Josephine Duvall-Young - Emergency, Acute and Rapid Access Ophthalmology: Practical, Clinical and Managerial Aspects

In recent decades, ophthalmology has become increasingly superspecialised, with the result that there is a degree of deskilling of ophthalmologists and a need to rediscover the general ophthalmologist, also sometimes referred to as the comprehensive ophthalmologist . This is particularly a problem in countries where eye care is medically delivered and hospital based, notably the UK. The problem will however arise if it has not already done so in other health care systems. This book is written to address the demands and problems of the UK National Health Service (NHS) delivery of ophthalmology, but also has a more general target in ophthalmology worldwide.

There are many excellent textbooks in the field of ophthalmology , taking either a general or a more specialised approach. This book is not intended to be a comprehensive referenced text, but more a guide to how to approach the provision of urgent and emergency eye care within a superspecialised hospital discipline. Only the most significant literature relating to reviews, major trials or guidelines will be referenced. Some topics will be mentioned briefly as a reminder and to help when planning the training of ophthalmologists and allied health professionals.

Referrals direct to hospital ophthalmology in the UK have been growing steadily and rapidly since about 2006 due to a number of factors. The demographic changes associated with an increasing population and greater longevity are part of all considerations of health care provision. However, more specifically, at that time, the change in the NHS contract with optometrists allowed them to refer patients directly to hospital departments of ophthalmology, rather than to their GP. As optometrists have acquired more and more technological equipment they are able to detect abnormalities which they could not previously see using more basic instruments such as a direct ophthalmoscope. The contract requires them to report any abnormality which could be significant to eyesight or general health, and since the referral now goes straight to the hospital instead of the GP, the number of referrals has exploded out of control. In conjunction with this change, lay access to online information about abnormalities detected gives rise to sometimes unwarranted anxiety. The internet as well as printed and broadcast media additionally feed the cultural shift in health seeking behaviour which is well recognised in a society encouraged to believe in entitlement to services. Apart from the very significant and somewhat unanticipated effect of changing the optometrists contract, patients themselves have altered their behaviour, and approximations for the annual increase in self referred eye emergencies are of the order of 10%. These numbers are unsustainable and the service delivery has to be managed. This is part of the role of the subspecialty recently recognised by the Royal College of Ophthalmologists, currently termed emergency ophthalmology but more appropriately termed emergency and rapid access ophthalmology.