RCOphth Age Related Macular degeneration services: Commissioning Guidance

The consultation sought views on the proposed Age Related Macular degeneration (AMD) Services: Commissioning Guidance. The aim of this guidance is to develop principles and minimum standards of care for AMD to decrease variations of care across AMD services in England and Wales. It also addresses the current and future capacity planning of AMD services. More information about the guidance can be found on the RCOphth website.

Our response to the consultation was as follows: 

1. We welcome this Guidance as it is very comprehensive and allows a multi professional approach and collaboration of work with primary care optometrists. However, we would suggest placing more emphasis and provide more details on the scope for collaboration between HES and primary care optometrists to ensure it allows commissioners with the flexibility needed to arrange services that meet their local needs. 

2. The evidence appraisal is consistent with NICE guidelines and includes relevant and up-to-date research, including acknowledgement of ongoing trials (brolucizumab anti-VEGF treatment).

However, while the document states that Amsler testing as a method to detect maculopathy is not a sensitive tool enough to detect activation/re-activation of wet AMD from current evidence, it is still the only widely available standardised tool for patients to self-monitor at home; and for optometrists to detect suspect maculopathy in the absence of OCT/slit lamp BIO or where other tests suggest normal fundus appearance. In the absence of any home monitoring devices and while it is not as sensitive as OCT, its use should not be discouraged as this may have a negative impact on patient groups affected by the guidance, in particular for patients between monitoring visits.

3. Although we understand that this guidance applies in England and Wales as commissioning arrangements are different in Northern Ireland and Scotland, it may be useful to add a note when a particular recommendation could apply across the UK.

4. We recognise that the Guidance proposes recommendations for future commissioning, which is welcome, but we would recommend ensuring that it aligns with the work already happening in England and Wales to improve pathways and encourages integration and innovation.

For example, this Guidance should be aligned with the ECRT endorsed (including by the RCOphth) pathways in England. While mostly aligned, we have noticed some key differences:

• ECRT pathway requires referral within 1 day for macular assessment in primary care/community eye service/hub prior to referral to secondary care (if needed), while this guidance advises referral direct to secondary care within 1 day.
• ECRT pathway requires practice performing macular assessment to have OCT in order to review/determine referral; whereas this guidance suggests OCT “can be helpful if available”
• ECRT pathway advises when patients are stable (no active disease), they are to be monitored in macular assessment settings with OCT as a must; but this guidance advises monitoring should be done with VA and OCT
• Where results of macular assessment are inconclusive/uncertain, ECRT pathway advises discussion with HES/HES virtual review of images to determine action to be take; whereas this guidance advises referral of such cases within 1 day to secondary care regardless.

While this list rightly identifies The College of Optometrists as COptom, we suggest changing the CoO abbreviations throughout the Guidance for consistency, in particular last line page 28 and third line page 29.

The reference to 'Royal Colleges' excludes The College of Optometrists (and other organisations) which also provide information leaflets for patients. We recommend amending this point in particular as the next point focuses on the management of AMD in primary care.

We suggest rewording this sentence to add clarity on the distinction between GOS and other services. GOS sight testing services are not monitoring services. It is important as a commissioning guideline that this document more explicitly states that services delivered by primary care optometry beyond General Ophthalmic Services (GOS) will need to be separately commissioned.

Primary care optometrists are not allied health professionals (AHPs) as defined by NHS England but are independent practitioners. Therefore, we would suggest rewording as below:

‘We recommended that stable patients be monitored via stable virtual review clinics. Primary care optometrists and AHPs (including ophthalmic nurses and orthoptists) may undergo or lead on training of staff and the development of such services, working alongside medical staff at all stages of the patient pathway.’

‘Additional risks should be explained for specific products e.g. anti VEGF therapy and the theoretical risk of thrombo-embolic events, floaters may occur following IVT; the importance of probable repeated injections should be discussed; the likely frequency at which these will be required, and long term nature of therapy.’

The importance of probable repeated injections and the likely frequency at which these will be required, and long term nature of therapy should not be considered as additional risks. We suggest removing this last part of the sentence or to include it as a separate point.

‘• Percentage of patients with confirmed Late AMD (wet active) being treated (or offered treatment) within 14 days of referral.

• Follow-up delays (Actual interval versus planned interval) defined as time from referral to first treatment.’

Should this last statement be part of the point above (or deleted)? Follow-up delays relates to ongoing appointment / treatment intervals and not the initial one.

While the AMD Commissioning Guidance rightly includes a reference to the College of Optometrists’ High Qualifications (e.g. pages 21 and 28), we would suggest adding a similar reference to the Executive Summary as an important element of Workforce Development and Training.

Submitted: March 2021