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Eyeing-up improved glaucoma services

Glaucoma – a subset of many diseases of the eye – affects 2 per cent of Irish people over the age of 40 and 3.5 per cent over the age of 80. Since it is asymptomatic and attacks the peripheral vision, people are often only identified when significant vision loss has occurred. However, there are plans to develop a virtual system of identifying and monitoring glaucoma in Ireland, which, allied to new surgical techniques can ensure fewer people will suffer glaucoma-related vision loss.

Glaucoma describes an abnormality of the optic nerve and high pressure in the eye. The most common form in Ireland is primary open angle glaucoma, a painless and asymptomatic disease that silently progresses over time. Currently, it is not possible to screen for glaucoma as there is no test that meets the screening criteria. The case-finding is done mainly by optometrists who conduct examinations on people over 40 who are seeking reading glasses. 

Glaucoma causes damage to the optic nerve and initially there are gaps in the peripheral field of vision, which gradually then coalesce into the full loss of the patient’s peripheral vision. The central vision is preserved, which means people can still see and often don’t feel the need to have their eyes checked.

Detection

Ms Aoife Doyle, Consultant Ophthalmic Surgeon at the Royal Victoria Eye and Ear Hospital (RVEEH), Dublin, said the optometrist will examine the appearance of the optic nerve and changes in the field of vision, and if they see issues of concern they will refer the patient to a consultant ophthalmologist.

At this point, said Ms Doyle, most people are commenced on eye drop medications as their treatment. The strategy is to start patients on one drop and if there is no stabilisation another drop is added. Ms Doyle said that drops work for most people and they do not require further treatment.

In about 20 per cent of people, however, the drops are not enough and these patients are harder to manage. They will require additional treatment measures and the first of these options would be laser surgery, via a trabeculectomy. In this procedure, a piece of tissue in the drainage angle of the eye is removed, creating an opening to reduce pressure in the eye. There are other surgical procedures that also lower the pressure in the eye.

There are also new micro-surgical options, Ms Doyle said, which provide an “in-between treatment” used when the drops are not working for patients, but which are not as invasive as the established surgical procedures.

Micro-invasive surgery is not as risky and there is a much shorter recovery period. In contrast, the risks with the longer-established surgical procedures are that the openings made in the eye to relieve pressure can close over time, and can lead to development of cataracts, infections or low pressure in the eye.

Management

In Ireland, there is a huge need for improved detection of glaucoma to better manage the population of people with the disease. This will require more actions in terms of education and publication drives targeting GPs, medical professionals and high-risk groups, said Ms Doyle.

Currently, many people with glaucoma have already suffered a significant loss of vision at time of diagnosis. “Early detection is critical because if people have lost their sight, you can’t get back anything that you have lost. Any visual loss that is there at the time of diagnosis is fixed, it won’t recover,” said Ms Doyle

People with diabetes appear to be at higher risk of glaucoma. However, if a person is on the national diabetic register they will automatically be invited for an eye test for diabetic retinopathy, and glaucoma can also be identified at that point. All people over 40 should have regular eye checks with optometrists, Ms Doyle said, adding that people of African origin are susceptible to an aggressive form of primary open angle glaucoma and can be slow to present for medical care.

Another huge challenge with glaucoma is how to manage, monitor, and treat the volume of patients that have the disease or are at risk of it and ensure that patients are seen by a specialist in a timely fashion. Ireland can look towards the UK model, said Ms Doyle, where much work has been done on increased involvement of nurse specialists in eye care and the development of a better primary care pathway in primary care centres. A similar approach in Ireland could ensure people are looked after earlier and closer to home.

Virtual pilot

The RVEEH will be setting up a pilot project later this year for a virtual eye care clinic. The plan is to feed information about patients in the form of images and data into a central IT database where it can be accessed and reviewed by a consultant ophthalmologist without having to see each patient in person.

This ‘virtual view’ approach is considered a better way to manage the numbers of patients that need to be checked for glaucoma. As the Irish population ages in the coming years, those numbers will continue to rise inexorably. The pilot project will test the IT systems and the plan is to have ophthalmology primary care centres around Dublin and the midlands feeding in information about local patients, which consultants can review. This means that patients with routine cases will no longer have to visit the RVEEH.

‘In about 20 per cent of people, however, the drops are not enough and these patients are harder to manage’

“We know the model works, and there has been a big investment on the equipment side, with it costing €120,000 to kit out a unit,” said Ms Doyle. “But this can serve all areas of ophthalmology, save money and the human cost of not getting to new people fast enough.”

Ophthalmologists will still do the first review of patients in the pilot to categorise their level of risk. Once patients have been started on drops they would move into a virtual clinic where they can be monitored and brought back if their disease progressed and has become a concern. If the patient remains stable, they could potentially be monitored virtually for decades, while attending their local ophthalmology primary care centre.

The software being used for the RVEEH pilot is called Medisoft, which is the same software used throughout the UK. The way it works is that a consultant ophthalmologist reviews on computer screens the three dimensional images of the eye and checks if the optic nerve is changing over time.

The specialist also monitors the level of pressure in the eye and patient medications and determines if the patient is stable. Subsequently, a letter is sent to the GP advising on the patient. The ‘virtual’ element allows the specialist to review around 30 patients in three hours as opposed to just 12.

The idea is that personnel such as nurses and technicians gather information by way of undertaking tests and photographs, which are then reviewed by specialists. The great advantage of the virtual system is that it allows ophthalmologists to get through bigger numbers of patients faster and identify those requiring intervention.

One of the first aims of the pilot is to show that the information technology is working and that the communication links are reliable. It may be the case that satellite centres will be set up in those hospitals that feed into the RVEEH, such as St Colmcille’s Hospital, Loughlinstown, and the midlands hospitals in Portlaoise, Mullingar and Tullamore. However, ultimately the plan is to have links with new ophthalmology primary care centres in the region and to roll-out the virtual network, s0 that it links with centres all over the country.

The virtual infrastructure for tackling glaucoma can be applied to address other important eye diseases and areas, such as paediatric ophthalmology, macular degeneration and diabetic retinopathy – the latter has its own successful screening programme. There is a proposal for new ophthalmology primary care units to be built around the country, but there has been no movement on this to date.

Surgery

When patients do not respond to drops, the next step is often laser surgery, the newest form of which is selective laser trabeculoplasty, a procedure that was introduced to Ireland 11 years ago. This is the equivalent of adding another eye drop, is minimally invasive, and is an easy procedure to perform with few risks. There are minimal complications and it works for 65-to-70 per cent of people.

However, there is a new micro-surgical procedure that involves the implantation of tiny tubes and stents in the eye. This surgery is done under the microscope and is often combined with cataract surgery. The implantation of eye stents provides a moderate reduction in eye pressure and is promising in mild-to-moderate glaucoma.

Another form of eye surgery recently started at the RVEEH is the Xen implant, said Ms Doyle.  This is a slightly larger, but still very small implant – 1mm wide and 6mm long – that goes from inside the eye, out into the lining of the eye. It requires a great deal of surgical precision, but is safer than the larger eye operations and is a good option for patients that are progressing, but not rapidly.

Long-established standard surgical procedures are effective.  However, because they have a range of potential complications and side-effects, they are held in reserve until absolutely required.

The quality of glaucoma care in Ireland looks set to improve in the coming years with a combination of successful older surgical techniques combined with new ones and a more efficient ‘virtual’ means of identifying and managing the disease.

  • The Irish College of Ophthalmologists (ICO) Annual Conference will include a symposia on ‘Evolving Concepts in Glaucoma Management’. Prof Jonathan Crowston, the Ringland Anderson Professor of Ophthalmology, University of Melbourne and Managing Director of the Centre for Eye Research Australia (CERA), will contribute to this symposium, where he will be joined by Prof Augusto Azuara Blanco, Professor of Ophthalmology, Queens University Belfast, and Mr Leon Au, Dual-Specialist Ophthalmic Consultant, Manchester Royal Eye Hospital. Prof Crowston’s talk will address the existing evidence for the impact of lifestyle choices on glaucoma risk and outline laboratory studies which have shown that diet and exercise can modify the ability of retinal ganglion cells to recover following injury.  Prof Crowston will also present this year’s Annual Mooney Lecture: ‘Climbing the glaucoma mountain- future challenges and opportunities’, which will outline current knowledge in glaucoma and highlight some of the challenges and opportunities that exist in research and clinical practice.  Prof Augusto Azuara-Blanco, a leading figure in international glaucoma circles and renowned for his extensive research in the field, will discuss the results of the EAGLE trial which recently reported the superiority of clear-lens extraction in terms of patient, clinical and economic outcomes compared with laser iridotomy, and how to use the results of the trial in clinical practice.  Mr Leon Au’s talk, ‘What’s New and What’s Good in Glaucoma Surgery’, will focus on the latest surgical development in glaucoma, particularly surrounding minimally invasive glaucoma surgery (MIGS) and will examine the various options, clinical data, and patient selection and how they compare with current standards. The ICO Annual Conference takes place at the Slieve Russell Hotel, Co Cavan from Wednesday 17 to Friday 19 May 2017. 

For further information and a full programme visit www.eyedoctors.ie

  

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