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

Consultant physicians working with patientsDiabetic eye disease Royal College of Ophthalmologists. Diabeticretinopathy preferred practice screening guidance. 9 NHS Quality Improvement, Scotland. Diabeticretinopathy screening clinical standards. 10 Royal College of Ophthalmologists. Guidelines fordiabetic retinopathy. 9Age-related macular degeneration Royal College of Ophthalmologists. Maximisingcapacity in AMD services. 9 Royal College of Ophthalmologists. Guidelines formanagement of AMD. 9 Royal College of Ophthalmologists. Guidelines forintravitreal injections procedure. 9Retinal vein occlusion Royal College of Ophthalmologists. Interimguidelines for the management of retinal veinocclusion. 96 Clinical work of consultantsMedical ophthalmology is an outpatient-based specialtyalthough there are usually facilities for day-case andinpatient admission for a minority of patients.Most ophthalmic physicians do not participate inout-of-hours work, but it would be feasible foran ophthalmic physician to be on an ophthalmologyon-call rota if there was cover provided by anophthalmic surgeon for the small proportion of casesthat require urgent surgery.Specialist clinics such as ocular inflammation andneuro-ophthalmology require direct consultantinvolvement and close supervision of trainees. With thehigh-demand services like AMD and diabeticretinopathy, there is often a more supervisory role.Ophthalmic physicians need to facilitate rapid referraland diagnosis of patients with macular degenerationand are responsible for the quality of the service. Otherhealth professionals such as nurses and optometristsmay be trained to assess and manage patients withmacular degeneration according to protocols. ‘Virtualclinics’, where clinical decisions are made on the basis ofocular images and visual acuity, are used in somecentres for diabetic maculopathy to determine whichpatients need to be seen in the diabetes eye clinic.Clinical administration work can be time consumingdue to the large numbers of referrals and outpatientreviews. Ocular inflammation and neuroophthalmologyclinics are particularly demanding asadditional investigations are often required and apatient may be under the care of a number of specialists.7 Opportunities for integrated careMedical ophthalmology is complex. Hospital services,general practice, community eye services and socialservices need to be coordinated. Optometrists servelocal communities and have the ability to perform amore complete ophthalmic examination than can beachieved in general practice but until recently this hasbeen underused by the NHS. The role of theoptometrist has been reviewed in the Generalophthalmic services review (2007) 11 and the Review ofcommunity eyecare services in Scotland (2006). 12Optometrists are now taking on extended roles, in someareas taking referrals from general practice, managinganterior segment eye conditions and glaucoma in thecommunity with extended prescribing rights, andworking up more complex cases to a higher level beforethey are referred to the hospital eye service. 12 Linkingcommunity optometrists with social services andhospital eye services allows optometrists to identifythose with failing sight and to refer on for treatmentand social-work assessments where appropriate.Cost-effective evidence-based treatments are lacking ina number of areas of medical ophthalmology butparticularly in the field of ocular inflammation wherethere are no licensed immunosuppressive medications.Clinical research should be encouraged and integratedwith routine clinical care.8 Workforce requirements for the specialtyThere are currently 10 consultant medicalophthalmologists and eight trainees in the UK. Thereare no academic medical ophthalmologists or academictraining posts at present.More than half of new referrals to ophthalmology arefor medical rather than surgical ophthalmic problems. 13It is recognised that there is a lack of trained medicalspecialists and that a substantial expansion in numbersof consultants is required to deliver services in the UK.It is estimated that a ratio of one ophthalmic physicianto eight ophthalmic surgeons in a unit is required, and itis predicted that in the future there will be one164 C○ Royal College of Physicians 2013