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At the heart of general practice since 1960

Why I resigned as IT clinical lead for my PCT

Mr Tony Moriarty outlines six new developments

in his field

1. Age-related macular degeneration: a growing problem

As our population grows, this will become an ever burgeoning medical complaint. Two forms exist: wet and dry. The wet form is the leading cause of blindness in this country over the age of 65.

Recently, photodynamic therapy has become more widely available in certain centres and this is being increasingly rolled out to peripheral units.

A dye is injected into the veins of the arm via an infusion (verteporofin) and a laser beam is shone at the retinal blood vessels as the dye passes through the leaking choroidal vasculature.

Several treatments are required over the first year, ultimately resulting in closure of the bleeding and leaking neovascular complexes in the fovea. NICE sanctioned the treatment nationally in 2003 and this will become an increasing available treatment.

Dry macular degeneration, unfortunately, remains a much larger cause of visual failure but there are no active treatments for this apart from anecdotal evidence that nutrients (and certain compound formulas such as Vision Ace or Icaps) may be helpful.

Low visual aids provided by low vision optometrists still remain the mainstay of treatment of this condition.

Implantation of intraocular telescopes is undergoing trials and remains an exciting prospect.

2. New glaucoma treatments

Chronic open angle glaucoma affects something in the region of 1 per cent of patients over the age of 40 and is a significant cause of blindness in the


New medications worthy of mention are the cardio-selective ?-blockers, such as betaxolol, which minimise systemic side-effects such as breathing and cardiac problems, and prostaglandin analogues such as latanoprost, travoprost and bimatoprost which are very promising recent additions in the treatment of chronic open angle glaucoma with minimal side-effects.

Glaucoma is also much better diagnosed and assessed by the use of optic nerve head analysis. For a long time we have relied on visual fields that are notoriously difficult to interpret in the assessment of glaucoma.

Now we have the ability to quantitatively assess the optic nerve head and the damage to it by assessing either the optic disc size or retinal nerve fibre layer population around the optic nerve head, allowing us to pick up early signs of damage and progression.

3. Cataract surgery improvements

Phacoemulsification has allowed cataract surgery to occur in sub 3mm incisions.

In this situation, the cataract can be dissolved with an ultrasonic machine inside the eye and aspirated without the need for large incisions and sutures.

Intraocular lenses can be folded into the old capsular bag from which the cataract was removed and advances in lens technology are occurring all the time.

These include the development of multifocal intraocular lenses, allowing good near and distance vision in addition to the development of accommodative intraocular lenses, which can change shape by forward and backward vaulting, thus simulating the normal crystalline lens and improving near vision.

4. Corrective (refractive) eye surgery

Advances abound in the correction of long (hyperopia) and short (myopia) sightedness. Laser treatments include surface laser (photorefractive keratectomy ­

PRK) or Lasik (laser in situ keratomileusis).

The latter involves lifting a tiny flap of cornea and lasering the bed of the cornea and replacing the flap down.

A hybrid of the two treatments ­ Lasek ­ involves lifting a flap of epithelium and lasering the bed and appears to be offering significant advantages.

High refractive errors can be treated with implantable contact lenses in patients unsuitable for laser treatment due to high prescriptions.

5. Debate on diabetic retinopathy

Laser treatment remains the mainstay for the majority of proliferative retinopathy and macular oedema but vitrectomy (removal of the vitreous jelly) is becoming a much more favoured procedure in cases unresponsive to laser therapy.

Screening for diabetic retinopathy plays a very major role and currently the debate continues as to the most cost-effective and sensitive methods.

In different localities, optometrists may be involved in screening or a photographic system may be involved.

The debate continues at a national level as to the best screening methods but the old days of the diabetic physician performing an annual fundoscopy as a means of checking seem to have been superseded forever.

6. Less GP involvement

The GP is becoming increasingly short-circuited in schemes allowing direct referral from optometry to secondary care and this may inevitably lead to deskilling.

Optometry may be seen by the Department of Health as the home for ophthalmology primary care rather than general practice, and we may see ophthalmology primary care clinics being set up in each locality.

Waiting times for surgery have reduced dramatically. But, large numbers of patients are now being sent to travelling clinics and DTCs and follow-up for these patients may not be available in the usual manner.

Further information

·Eye UK (links to UK eye websites)

·Cochrane Eyes and Vision

·Moorfields Eye Hospital

·The Royal College of Ophthalmologists

·American Academy of Ophthalmology

·Bandolier: Cataracts

·NICE guidelines for ARMD:

·eMedicine Journal: Ophthalmology

·The ageing eye:

Tony Moriarty consultant ophthalmologist, Stepping Hill Hospital, Stockport

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