NICE quality standard - Serious eye disorders

NICE sought views on its topic overview on the eye disorders quality standard and this is our response (January 2018).

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This topic overview describes core elements of the quality standard. These include the population and topic to be covered, key source guidance to be used to underpin potential quality statements, any related quality standards, published current practice information and national or routine indicators and performance measures. This quality standard will cover the diagnosis and management of serious eye conditions in adults including cataracts, glaucoma and macular degeneration. It will also cover preventing sight loss in adults. The College of Optometrists expressed an interest in formally supporting this quality standard and highlighted the following four key areas for quality improvement:

1. Encouraging people to look after their eye health and raising awareness of the need for regular eye tests

Why is this important?

It is important to stress that routine eye examinations pick up eye disease at the earliest stage and increase the chance that it can be treated effectively without sight loss occurring.

We would stress the importance of interventions that encourage regular eye examinations with an optometrist as important healthy lifestyle behaviour. The vast majority of cases of sight-threatening, non-communicable eye diseases are detected through eye examinations by optometrists and early detection is a key factor in improved patient outcomes.

Why is this a key area for quality improvement?

Eye disease is a significant morbidity burden in the UK expected to grow as society ages1 but which could be significantly mitigated through better prevention, earlier identification and early intervention.

A lack of awareness of increased risk and reduced uptake of eye care services means sight loss is more prevalent.

The NHS recommends that most people should have an eye test every two year2. Yet over a quarter of UK adults have not done so, and 8% of people have never had an eye test3.

Because people are concerned about sight loss4, there is considerable potential for reinforcing eye health messages to broader health promotion campaign, e.g. diabetes, smoking cessation, etc.

Supporting information

1 Epidemiological & Economic Model Sight Loss in the UK: 2010-20: Minassian & Reidy, EpiVision and RNIB (2009).
2 NHS Choices: How often can I have a free eye test?
3 Royal National Institute of Blind People (RNIB), State of the Nation's Eye Health, 2016.
4 RNIB, Blindness feared more than Alzheimer’s, Parkinson’s and heart disease’, 2014.

2. Ensuring timely treatment for people with sight-threatening conditions

Why is this important?

Increasing demands on eye health services due to the ageing population and the availability of new treatments are creating acute capacity bottlenecks with the Hospital eye Services (HES), especially in relation to age-related macular degeneration (AMD), diabetic eye disease and glaucoma.

Delays in follow-up appointments can lead to further deterioration of sight, making the ongoing condition harder to manage effectively. This may lead to further demand for follow-up appointments. Managing chronic sight-threatening conditions effectively is dependent on regular appointments at specified intervals, so the more pressure there is within the system for appointments; the harder it is to prevent deterioration.

There are opportunities to make better use of the existing network of community-based eye service providers to reduce pressure on GPs and hospital services4,5.

There is also potential to increase the use of these services to deliver post-operative assessment and low vision care, and models such as Minor Eye Conditions Scheme (MECS), a collaborative approach between providers which has reduced the number of referrals to hospitals via GPs and increased community management6.

Why is this a key area for quality improvement?

It has been predicted that between 2010 and 2020, there would be a 26% increase in patients with AMD, a 20% increase in patients with Ocular Hypertension (OHT) or glaucoma and a 25% increase in people with diabetic eye disease1.

We are just over the halfway point and a 30% increase in ophthalmology outpatient attendances over the last five years is already being reported and this is set to rise further leading to unmanageable capacity problems in the HES2.

The hospital eye service is overwhelmed and patients are losing sight because of delayed treatment due to postponed hospital eye service appointments3.

Urgent change is needed if we are to avoid unnecessary sight loss and will involve using all the skills available across the eye care pathway4,5.

Supporting information 

1 Epidemiological & Economic Model Sight Loss in the UK: 2010-20: Minassian & Reidy, EpiVision and RNIB (2009).

2 The Royal College of Ophthalmologists

3 Surveillance of Sight Loss due to delay in ophthalmic review in the UK: Frequency, cause and outcome, Mr Barny Foot, Professor Caroline MacEwen:

4 Clinical Council for Eye Health Commissioning (CCEHC), Primary eye care framework, 2016

5 CCEHC, Community ophthalmology framework 2015

6 Konstantakopoulou E, Edgar DF, Harper RA, et al, Evaluation of a minor eye conditions scheme delivered by community optometrists, BMJ Open 2016;6:e011832. doi:10.1136/bmjopen-2016-011832 

3. Better access to habilitation and rehabilitation services

Why is this important?

Low vision has a significant impact on a person’s independence and quality of life. For example, older people with low vision are more likely to fall1 or suffer from social isolation and depression than their sighted peers.

Children and young people with low vision are at risk of poor outcomes since reduced visual input presents a major obstacle to the acquisition and development of fundamental developmental skills in early and later childhood.

Independent research has identified that good vision rehabilitation avoids significant health and social care costs; the costs avoided are more than three times the cost of delivering the service3.

Why is this a key area for quality improvement?

The current system of low vision habilitation and rehabilitation services is fragmented and more joined up commissioning is needed to ensure consistency of services for users, and the avoidance of a postcode lottery. In some areas, services do not exist and the population need has not been assessed.

In many areas, there is no accessible community low vision service, and the referral route can involve the optometrist referring to the GP, and the GP referring to the HES. Most HES departments provide low vision clinics supported by an eye clinic liaison officer (ECLO). ECLOs are key in linking patients to services and helping them understand the impact of their diagnosis2. An ECLO service is an essential part of the eye health and sight loss pathway and therefore should be included in contracts and service specifications.

Low vision services should be seamlessly incorporated into the eye care and sight loss pathways and not as an afterthought. Many adult patients access low vision assessments when sight loss has occurred and further treatment is no longer effective. Earlier anticipated access to low vision services could lead to better outcomes, when there is some useful vision present2.

Supporting information 

1 The College of Optometrists, Focus on Falls report, 2014
2 Clinical Council for Eye Health Commissioning (CCEHC), Low vision, habilitation and rehabilitation framework for adults and children, 2017
3 RNIB, Effective Vision Rehabilitation can avoid significant costs to Health and Social Care

4. Better eye care for people with special needs, e.g. learning disabilities, dementia

Why is this important?

Sight loss is under-diagnosed in people with dementia because one condition can mask or be mistaken for another.

People with learning disabilities are ten times more likely to experience serious sight problems than the general population, a disparity that is even more marked at a young age, so it is vital that their eye care needs are recognised and accommodated2.

The College of Optometrists has published a Guidance for Professional Practice, which includes a section on “Examining patients with learning disabilities”3 and a section on “Examining patients with dementia or other acquired cognitive impairment”4. The Guidance provides recommendations to support optometrists when examining a patient with special needs.

Optometrists are a key partner in improving a dementia patient’s quality of life, following diagnosis. Evidence from the Prevalence of Visual Impairment in Dementia (PrOVIDe) project shows that effective eye examinations are possible in most patients who have dementia1. As optometrists regularly see the segment of the population who are most at risk of developing dementia, they are in a good position to make positive differences to their lives by taking the appropriate steps to correct their visual impairment. The College Of Optometrists has produced resources for patients and carers, offering essential information on the importance of eye health for people with dementia.

Why is this a key area for quality improvement?

A recent study into the prevalence of dementia and sight loss found nearly one-third of people with dementia also had significant sight loss1. Almost half of the participants could have their sight loss corrected by wearing glasses, offering potentially significant improvement to quality of life and reducing the risk of avoidable injuries through falls. Ensuring that people with dementia get regular eye tests is vital.

People with learning disabilities experience profound health inequalities including eye health. It is estimated that around 2% of the population have a learning disability who would have a range of mild to more profound and multiple learning disabilities2.

Supporting information 

1 Bowen M, Edgar DF, Hancock B, Haque S, Shah R, Buchanan S, et al. The Prevalence of Visual Impairment in People with Dementia (the PrOVIDe study): a cross sectional study of 60-89 year old people with dementia and qualitative exploration of individual, carer and professional perspectives. Health Serv Deliv Res 2016;4(21)

2 SeeAbility, Delivering an Equal Right to Sight, 2016

3 College of Optometrists, Guidance for Professional Practice, Examining patients with learning disabilities  

4 College of Optometrists, Guidance for Professional Practice, Examining patients with dementia or other acquired cognitive impairment