Consultant physicians working with patients - Royal College of ...

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2 Specialties Medical ophthalmologyMedical ophthalmologyDr Richard P Gale BSc MBChB MRCP MRCOphth MEdConsultant medical ophthalmologistDr Catherine Guly MbChB MRCOphth MRCP(UK)Consultant medical ophthalmologist1 Description of the specialty‘Ophthalmic physicians’ or ‘medical ophthalmologists’are trained in both medicine and ophthalmology andare skilled in the diagnosis and management of systemicdiseases affecting the eyes and vision as well asophthalmic conditions that do not require surgery.Patients with generalised vascular, autoimmune,neoplastic, inherited and degenerative disorders mayfirst present with ophthalmic symptoms and signs andan understanding of systemic disease, as well as thecomplex interaction between physical, social andpsychological factors, is essential to providing a holisticapproach to patient care. 1Medical ophthalmologists have varying roles around theUK but are mainly employed as ophthalmic specialistscaring for patients and providing services in one ormore of the following areas: ocular inflammation (which includes uveitis andinflammatory diseases of the cornea and orbit) diabetic eye disease neuro-ophthalmic problems (vision and the brain) retinal disease (which includes age-related maculardegeneration (AMD), retinal vascular occlusionsand hereditary eye diseases).Ophthalmic physicians may undertake laser treatmentsof the retina and deliver drug injections into the eye(intravitreal injections). Other roles undertaken bysome ophthalmic physicians include supervision of eyecasualty or primary care clinics and managing diabetesretinal screening programmes. Ophthalmic physicianssupport patients with visual impairment, and theirfamilies, and provide access to rehabilitation and socialsupport services.With an ageing population, an increasing prevalence ofdiabetes and the growing use of biological therapies(intravitreal and systemic), the workload and demandfor ophthalmic physicians is expected to continue toincrease.2 Organisation of the service and patternsof referralOrganisation of the serviceOphthalmic physicians are usually based inophthalmology departments or eye hospitals but havelinks with other physicians. Most patients are seenwithin the ophthalmic setting but some ophthalmicphysicians offer outreach services to neurology andinfectious disease units and for hospital inpatients.Services are usually outpatient based, with access today-case and inpatient beds required for a minority ofpatients.ReferralsOphthalmic physicians receive referrals from otherophthalmologists, GPs, physicians and optometrists,and through the diabetes retinal screening programme.Direct referral from community optometrists isencouraged for certain conditions where a delayedreferral could result in loss of vision, for example in thecase of AMD. Many conditions managed by ophthalmicphysicians initially present urgently through eyecasualty clinics.Ophthalmic physicians generally offer secondary andtertiary level care although some offer primary carethrough supervision of eye casualty or primary careclinics. Tertiary referrals usually involve patients withcomplex ocular inflammatory or neuro-ophthalmicdiseases.3 Working with patients: patient-centredcareEnsuring that the patient is at the centre of thingsPatient education and support is fundamental to thepractice of medical ophthalmology, where manypatients have chronic disease and lifestyle factors caninfluence the visual and systemic outcomes. TheDepartment of Health’s Supporting people withlong-term conditions 2 discusses the importance of givingC○ Royal College of Physicians 2013 161
Consultant physicians working with patientspatients the knowledge and skills to care for themselves.For example, good blood-glucose and blood-pressurecontrol reduce the risk of progression of diabeticretinopathy and help to preserve vision. Liaison withGPs, physicians and specialist nurses is important toreinforce these messages and to provide additionalsupport. Skilful counselling is required to inform andeducate while recognising the individual’s expertise intheir own condition.Patient support groups, which include those for patientswith visual loss and those with specific medicalconditions, enable patients to gain from the lifeexperience and understanding of others. An ophthalmicphysician will have links with one or more localsocieties for the visually impaired and many alsosupport charities at a national level.Visual impairmentOphthalmic physicians need to take account of thespecial needs of the patient with visual impairment,whether temporary or long term. The Royal NationalInstitute of Blind People (RNIB) ‘Losing PatientsCampaign’ has highlighted the difficulties faced byblind and partially sighted people who are given healthinformation that they cannot read. 3 Patient informationshould be available in a format that is accessible topatients with visual impairment and currently the NHSfalls behind on this ideal. Staff should be trained toassist those with visual impairment and to be alert tothe difficulties of communicating for patients with dualsensory impairment.In the UK, only one in three blind or partially sightedpeople is working. 4 Diabetic retinopathy and uveitis arethe leading causes of visual impairment in the workingyears of life 5 and these groups in particular need accessto specialist employment advice, which is usuallyprovided through charities. Advancing technology andcomputer software mean that many patients with sightloss can often retain their jobs if they are given adequatesupport.Timely registration using the certificate of visualimpairment (form BP1 in Scotland) enables patientswith poor vision to gain access to practical and financialsupport (although access to services for the visuallyimpaired should always be on the basis of need ratherthan registration).Ethical and religious considerationsOphthalmic physicians should be sensitive to culturaland religious beliefs and how these impact on a patient’sacceptance and understanding of their condition andtreatment.Patient-centred eye servicesA patient seeing an ophthalmic physician may need tohave a number of assessments and investigations, eg anorthoptic assessment and a visual field test for aneuro-ophthalmic appointment or retinal photographyand optical coherence tomography imaging at a diabeteseye clinic. Treatments such as intravitreal injections andretinal laser therapy are provided through outpatientdepartments.Services should be organised to enable patients to havetheir investigations and clinical review at the sameappointment wherever possible to minimise hospitalattendances. The Royal College of Ophthalmologistsissued guidelines on the commissioning of services forAMD in 2007 and recommends a ‘one-stop’ clinic,where investigations and treatments are performed atthe same visit. 64 Interspecialty and interdisciplinary liaisonWithin the ophthalmology department, ophthalmicphysicians work closely with ophthalmic surgeons,optometrists, orthoptists, ophthalmic photographers,electrophysiologists and ophthalmic nurses.Increasingly, ophthalmic nurses and optometrists arebeing trained to see and manage patients according toprotocols for conditions such as AMD and acuteanterior uveitis.Working with ophthalmologistsOphthalmology is divided into a number of subspecialtyareas and while the vast majority of patients aremanaged by one specialist, some patients may bemanaged by an ophthalmic physician in associationwith an ophthalmic surgeon. Patients may need to bereferred on for ophthalmic surgery, and others withcomplex disease benefit from seeing an ophthalmologistwith a special interest in their condition, eg a patientwith glaucoma secondary to uveitis may see anophthalmic physician, for control of their ocularinflammation, as well as a glaucoma specialist.An ophthalmic physician may be called to assist withthe management of ophthalmic patients with medicalneeds, for example a patient under the care of a cornealsurgeon requiring immunosuppression for a complexcorneal transplant.162 C○ Royal College of Physicians 2013
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