Optometry Australia has called on the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) to partner in the development of a model that would see appropriately trained optometrists administering anti-VEGF injections to patients with wet age-related macular degeneration (nAMD) and diabetic macular oedema (DMO), with the potential for treatment of retinal vein occlusion (RVO) as well.
Darrell Baker, National President of Optometry Australia, said the profession of optometry has a “moral obligation” to explore strategies to help relieve the burden of treatment for this increasingly prevalent eye disease.
Australia’s optometrists are seriously under-utilised compared to their counterparts in similar developed nations like the United Kingdom, New Zealand and the United States
nAMD is the leading cause of blindness among non-Indigenous Australians over 50-years. The total number of patients receiving anti-VEGF to treat nAMD (Lucentis and Eylea) increased from 7,457 patients in 2007 to 50,964 total patients in 2017. Similarly the number of people being treated for DMO and RVO is increasing, from 3,990 patients being treated for DMO in 2015 (when PBS authorisation for treatment came into effect) to 11,137 patients in 2017; and from 3,191 RVO patients in 2015 to 10,781 patients in 2017.1
Servicing these needs in Australia are 1018 ophthalmologists, most of them practising in major cities,2 leaving a service short-fall in regional, rural and remote areas.
INTERNATIONAL EVIDENCE OF SUCCESS
Mr Baker believes that by training optometrists to administer anti-VEGF therapy, many of the barriers to accessing treatment for nAMD would be removed.
“Australia’s optometrists are seriously underutilised compared to their counterparts in similar developed nations like the United Kingdom, New Zealand and the United States. We must begin looking at how we can best use the available, skilled eye care professionals we have to better meet unmet patient need,” he said.
Indeed, registered nurse practitioners and optometrists in the United Kingdom and nurses in New Zealand have been administering anti-VEGF injections for some time, with positive consequences.
One 2019 study in the United Kingdom reported that delivery of routine retina care is increasingly provided by ophthalmic nurse practitioners, hospital optometrists, technicians and orthoptists. The study reported that, “Results show positive patient satisfaction with a nurse-led injection service, with little variation in patient experience when compared to a doctor-led service, and an acceptable safety profile.”3
In Palmerston North Hospital Eye Department, New Zealand, two initiatives were successfully incorporated in an effort to reduce resource constraints – a senior nurse-led macular review clinic and a nurse-led intravitreal injection clinic.
The authors reported “a reduction in unintended delays for both reviews and treatment”. Additionally, the re-allocation of resources freed senior medical officers to offer clinics, reducing wait times for new patients requiring initial assessment before starting treatment.4
A prospective safety audit undertaken in the Ophthalmology Clinic, Greenlane Clinical Centre in Auckland, involving the administration of 2,900 injections over 18 months by two nurse specialists, concluded that the nurse specialist-delivered injection service “is a safe and effective service for treatment of wet AMD, diabetic macular oedema and vein occlusion”.5
A COLLABORATIVE MODEL
Mr Baker said a breadth of action will be necessary to provide timely and affordable access to treatment via intravitreal injections for all patients who need it in Australia.
“Better utilisation of our skilled optometry workforce should be considered as part of the answer,” said Mr Baker. However he also acknowledged that “not all, or even most, optometrists would want to be involved. But it would mean that some optometrists could be trained up to work with ophthalmologists to support better patient access.”
Optometry Australia’s first preference for the profession’s involvement in the provision of intravitreal therapy would be collaboration between optometrists and ophthalmologists to co-manage patients with nAMD and DMO.
The Association envisages working with RANZCO to develop protocols and documented standards for patient management and treatment, and to develop a training program for interested optometrists. Training may follow the UK model which has involved three days of theoretical training followed by observation then hands-on practical training under the supervision of a retinal consultant during which time the optometrists would be required to administer a defined number of injections.
As is the case with glaucoma, optometrists would refer patients with signs of macular degeneration and DMO for diagnosis and, as required, the ophthalmologist would set out a treatment plan. The patient’s optometrist would then implement the plan in collaboration with, or with remote supervision of the ophthalmologist, sharing retinal imaging as needed, and relying on the ophthalmologist’s expertise and specialist care should it be required.
Mr Baker said increasingly sophisticated imaging technology and inter-professional information transfer is enabling the ability for remote decision making.
“It has been shown that safe care can be provided when the optometrist and patient are geographically separated from an ophthalmologist, and this is supported within the Medicare Benefits Schedule. Optometry Australia believes using this model for nAMD, DMO and RVO would drastically improve service availability across the country and reduce the burden of treatment for patients. Optometrists across the country already identify disease that may require intravitreal injection; enabling specialist opinion and treatment through technology will enable more patients to be treated more efficiently,” Mr Baker said.
Billing, to ensure both optometrists and ophthalmologists are appropriately remunerated for services, is another area that would need discussion, should a collaborative model of care proceed.
“Within a collaborative arrangement, once the professions have agreed, this will simply require a change to the MBS item rather than new legislation,” Mr Baker said, adding that patients are likely to benefit financially from optometry’s provision of injection therapy.
Currently, by the end of the second year of treatment, 40% of patients who have commenced anti-VEGF treatment have dropped out, mainly due to out-of-pocket costs.6
“We know that there are very low rates of bulk-billing for anti-VEGF injections and that patients typically pay hundreds of dollars per injection. On the other hand, 94% of optometrists bulk bill their services, so if this billing model is maintained, we can anticipate vastly reduced patient expense,” said Mr Baker.
The 2019 MBS Review Taskforce recommended intravitreal injection rebates be reduced by 69%. If adopted by the Federal Government, patient out-of-pocket costs are likely to increase under the current ophthalmology model as costs are passed on by providers.This in turn is likely to push more patients into an already constrained public health system, as highlighted by Dr Peter Sumich, former President of the Australian Society of Ophthalmologists.7
Other barriers to care, namely the distance many patients travel to receive therapy, and injection fatigue over time, are also expected to reduce with optometric involvement.
“Patients in regional and remote areas who can travel to their local optometrist will not incur the expense of regular long distance travel to attend ophthalmology appointments in major cities. Additionally, because these patients often have established loyal relationships with their local optometrist, they may be less inclined to miss review and treatment appointments,” he said.
Mr Baker said Optometry Australia is eager to begin working with RANZCO to develop an effective model that will significantly reduce barriers to treatment and improve outcomes.
“It seems most likely that demand for anti-VEGF therapy will increase, and this problem will get worse. As a sector we have a responsibility to explore how we can do things differently to better meet patient need. The UK has shown us that an enhanced role for non-medical health workers, like optometry, can be part of the answer… Optometry Australia is looking forward to constructive discussions with RANZCO so that we can begin to make change.”
When mivision asked David Andrews, Chief Executive Officer of RANZCO about the College’s position on a collaborative care model for the delivery of anti-VEGF therapy, and whether it would be interested in entering discussions with Optometry Australia, Mr Andrews replied, “Our position around intravitreal injections has not changed and we do not believe it is necessary that optometrists provide this service”.
- Ranibizumab and aflibercept: analysis of use for AMD, DMO, BRVO and CRVO Drug utilisation sub-committee (DUSC), May 2018. www.pbs.gov.au/industry/listing/participants/public-release-docs/2018-05/aflibercept-ranibizumab-DUSC-PRD-2018-05.pdf.
- Medicare Benefits Schedule Review Taskforce, Ophthalmology Report 2019/ www1.health.gov.au/internet/main/publishing.nsf/Content/mbs-review-2019-taskforce-reports-cp/$file/Final-Report-Ophthalmology-August-2019.pdf
- Gale, R.P., Mahmood, S., Devonport, H. et al. Action on neovascular age-related macular degeneration (nAMD): recommendations for management and service provision in the UK hospital eye service. Eye 33, 1–21 (2019). https://doi.org/10.1038/s41433-018-0300-3
- Jiyeon Kim, John Ah-Chan and Greig Russell. Kim et al., J Improving Patient Access to Intravitreal Anti-Vascular Endothelial Growth Factor Treatment through an Integrated Collaborative Team Care Approach. Clin Exp Ophthalmol 2018, 9:6 DOI: 10.4172/2155-9570.1000768
- Samalia P, Garland D, Squirrell D. Nurse specialists for the administration of anti-vascular endothelial growth factor intravitreal injections. N Z Med J. 2016 Jul 15;129(1438):32-8. PMID: 27447133.
- New App Revolutionises Ophthalmology Authority Prescription Approvals. Mivision February 2021.
- Taskforce Recommends Optometrists, Nurses Assessed for Anti-VEGF. Mivision 27 September 2019.