www.goodhope.nhs.uk/departments/eyedept/ ==== Home / Admin Other conditions Contact dept / Personnel Web site feedback Secretaries Appointments Eye drop enquiries Links for students Online eye text book About this site Contents Contents Children/Othoptic clinic Contact lenses Rehabilitation & coping with poor sight Low vision clinic Magnifiers Glaucoma Professionals Letters for professionals Professionals: rubeotic Professionals: ang closure Professionals: POAG Trab audit 2008 What is glaucoma? Drops for glaucoma Intraocular hypertension Low tension glaucoma Pre-perimetric glaucoma Rubeotic glaucoma Acute angle closure Chronic angle closure Animations Glaucoma animation Progression simulation Rubeotic glaucoma Rubeotic glaucoma animation Angle closure, Narrow angle, Laser iridotomies Laser iridotomy animation SLT laser animation Visual fields Trabeculectomy Trabeculectomy animation Students: Cases Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 case 7 case 8 case 9 case 10 case 11 Macula Cases 1 for students 2 hard drusen Central Serous Retinopathy 4 CCNV (wet ARMD) 5 Occult CCNV 6 Soft drusen Pre-macula haem Bests 10 PDT 11 rip 12 CNV 13 CSR & PED 14 Dry/Occult 15 polypoidal 16 myopic early CNV 17 macula hole 18 more fluid with oct 19 fluid reaccumulates 20 peds & nsd 21 AOFVD 22 AOFVD/ERM 23 speckles 24 VMT 25 ERM 26 Juvenile retinoschisis 27 early classic ARMD pathology & treatment Understanding macular degeneration Are you at risk? Coping: poor sight in one eye Coping with poor sight: hints animations etc Diagram: link Large diagram 1 Large diagram 2 Animation more detail lucentis dry ARMD hard drusen soft drusen geographic AOFMD ERM VMT macula hole wet Lucentis/Avastin treatment Occult type 1, PED Occult type 2 Classic myopic Rip Polypoidal RAP extensive subfoveal haemorrhage Peripapillary CNV VMC professionals CSR none-ARMD macula ERM VMT macular hole Juvenile macular dystrophies PFT parafoveal telangiecasia Magnifiers Rehabilitation & local services Low Vision Clinic RNIB link Procedures Your first visit Fluorescein angiogram & photography Laser Refraction (test for spectacles) Orthoptic/squint examination Minor lid surgery, cyst etc Diabetes Lifestyle Alcohol Smoking How to prevent retinopathy Type 2 diabetes (diet/tablets) Insulin users Types of retinopathy Blood pressure Cholesterol, prevention etc Other retinopathy issues Driving Other problems Allergic conjunctivitis Blepharitis Cataracts Cataract surgery animation Cataract surgery at Good Hope Chalazion, styes, eyelid Dry & sore eyes Herpes simplex keratitis (cornea) Naevi Links/other problems Central serous retinopathy Migraine Posterior vitreous detachment Stroke / TIA corneal ulcers Recurrent corneal abrasions Retinal vein blockage/occlusion Squints & Lazy eyes Thyroid eye disease Watery eyes, adult Watery eyes in children

Background

Wet ARMD involves CNV growth and leakage under or near the macula. The CNV and he leakage damage the macula, causing loss of central vision. The CNV, without treatment, often cause significant scarring and loss of central vision. The growth and leakage can be reduced/stopped with anti-VEGF injections in the eye. the drug (anti-VEGF injections) only really work for 4 weeks, and then the effect wears off the leakage/growth starts 4 weeks before visual changes this means visual changes (distorted/wavy/patchy central vision) follow CNV growth by 4 weeks and so they cannot be relied on to detect very early disease. The only practical way of detecting early disease is with OCT. As the drugs work for 4 weeks, 4 weekly OCTs are needed to detect early disease. This leads to a massive number of patients visits and OCTs, too many for doctors to examine. Various units have trained technicians to carry out and interpret the OCTs, and Good Hope is trying to develop such a service When OCTs are cheaper these may be carried out by optometrists, and eventually at home, but until the OCT software can interpret the images with a ‘computer’, a person has to interpret the OCTs In practice then, after the first 3 injections (i.e. one every month for 3 months, are needed at the beginning) every patient has either an OCT or injection or both every 4 weeks After the first 3 months, patients then attend monthly for an OCT, and if there is fluid, an injection is arranged as soon as possible  if there is no fluid, the OCT repeated 4 weeks later It would be convenient for the patient if the injection could be carried out at the same visit as the injection. In practice this has been difficult for us to arrange as we are not sufficiently organised, but also the number needing the injections is so unpredictable the service becomes difficult to manage.

The organisation

Our technician who does the OCTs is just about to be ready to grade the scans without direct supervision, taken 6 months to train Has been supervised for the 6 months She will enter the data onto Medisoft our system...takes 10 minutes/patient!!!!!!!!!! This will generate GP letters and notes A clerk organises the visits 20 patients a week We include a few diabetics ...monitor cme; a few soft drusen in smokers (i.e. high risk, 3 month review) Scans are monthly if the last injection was in last 6 months, otherwise intervals progressively extend Patients can ring up for an OCT if they notice visual symptoms Symptoms come 4 weeks after CNV..so we have to OCT to detect the CNV Patients are invited back for a further OCT 4 weeks after every injection The one problem is bilateral... when we inject but only one eye we should OCT the other eye We need to ask the technician to address smoking and blood pressure if she is the only person seeing the patient Of course we know we might be missing the very early case with a tiny haemorrhage and no visible OCT changes, but the proportion of these is small

Later

When the technician is ‘qualified’ to interpret the OCTs, The technician and doctor will still grade some OCTS together, as part of the audit process To interpret ‘borderline’ OCT, when it is difficult to make a decision We need to develop the service further and try and grade patients Some patients probably need anti-VEGF injection every month (call this group e) Some people may need them only occasionally (call this group o) Many patients will be in between (call this Grade ib) If there is a lot of fluid, 3 injections are probably needed to flatten the retina If there only a little fluid, and the patient is in group o, only one injection is booked If there is a medium amount of fluid, 2 injections are booked If it were possible to grade patients: Grade e would not need OCTs monthly, they would attend for injection only, saving clinic /patients time/money making it easier to plan (the fellow eye night need OCT, perhaps at the same time as the injection of the eye being treated Grade o patients would generally just need a an OCT occasionally

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