Unassessable- that’s what they are!

Sarah Janikoun

Samantha Mann

Denise Mabey

What is the ‘unassessables’ clinic?

All diabetics in UK have retinal photos annually

They are sent to the ‘unassessables’ clinic if:

-the photos are unreadable

-the patient is unable to sit at the camera

-or unable to cooperate

Staff in the unassessables clinic

Mrs Denise Mabey FRCS cataract surgeon and generalist

Dr Sarah Janikoun MRCOphth diabetic retinopathy practitioner and generalist

Reasons for audit

Assess possibility of reducing unnecessary review of disabled patients at very low risk of diabetic retinopathy…

Can we safely amend opt out process?

How much good are we doing with this service?

Results

Age of patients seen in the unassessables clinic (375 patients)

15 RIP( 4%)

29

31

79

133

106

15

0

20

40

60

80

100

120

140

Age Groups

30-39

40-49

50-59

60-69

70-79

80-89

>90

Numbers

of

patients

33% over 80 years 66% over 70 years

Reasons for being unassessable (N=233) : ocular disease

Cataracts 133 57%

Capsular thickening 10 4%

Vitreoretinal disease 8 3%

Pterygium 7 3%

Corneal scarring 5 2%

Old ocular trauma 5 2%

Ptosis 4 1.7%

Squint 4 1.7%

Asteroid hyalosis 2 0.8%

Corneal graft 1 0.4%

Blepharophimosis 1 0.4%

Reasons for being unassessable: practical and intractable

(underestimate)

Dementia 23

Wheelchair bound 6

CVA 3

Reasons for being unassessable: probably only temporary

Small pupils: 6

Ill advised removal of contact lens 2

(aphake and keratoconus)

Refractive error 5 TOTAL 13 (5%)

Returned to DECS 8

Cataracts

‘early cataract’ 62 26%

Referred to waiting list 63 27%

Refused cataract surgery 8 3%

TOTAL 133 57%

Capsular thickening 10 4%

Diabetic retinopathy

Mostly no retinopathy R0M0 238 (94%)

R1M0 8 (3.4%)

R1M1 3 (1.28%)

(under St Georges, sent to Medical Retina clinic, already under our med ret clinic with recent CVA)

R2 3 (1.28%)

One already seen in Med Ret, others referred)

R3 1 (0.4%)

(well treated –stable)

Medical retina disease (old and new)

Dry ARMD 14 (6%)

Wet ARMD 2 (0.8%)

CRAO 1 (0.4%)

BRAO 1 (0.4%)

Vein occlusion 5 (2.%)

Referrals to medical retina clinic 7 (3%)

Glaucoma

Already under STH glaucoma clinic 26

Referred to STH glaucoma clinic 26

(Urgently 2)

Under Moorfields glaucoma clinic 3

Under St George’s for eyes 2

Under Kings for glaucoma/med ret 8

Ocular conditions present Cataract 133 Glaucoma 52 ARMD 16 Capsular thickening 10 Vitreoretinal scarring/macular hole 8 Pterygium 7 Disorganised eye due to injury 5 Corneal scarring 5 Refractive error 5 Vein occlusion 5 Squint 4 Ptosis 4 Retinal arterial occlusion 2 Pre-proliferative diabetic retinopathy 2

Ocular conditions present Asteroid hyalosis 2 Keratoconus 1 Dystrophia myotonica 1

Entropion 1 Optic atrophy 2 VII Palsy 1 HZO 1 Corneal grafts 1 Blepharophimosis 1 Coloboma 1 Ischaemic optic neuropathy 1 Blepharitis 1 Retinitis pigmentosa 1 Eye infection 2

Unassessable by us

One eye 6

Two eyes 11 (Mostly medically unfit)

Very disabled 6 (not usually a problem)

Dementia 23 (underestimate)

Bilateral unassessables

Glaucoma +/- surgery (3)

Corneal scarring (2)

Dementia (6) (Underestimate and one had eye infection)

Patients ‘at risk’:

R1M1 3 patients

R2 3 patients

R3 1 patient (not really)

Wet ARMD 2 patients

Urgent glaucoma 2 patients

Total 11 (4%)

What is an acceptable level of risk?

Patients who benefitted from the unassessable clinic

63 patients had cataract extraction 27%

(only 3 known to have poor outcome uveitis/CMO)

26 patients referred/restored to glaucoma clinic 11%

10 patients had YAG to capsule 4%

5 sent for useful refraction 2%

5 sent to low vision clinic to manage their poor vision better 2%

2 referred urgently for wet ARMD 0.85%

2 had treatment for ocular surface infection 0.85%

Activity benefit to the department

(let alone the patient)

Income from cataract surgery

Income from capsulotomy

Limitations of this audit

Using GP clinic letters led to limited information.

eg. Ocular trauma and corneal scarring may be the same thing.

Reference was not always made to mental state (copy goes to patient)

Reference was not always made to degree of physical disability

Opt out process or

Biennial follow up – or longer

Patients who are impossible to examine are therefore impossible to treat. ? Ethical to screen them? We now only refer patients to this clinic who can sit upright in a chair

Patients who are easy to assess ocularly but unable to cooperate and would be very hard to treat

Patients who are at very low risk of diabetic retinopathy

Current opt out criteria

4 Categories for ineligible, exclusion and suspension

The following categories will be covered under the policy:

No perception of light in both eyes Informed opt-out Medically unfit for screening. This includes the

following circumstances: Terminally ill Unable to be treated Unable to be screened by digital imaging or another

approved screening method

Has to be initiated by GP or clinical lead.

Benefits of the unassessables clinic

A previously hidden population of patients including those from care homes have an opportunity for improved vision from surgery, refraction, entropion repairs etc.

We are catching a proportion of glaucoma patients who are otherwise lost to the service.

Patients who are difficult to examine are in a clinic set up for them.

Decisions can be made immediately with experienced medical staff present.

The clinical activity obtained from this clinic is quite high. BUT…….

BUT…… How much blindness are we preventing from

diabetic retinopathy…??????

1 R3 already treated 3 R2s already being seen somewhere for their

retinopathy…

Should the NCB (National Commissioning Board) be funding the SLB (slit lamp biomicroscopy) service?

Issues

Withdrawing from the screening service could be easier. Currently has to be clinical lead or GP.

Annual review is unnecessary in some cases.

How many visually improvable cases are still hidden from us who are not diabetic?

Dementia and cataracts….?????study on usefulness of cataract surgery in demented patients

Cataract and dementia to do or not to do....

Link between cataracts and Alzheimers aetiologically

Paper indicating that cataract surgery does not improve cognitive behaviour in normal people

Papers supporting improvement in dementia scores after cataract surgery (Japan)

New Outcome Sheet

THANK YOU