Report on ‘overstretched’ NHS Ophthalmic services gives cause for concern

12 April 2016

The President of the Royal College of Ophthalmologists, Professor Carrie MacEwen, has warned the BBC that NHS ophthalmic services are struggling to keep up with an increasing demand caused by more eye diseases in an ageing population requiring long term care.

The BBC reported that hospital attendances have increased year on year in the UK, with over 100 million outpatient appointments made in England alone during 2011-13, of which nearly 10% were for eye care alone (according to a study commissioned by the Health & Social Care Information Centre published in January 2015).

What’s more, there has been a reported increase of up to 30% in eye clinic attendances over the last five years which according to Professor MacEwen is leading to unavoidable pressure being mounted on hospital eye services.

There are a number of conditions in which recognition of the correct diagnosis and / or institution of the right treatment is commonly delayed. This tends to happen more in general practice or at hospital A&E departments. Delay can result in significant permanent reduced vision.

Examples can include the following:

(i) Acute Red Eye

This is very common and is usually due to a benign disease such as bacterial viral or allergic conjunctivitis which may be treatable with eyedrop medication. The symptoms are usually redness, discharge, and a foreign body sensation.

Sometimes more serious and less common conditions are mistaken for conjunctivitis.  Examples include acute angle glaucoma, acute uveitis, bacterial keratitis, or herpetic keratitis. A delay in diagnosis of these conditions may result in severe permanent visual impairment.

(ii) Penetrating Ocular Trauma

Perforating wounds of the eye are sometimes missed in casualty. These can often result from accidents involving mechanised manual work such as hammering, chiselling, high-speed drilling, grinding or cutting.

Visual acuity must be measured by attending clinicians in such cases. Sometimes examination of the eye remains unremarkable and the possibility of an underlying penetrating wound is missed. Thorough ophthalmic examination is nonetheless essential, including dilation of the pupil. Failure to identify a wound or a retained foreign body in the eye can otherwise lead to acute visual loss.

(iii) Retinal detachment

Delayed diagnosis and / or referral for retinal detachment is not unknown. This is particularly so as a GP or A&E doctor will be extremely unlikely to identify this on examination and even an optometrist with the benefit of pupil dilation will find it difficult. An ophthalmic referral is therefore both urgent and essential. The symptom ‘clues’ which should guide this will often include sudden loss of vision, the onset of floaters (deposits in the eye) with flashes,  then a curtain ascending across the field of vision leading to loss of central vision. Treatment should almost always performed by specialist vitreo-retinal ophthalmologists. A delay of days (if not hours) to surgery is often indefensible.

(iv) Age related macular degeneration (AMD)

AMD is a condition that affects the central past of vision (macula), particularly in those over the age of 50 years. It can be untreatable ‘dry’ AMD (a gradual loss of central vision) or ‘wet’ (a rapid, permanent, and significant loss of vision caused by leaking blood vessels under the retina).

Wet AMD can be treated with regular repeat injections into the eye. It can stablise visual loss in up to 95% of cases and can improve visual acuity in up to 40% of cases.

Timing of diagnosis and treatment is critical to success. There is often a delay in referral to hospital by GP’s and optometrists. The relevant guidelines on the management of AMD recommend a referral is made within one week of suspected wet AMD and the commencement of treatment within a further week, allowing a two-week window of opportunity for affected patients. Delayed initial treatment of any more than four weeks is usually considered to be indefensible.

AMD is a common eye condition which was previously untreatable, but can now be treated successfully. However this adds to demand on eye clinics.

Elderly ‘follow up’ patients with AMD are often the most vulnerable in the current NHS environment and at the greatest risk of irreversible sight loss.

(v) Diabetic retinopathy

This is the major cause of visual loss in working-age patients. It is early asymptomatic in early stages, with visual loss occurring due to progression and proliferation. Some cases may be amenable to retinal laser photocoagulation and other more recent treatment developments such us intravitreal VEGF inhibitors.

Once proliferative diabetic retinopathy is recognised, it is recommended that laser treatment is delivered within two weeks, failing which there is an increased risk of vitreous haemorrhage occurring.

(vi) Glaucoma

Chronic open angle glaucoma (COAG) is the most common form of glaucoma, characterised by raised intra-occular pressures (IOP), optic nerve head damage, and consequential visual field loss. COAG is not symptomatic until there is advanced visual loss so effective treatment relies on identification of pre-symptomatic disease. Clues to diagnosis might include increased IOP’s (the normal range is between 10-21 mm Hg), optic disc changes, and visual field abnormalities.

If and when diagnosis of glaucoma is made, the condition still needs to be appropriately managed. Glaucoma requires long-term repeat appointments for close monitoring and care.

Between June 2005 and May 2009, the National Reporting and Learning Service (NLRS) received reports of 44 glaucoma patients who experienced deterioration of vision, including 13 reports of total loss of vision attributed to delayed follow-up appointments. A further 91 incidents related to delayed, postponed, or cancelled appointments, but the level of harm is not known. These statistics have undoubtedly got worse as NHS patient demand has steadily increased over the last 6 years.

(vii) Giant Cell (temporal) arteritis

GCA is uncommon but has the potential to render a patient completely blind in both eyes within a few days. Early recognition, referral, and treatment is therefore essential and GCA should be regarded as a medical emergency.

GCA is characterised by inflammation of the medium sized arteries. It virtually never occurs in those under the age of 50 and more common in women. Features include headache, scalp tenderness with difficulty combing the hair or pain on resting the head on a pillow, and pain on the jaw muscles on chewing. GCA should always be considered in any older patient with new onset severe headache.

Visual loss occurs early in the course of disease and once established, rarely improves. Early treatment with high-dose steroids is imperative to prevent further visual loss.

Professor MacEwen explained to the BBC that “Many eye diseases which can cause sight loss are more common in older people and our ageing population means the demand on ophthalmology, like all areas of healthcare, is increasing like never before”.

According to the BBC, a search undertaken by the National Reporting and Learning System (NRLS) identified nearly 500 incidents describing loss or deterioration of vision as a consequence of delayed diagnosis between 2011 and 2013 in England and Wales. There are probably many more such incidents that have gone unreported.

Clara Eaglen, RNIB Eye Health Campaigns Manager, has said: "It is clear that ophthalmology departments are under acute strain. This new warning by the Royal College of Ophthalmologists underlines the need for urgent action, particularly for follow-up appointments. We are hearing from increasing numbers of patients whose follow-up appointments are being delayed or cancelled, leaving them worried and putting them at risk of losing further sight. Patients are of course incredibly grateful to the NHS staff who are working long hours, under intense pressure, as they try to keep up with demand for services.  The Government must urgently review the situation and ensure staff are given the resources they need to deliver high quality care."

The Royal College of Ophthalmologists (ROC) is carrying out a national study to identify patients who have come to harm due to hospital-initiated delays for follow up appointments. According to the BBC, the study’s preliminary results indicate that across the UK, at least 20 patients per month suffer sight loss from such delays.

According to the ROC, solutions to this problem include:

  1. Recommended guidelines to optimise efficient care
  2. The use of expanded skills and roles of other specialist eye staff such as ophthalmic nurses, optometrists, and orthopists
  3. Increasing networks between primary and secondary care
  4. Giving patients a voice by improving understanding of their condition and the importance of their follow up appointments being kept within the time recommended by their doctor

If you have concerns about delays in clinical ophthalmic treatment resulting in visual loss, an experienced legal specialist familiar with ophthalmic medicine might be able to help you investigate whether the treatment you received was negligent, and if so then help you to claim financial compensation. For more information contact our Clinical Negligence and Personal Injury team.

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