relation to training, the entire training curriculum and examination system and everything to do with that,” Mr Peter Barry, one of the founding members of the ICO and now its Clinical Programme Director, told the Medical Independent.
Increasing patient numbers and the growing incidence of chronic diseases are placing an enormous strain on the current model of eye care in Ireland, according to ICO CEO Ms Siobhan Kelly.
Common eye conditions that were previously untreatable 25 years ago can now be treated very successfully and ophthalmologists can better prevent blindness in a much larger percentage of patients, according to Mr William Power, President of the ICO and Consultant Ophthalmic Surgeon at the RVEEH, Dublin.
“There has been a lot of changes in the past 25 years of new modern technology. When you take the common things that we do — for example, the way we do cataract surgery now and what we did 25 years ago has changed dramatically.
“All cataract surgery, for all intents and purposes, is now done under local anaesthetic as a day case, with an incision of 2-3mm with no suturing, with a foldable lens. So the advantage from a patient’s point of view is it is a much less-invasive procedure and rehabilitation in terms of their vision is much quicker. Most people are noticing that following their cataract surgery now, within a couple of days their vision is significantly improved and most of them are at driving level within a few days, whereas 25 years ago they would be coming back to us at about six weeks and we would have been talking to them about removing stitches and reducing their astigmatism and then about a month after that they’d come back to get glasses. So it has transformed, the speed at which their vision recovers and it is also a much safer procedure now.”
There have also been significant advances in treating both dry and wet age-related macular degeneration (AMD). “The treatment we are using now for wet AMD wasn’t around 25 years ago and… while it is an ongoing treatment, a greater number of patients are holding on to their vision.”
As revealed by MI recently, a team at the RVEEH is currently preparing for the first limbal stem cell transplantation operation in Ireland.
Mr Power will carry out the first procedure, aimed at restoring vision in patients with damaged or diseased cornea, in early June. Up until now, Irish patients have had to travel to the UK for a limbal cell transplant.
The process to allow limbal cell transplantation to go ahead in Ireland has taken six-to-seven years’ work, with collaboration with scientists in DCU under Prof Martin Klein and the Irish Blood Transfusion Service (IBTS), to provide the required sterile environment for transplant-quality limbal cells, he explained. A licence to carry out the procedure also had to be granted by the Health Products Regulatory Authority (HPRA), which Mr Power revealed was approved just under six weeks ago.
He anticipates four-to-six Irish patients will receive limbal cell transplants in the next year or two and numbers can increase if the demand is there.
“This is a really nice example of ‘from bench to bedside’… and we think it will be the first tissue stem cell transplant in the country,” Mr Power said.
Eye diseases that can result in sight loss are more common in older people, and as Ireland’s ageing population increases, so does the demand for ophthalmology services, she noted.
In addition, quality of life expectations have also changed dramatically in the past 25 years, with people in their 70s and 80s motivated to have corrective eye procedures so that they can continue to drive and pursue other activities where good vision is essential.
The Medical Fitness to Drive regulations recently enforced in Ireland have also meant that GPs and ophthalmologists must follow strict criteria in considering a person’s ability to drive, which in turn pushes the demand for eye care services so people can retain their driving licence.
This, coupled with the huge medical advances in the treatment of eye conditions and the increasing successful outcomes for patients, means the growing demand on the specialty of ophthalmology is increasing at a greater rate than ever before, Ms Kelly pointed out.
HSE ophthalmology waiting lists for both adults and children for outpatient and day case surgery are among the longest out of all the specialties, and Ms Kelly confirmed the College has persistently pushed for increased ophthalmology staffing.
“What we would argue very strongly is that there is not enough of either medical or surgical ophthalmologists, so it is something we most definitely are continuing to advocate very strongly for — the appointment of more consultants,” she said.
Following research funded by the ICO into the delivery of eye care in Ireland and with the support of other eye care stakeholders, the HSE and the Department of Health agreed on the need for a strategic approach to delivering better eye care into the future.
The result was the creation of the National Clinical Programme (NCP) for Eye Care by the HSE and the allocation of a Clinical Lead in Ophthalmology.
Mr Barry was appointed Clinical Lead for the NCP in Ophthalmology in 2015 following Mr Paul Moriarty’s leadership in the role since 2012.
Postgraduate training in ophthalmology in Ireland
Postgraduate training in ophthalmology in Ireland has evolved through many changes since the ICO was founded in 1991 and none more so than in the last decade, according to Ms Yvonne Delaney, ICO Dean of Postgraduate Education and Training.
A major change has been the purposeful incorporation of competence-based education to both the medical and surgical curricula. “Critical to understanding the need for this change is the paradigm shift which has taken place in postgraduate medical education, with a worldwide movement away from time-based to competency-based programmes. The Medical Council requires that national training programmes remain in line with international best practice and the incorporation of competence-based training is important for continuing accreditation by the Medical Council,” she said.
The HSE is also eager to eliminate unnecessary ‘gap’ years to improve graduate retention and more effectively align training programmes to future manpower demand and patient need, Ms Delaney explained.
In recent years there has been a reconsideration of the length of surgical and medical training across many specialties. A prolonged training journey, particularly in an environment where a third of all medical graduates are now graduate entry, has been cited by trainees as a significant issue in their willingness to stay and train in Ireland, she noted.
“In response, the training journey has been rationalised, with an increased focus on acquiring clinical skills and competencies during the early years of training, while broader skills such as research and critical appraisal of the literature will be more purposefully embedded into the revised programmes for higher training,” Ms Delaney said.
A key feature of the new training pathway is that career progression and entry into medical or surgical ophthalmology is now linked to trainee performance during the common core years of training, she explained.
Other challenges include financial pressures, increasing sub-specialisation and the risk-averse environment where training now takes place, which all place additional restraints on available training opportunities.
“Many challenges lie ahead but despite some uncertainties, the ophthalmic community — trainers, trainees and the College — will work together to ensure the continued delivery of high-quality ophthalmic training in the College and at all training sites nationally,” Ms Delaney said.
The overall aim of the NCP for Eye Care is to rebalance the delivery of care to a more community-based model, as hospital centres are now overburdened by chronic diseases, most of which could be appropriately diagnosed, treated and managed in the community by eye doctors in a decentralised model, he explained.
“What has altered an enormous amount is the scope of practice of community ophthalmic physicians. Twenty-five years ago their role was, more or less, looking after the children that were referred in by the public health nurse and school screening programme, whereas very many of the community ophthalmic physicians now function at a very much higher level than that — working in hospital clinics, doing intravitreal injections, performing fluorescein angiography and doing laser treatment and looking after and managing standard ophthalmic patients in the hospital system — so I think their role has really changed, unlike surgeons,” he explained.
Primary care review
The HSE’s Primary Care Division has now carried out a comprehensive review of the primary care eye services currently provided to children and adults nationwide, including directly-provided HSE services and contracted primary care services.
The role of the Primary Eye Care Services Review Group is to determine the needs of the population for these services and review the current service in terms of quality, safety and consistency and to identify issues for action.
The work of the Group is nearing completion and while it was hoped its report would be published last summer, it is now due to be published in the coming months.
“While the review has not been published, the National Eye Care Plan, which was written by the College, envisages a decanting of a sizable amount, maybe up to 50 per cent, of stable hospital outpatients into community clinics staffed by community ophthalmic physicians and equipped at a level to provide for the outpatient services, which are currently provided in the eye departments in the hospitals, to treat pretty much everything bar the surgery,” explained Mr Barry.
He said this would mean the development of the concept of the “eye care team”, comprising the ophthalmologist, orthoptist and optometrist all working together.
“There is a traditional lack of co-operation and mutual apprehension between ophthalmology and optometry and I think it is very important that is cast into the history books. I think it is very important that people are invited to work in these teams in accordance with their skillsets… ” he commented.
Improved remuneration for community-based ophthalmologists “which is not great at the moment” and a more structured and formally-recognised career pathway, which the College is working on through its training programme structures, will also be essential to the repositioning of care, Mr Barry stated.
“The College has multiple goals going forward. One of these is to develop both the training and the future positions for medical ophthalmology,” confirmed Mr William Power, President of the ICO and Consultant Ophthalmic Surgeon at the Royal Victoria Eye and Ear Hospital (RVEEH), Dublin.
Ms Kelly confirmed that in recent years, the College has become more involved in advocacy on the broader-ranging eye health and modifiable blindness risk issues such as obesity/diabetes, tobacco and alcohol control.
“After our 21st birthday was when we looked back and thought, we have been very focused on training, so let us see if we can expand our role in the other areas we have an interest in, such as an increased focus on prevention and not just treatment,” she explained.
“Prevention is very important and so much blindness is preventable, so we are very keen to get that message out there, that there is so much within people’s own control in relation to their eye health. The importance of early detection cannot be overstated and the College is also committed to educating the public on how often they should have an eye check, particularly those in the higher-risk categories, is also a key priority.”
The College was heavily involved in the setting up of the national diabetic retinopathy screening programme, which finally commenced its phased roll-out in 2013. More than 153,000 screening tests have now been carried out under Diabetic RetinaScreen, which offers free, regular screening and treatment of diabetic retinopathy to those with diabetes aged 12 and over.
While refractive laser surgery is one of the most rapidly-evolving areas in ophthalmology and has seen significant advances in the last 25 years, it is now an area that has become increasingly commercialised and commodified.
The ICO has taken a strong stance in recent years to warn the public of the dangers of commercial laser eye surgery, often carried out by surgeons who fly in and fly out of the country, and the hard-sell tactics by large high street providers.
The College has multiple goals going forward. One of these is to develop both the training and the future positions for medical ophthalmology
Ms Kelly said the College is committed to its efforts to work with the relevant decision-makers on securing a clause for responsible advertising of medical and surgical services in the forthcoming Patient Safety Licencing Bill.
The publication of Refractive Surgery Guidelines and Advertising and Marketing Guidelines by the ICO in 2015 is an important public statement of the College’s expertise on patient safety matters, Ms Kelly said.
In line with increasing awareness of eye health and the role of ophthalmologists, the College is also now known as Eye Doctors Ireland, a more public-friendly description.
“There has been so much development clinically in ophthalmology over 25 years, so much that can be done now to preserve sight that couldn’t be done up until even a short period ago, but we have just got to make sure that there are the facilities, funding and doctors in post to deliver the care needed. We want to ensure that the ophthalmic service gets the funding it deserves from the HSE,” Ms Kelly concluded.
This year’s ICO Annual Conference will be held in The Europe Hotel, Killarney, from Wednesday 18 to 20 May. See page 43 for full programme details.