The Centre For Eye Health (CFEH) in Sydney is celebrating 10 years of optometric practice. Founded by Guide Dogs NSW/ ACT (GDN) and the University of New South Wales (UNSW), the Centre’s aim is to reduce the incidence of preventable blindness by providing patients with access to state of the art imaging and diagnostic services with no out of pocket expenses.
To facilitate this, CFEH staff have worked collaboratively with the Prince of Wales Hospital (POWH) ophthalmology department for the last decade, pioneering methods of collaboration and new referral pathways with the potential for wider application throughout Australia.
Integral to this model of care has been developing collaborative relationships with referring practitioners. CFEH either assumes patient management, or reports on the specific referred condition, while the referring optometrist continues to fulfil all other optometric needs for their patient.
THE GENESIS OF CFEH
CFEH came about as a result of a GDN strategy review in 2006 and findings from a survey of existing clients who had suffered significant vision loss. A common perception amongst this group was that inadequate or delayed diagnosis of their visual condition had contributed to the extent of their visual loss. These findings, combined with the acknowledgement of an overburdened public health system and aging population, led to a strategic shift by GDN to encompass preventative eye care as well as the maintenance of the core activities relating to mobility services. Without this proactive diversification, the board feared a tsunami of demand for GDN’s existing services, which would have become increasingly difficult to finance in the absence of government funding.
The planning and execution of CFEH was achieved through the efforts of UNSW Associate Professor David Pye and the late Joe Finucane, the CEO of GDN at the time the Centre was developed. Operations began in December 2009 with Professor Michael Kalloniatis as the inaugural Centre Director.
CFEH was established as a referral centre for patients suspected of having ocular disease. It was equipped with a comprehensive array of the latest ophthalmic equipment and promoted as a diagnostic and imaging centre. An extensive network of referrers quickly developed, attracted by the thorough patient assessments and comprehensive patient reports provided. Currently, around 78% of optometrists and 30% of ophthalmologists in NSW/ACT are registered referrers to CFEH and in 2019 alone, projections indicate approximately 10,000 patients will be seen.
OPTOMETRY’S CHANGING LANDSCAPE
Two major transformations have occurred in managing eye disease over the past two decades. First, treatment options are now available for the major causes of vision loss and blindness, including age related macular degeneration (AMD), glaucoma, and diabetes related eye disease. Secondly, technological advancement, including structural information unthinkable a few decades ago, now provides clinicians with access to a wide variety of essential diagnostic information, providing an opportunity to reduce the incidence of vision loss and blindness in our society.
Over the last 10 years, CFEH has evolved and grown significantly even as the landscape of private optometry practice has changed and practitioners have acquired their own imaging equipment. The Centre’s shift towards disease management began in 2016 with the development of the glaucoma management clinic (GMC) in conjunction with POWH ophthalmology staff Professor Minas Coroneo, Dr Michael Hennessey, Dr Katherine Masselos, Dr Nagi Assaad, and other consultants and registrars.
The GMC is a shared care service providing both optometric and ophthalmological assessment of patients with either diagnosed or suspected glaucoma.
In 2019, further inroads into patient management have been made with the establishment of the new Retina Clinic – an optometry-led intermediate-tier clinic with pathways for monitoring patients with retinal conditions such as dry AMD or mild to moderate diabetic retinopathy that do not require ophthalmological intervention. Patients referred to CFEH by their optometrist for management of a specific condition (for example glaucoma) continue under the care of their referring practitioner for all other optometric needs.
Looking further ahead, CFEH will continue to develop, implement and refine clinical pathways with major hospitals. Recently, over 400 non-urgent referrals to a major hospital were assessed, finding that almost half of these referrals could be adequately dealt by an intermediate-tiered optometric clinic such as CFEH or community optometrists, rather than burdening the public health system. The diversion of these patients to optometrists offers a potentially significant benefit to an overloaded public health ophthalmology system and is an area in which CFEH is keen to make a positive impact.
In 2020, CFEH will commence a working relationship with Associate Professor Andrew White and his team at Westmead Hospital Ophthalmology as part of the Community- Eye-Care initiative. CFEH will also work more closely with GDN through the establishment of a Visual Function Assessment clinic where patients with vision loss will be extensively assessed, helping GDN client services tailor low vision and other vision rehabilitation solutions.
EDUCATIONAL CONTRIBUTION TO THE PROFESSION
Educating current and future referrers, as well as other health care providers is another major role of CFEH, which has an online continuing education platform for optometrists, specialising in ocular disease and imaging interpretation. Since the inception of the educational platform in 2013, a total of 70 live webinars have been broadcast and numerous independent learning modules created to upskill practicing optometrists in the detection and management of ocular disease. The webinar program is growing rapidly with a 15.5% increase in participation in 2019, compared with 2018, as more optometrists acquire optical coherence tomography technology.
Other educational activities include the development of an online course for general practitioners relating to the grading of diabetic retinopathy images. The development of freely downloadable ‘chairside references’, focused on the differential diagnosis of ocular disease, has seen frequent use over the past six months. Additionally, CFEH has initiated the provision of several imaging workshops in rural NSW (in association with GDN) and the convening of one undergraduate and two post graduate courses annually, relating to ocular disease through UNSW.
One of the key requirements for the provision of high quality clinical service and education is that it is evidence-based. Staff at CFEH have worked tirelessly to refine and develop models of care and clinical processes ensuring clinical decisions are based upon the best available scientific evidence.
Research conducted by CFEH, in collaboration with clinicians and researchers from other disciplines, has led to a large number of publications in several prestigious journals. During 2018, more than 20 CFEH peerreviewed papers with a CFEH address were accepted for publication, furthering the knowledge base in areas such as the understanding of ocular disease (including glaucoma and AMD amongst others); the use of pattern recognition to develop automated ways of assessing clinical data; the development of new referral pathways; assessment of collaborative patient management paradigms and translational research with significant clinical application for optometrists.
Over the years, staff based at CFEH have been awarded prestigious grants from the National Health and Medical Research Council and other external bodies to support the research being undertaken with a cumulative total of over AU$4.2 million.
By adding to the existing knowledge base of ocular disease and also developing strategies and clinical pathways relating to early detection, monitoring and management of eye disease, CFEH is having a positive impact on the reduction of preventable blindness.
The challenge for the Australian Health System is to ensure that all individuals with eye disease are identified and suitably managed. Work at CFEH has served to develop, apply and refine clinical protocols involving optometrists and ophthalmologists within an integrated health care system.
Collaboration between the POWH department of ophthalmology and CFEH is setting a standard for optometry/ophthalmology integrated care in Australia. The Centre plans to develop further collaborations with other hospital ophthalmology departments to increase the geographical accessibility of diagnostic and managements services, ensuring greater positive rates of preventable blindness in NSW and the ACT.