New Zealand’s ageing population is experiencing an upsurge in common age-related eye diseases. Clinical nurse specialist VICKY MIYEONG YOU reports on an innovation at Greenlane Eye Centre that has seen nurses trained to deliver collaborative specialist treatment for one of these diseases – wet macular degeneration.
Age-related macular degeneration (AMD) is the leading cause of blindness in people aged over 50.
In 2009 people with AMD made up nearly half (48 per cent) of the registrations with New Zealand’s Blind Foundation for that age group, much higher than the registrations for other age-related causes of blindness, such as glaucoma (16 per cent) and cataracts (11 per cent).
New Zealand’s rapidly ageing population means all age-related diseases – including those of the eye – are an increasing burden on the health sector. Statistics New Zealand data shows that in the early 1970s the elderly comprised 8.5 per cent of our population. Today they comprise 12.3 per cent; the increase in the number of elderly has outpaced the growth in the general population.
To reduce the impact of age-related diseases on the health sector, nurses in a range of specialties have been trained in tasks traditionally done by doctors. In this review, I discuss my own experience of working in collaboration with ophthalmologists to deliver specialist treatment for wet AMD (see box for more about AMD).
Treatment of AMD
Historically, the abnormal retinal blood vessels of wet AMD used to be treated with laser. Although this arrested the development of wet AMD, only a small number of patients benefited as laser treatment scars the retina and damages vision.
Laser treatment has been replaced over the past decade by the use of anti-vascular endothelial growth factors (anti-VEGF). These medicines are injected straight into the eye in a technique known as intravitreal therapy (IVT). Avastin, being the cheapest of the anti-VEGF agents ($30 per treatment) is used as first line therapy in
New Zealand. The other two anti-VEGFs are Lucentis, and Eylea ($1,500–$2,000 per treatment), which are reserved as second line therapy for patients who fail to respond to Avastin.
While there is no cure for wet AMD, regular treatment with an anti-VEGF is effective, if the treatment is applied in a timely manner.
The growth in demand for IVT
At Greenlane Eye Clinic, the number of IVT injections given has almost doubled, from 2,500 in 2012 to more than 4,500 in 2015. The increase in demand for this treatment includes not only the ongoing demand generated by patients with wet AMD but also the expansion of the use of the anti-VEGF agents into the expanded treatment of both diabetic macular oedema and retinal vein occlusion.
Total number of IVT injections per year.
Courtesy of Samalia et al., 2015 (see below)
Senior hospital management recognised that there were insufficient medical staff to cope with the surge in demand so it was decided to recruit and upskill senior ophthalmic nurses to administer IVT.
Nurses trained to monitor and treat AMD
In 2013 myself and two other nurse specialists, already skilled in sub-Tenon local anaesthetic administration, were trained to administer IVT. After the training was completed, our practice was audited and we were credentialed to undertake IVT clinics in collaboration with ophthalmologists. Today, nurses carry out more than 85 per cent of IVT, whereas back in 2013 IVT was only performed by doctors.
In addition to providing the injection treatments, nurses also educate patients on modifiable AMD risk factors. These risk factors include smoking, prolonged exposure to strong sunlight, and poor diet. Patients are advised that a diet rich in carotenoids (fruit and vegetables), omega-3 fatty acids and fish products can slow the development of wet AMD.
One-stop AMD service
Recently patient care at Greenlane Eye Clinic has been streamlined with a ‘one-stop’ service. Previously patients diagnosed with wet AMD were treated at an IVT clinic two to three weeks after their initial assessment. Now patient assessment and treatment are completed on the same day. An ophthalmologist monitors and assesses the patient and those needing treatment are immediately seen by the nurse for IVT.
A United Kingdom study in 2007 found that the cumulative health care cost of patients with AMD in both eyes was seven times those of healthy individuals. In New Zealand it is estimated that the number of people with AMD will increase to 13 per cent by 2026, so it is important to educate the public about AMD and what they can do to lower the risks.
The current model of a hospital-based AMD service is not sustainable, given these anticipated demands. As a result, I believe there is a need to explore alternative models of care; these may include collaboration with community optometrists, further expansion of the nursing role and local satellite ophthalmology clinics.
The Greenlane experience has proven that offering collaborative ‘one-stop’ clinics – where AMD patients are assessed by ophthalmologists then treated with IVT by nurse injectors – is a safe and effective model for providing care to our patients with wet AMD. :
Written by: Vicky MiYeong You, RN, MNurs, clinical nurse specialist, Greenlane Clinical Centre, Auckland District Health Board.
Co-authors: Reena Patel, RN, MHSc, School of Nursing, University of Auckland; Sue Raynel, MA, BHSc, OND, RGON, Research & Development Manager, New Zealand National Eye Centre, University of Auckland; David Squirrell, BMed Sci (Hons), MBChB (Hons), FRCOpth, FRANZCO, consultant ophthalmologist for Auckland District Health Board.
Acknowledgments: Samalia P, Garland D, Zhen W, You V, & Squirrell D (2015). Nurse specialists for the administration of anti-vascular endothelial growth factor intravitreal injections. Unpublished manuscript.
What is age-related macular degeneration (AMD)?
The macula is the central part of the retina that provides us with fine vision. In the early stages of the disease, vision is often blurred and distorted but in the late phases of the disease blindness may eventually develop.
Afflicted patients have difficulty with the normal activities of daily life, such as reading, writing, cooking and driving. The condition may necessitate early retirement, which in turn increases the risk of financial hardship. AMD also increases the risk of falls and injury and there is a recognised link between AMD and depression.
A New Zealand Medical Journal article by Waikato ophthalmologist David Worsley last year estimated that 10.3 per cent (184,400) of people between the ages of 45 and 85 years were affected by AMD in 2014. The article predicted that by 2024 this will increase to 12.9 per cent (208,200) (5), meaning that, in less than 10 years’ time, AMD is expected to affect one in seven people aged over 50 and one in four aged over 80.
There are two types of AMD, dry and wet. The dry form results from atrophy of the retinal pigment epithelium, leading to loss of photoreceptors. There is no treatment for dry AMD.
Wet AMD results in vision loss due to abnormal blood vessel growth. The proliferation of these abnormal blood vessels in the retina is stimulated by vascular endothelial growth factor (VEGF). The new vessels are fragile and leak blood, leading to irreversible photoreceptor damage and rapid vision loss.