Tests, Treatments and Procedures to Question – Public Information Sheet
What is Choosing Wisely Australia?
The goal of Choosing Wisely is to improve the quality and safety of health care in Australia by promoting conversations between doctors and their patients on avoiding wasteful or unnecessary medical tests and treatments. Not all tests add value for the patient and some can be costly or harmful. Choosing Wisely encourages shared decision-making, supporting consumers to be proactively engaged in their own care including discussions around tests, treatments and intervention options.
The Choosing Wisely messages have been developed by RANZCO ophthalmologists and are highly technical in nature. This Public Information Sheet aims to help patients understand these same messages and what they can do to choose wisely.
Board Approved Choosing Wisely Recommendations
Do not use corneal cross linking for every patient with keratoconus.
It is indicated when there is clear evidence of progression via change in refraction, anterior and posterior topographical data and tomographic data. In younger patients’ consideration can be given to crosslinking without evidence of progression if there is a strong index of suspicion that progression will occur without intervention.
Brown, S. E., Simmasalam, R., Antonova, N., Gadaria, N., & Asbell, P. A. (2014). Progression in keratoconus and the effect of corneal cross-linking on progression. Eye & contact lens, 40(6), 331-338. O’Brart, D. P. S. (2014). Corneal collagen cross-linking: a review. Journal of Optometry, 7,113-124.
Hashemi, H., Khabazkhoob, M., & Fotouhi, A. (2013). Topographic keratoconus is not rare in an Iranian population: The Tehran Eye Study. Ophthalmic Epidemiology, 20(6), 385-91.
Hersh, P. S., Stulting, R. D., Muller, D., Durrie, D. S., & Rajpal, R. K. (2017). United States Multicenter Clinical Trial of Corneal Collagen Crosslinking for Keratoconus Treatment. Ophthalmology, 124(9), 1259-1270. Witting-Silva, C., Chan, E., Islam, F. M. A., Wu, T., Whiting, M., & Snibson, G. R. (2014). A Randomised, Controlled Trial of Corneal Cross-Linking in Progressive Keratoconus. Ophthalmology, 121(4), 812-821.
Do not use topical antibiotics pre or post intravitreal injections.
Topical antibiotics (either before or after intravitreal injection) have not been found to decrease the risk of endophthalmitis.
Hunyor, A. P., Merani, R., Darbar, A., Korobelnik, J., Lanzetta, P., & Okada, A. A. (2017). Topical antibiotics and intravitreal injections. Acta Ophthalmologica, 96(5), 435-441.
Cheung CSY; Wong AWT, Kertes PJ, Devenyi RG, Lam WC. Incidence of endophthalmitis and use of antibiotic prophylaxis after intravitreal injections. Ophthalmol [Internet]. 2012 Aug:119(8):1609-14.
Milder E, Vander J, Shah C, Garg S. Changes in antibiotic resistance patterns of conjunctival flora due to repeated use of topical antibiotics after intravitreal injections. Ophthalmol [Internet]. 2012 Jul:119(7):1420-4.
Kim SJ, Toma KS. Ophthalmic antibiotics and antimicrobial resistance. A randomized, controlled study of patients undergoing intravitreal injections. Ophthalmol [Internet]. 2011 Jul(7);118:1358–1363.
Do not investigate systemically well patients with a first, uncomplicated episode of acute anterior uveitis.
No investigations are necessary for the first episode if there is a negative system review. If it is a second episode or the history suggests a possible underlying cause, appropriate investigations are:
- U and E
- Syphilis serology
- HLA B27
Other tests are expensive, and the yield is very low.
Agrawal, R. V., Murthy, S., Sangwan, V., & Biswas, J. (2010). Current approach in diagnosis and management of anterior uveitis. Indian Journal of ophthalmology, 58(1), 11-19.
Forooghian, F, Gupta, R, Wong, D, Derzko-Dzulynsky, L. (2006). Anterior uveitis investigation by Canadian ophthalmologists: insights from the Canadian National Uveitis Survey. Canadian Journal of Ophthalmology, 41(5), 577-589
Topical steroids should not be used unless infection has been ruled out in patients with red eye.
Undiagnosed red eye should never be treated with topical steroids in patients where infection must be ruled out.
Tan, S. Z., Walkden, A., Au, L., Fullwood, C., Hamilton, A., Qamruddin, A., Armstrong, M., Brahma, A. K., & Carley, F. (2017). Twelve-year analysis of microbial keratitis trends at a UK tertiary hospital. Eye,31(8), 1229.
Watson, S., Cabrera-Aguas, M., & Khoo, P. (2018). Common eye infections. Australian Prescriber, 41, 67-72.
Tests, Treatments and Procedures to Question
Message 1: In the absence of relevant history, symptoms and signs, ‘routine’ automated visual fields and optical coherence tomography are not indicated.
Explanation for patients: Advances in technology have resulted in the development of many sophisticated instruments to aid in the diagnosis and treatment of eye disease. However, in many cases, a medical history and a clinical examination are all that is required.
Automated visual field testing and optical coherence tomography (OCT) are commonly performed investigations that often provide invaluable information for diagnosis and treatment. They are, however, often an additional cost for the patient and are only necessary if the patient’s history and examination suggest they are needed.
What can patients do? Ask your health professional what tests are being conducted and why, especially if just going for a “routine check-up”. If you have diabetes or eye disease such as glaucoma in the family, it is important to let your health professional know when you have a routine eye check-up.
Message 2: AREDS-based vitamin supplements only have a proven benefit for patients with certain subtypes of age-related macular degeneration. There is no evidence to prescribe these supplements for other retinal conditions, or for patients with no retinal disease.
Explanation for patients: Age-related macular degeneration (AMD) can be a very debilitating disease and most patients want to do everything they can to keep it at bay. Treatment options, especially for “dry” AMD, include dietary changes, not smoking and in some instances, taking vitamin supplements.
The Age-related Eye Disease Studies (AREDS) show there is good, long term evidence that vitamin supplements can reduce the risk of progression of AMD.
However, the evidence exists only for those patients whose disease has reached a certain level of severity. For earlier stages of the disease, or when taken as a preventative measure in patients with no macular degeneration, there is no proven benefit. Moreover, high doses can be harmful and are an added cost and inconvenience to the patient.
What can patients do? Talk with your eye doctor to find out if you need a vitamin supplement. Check the label of the vitamin supplement to see if the formula is based on the AREDS study#2. For more information on vitamin supplements and AMD visit www.ranzco.edu or www.mdfoundation.com.au
CATARACT SURGERY AND MEDICATIONS
Message 3: Don’t prescribe tamsulosin or other alpha-1 adrenergic blockers without first asking the patient about a history of cataract or impending cataract surgery.
Explanation for patients: There is a group of drugs known as “alpha-1 adrenergic blockers” that are being increasingly prescribed by GPs and urologists to patients, usually men, for urinary retention and urinary flow problems. The commonest trade names for these drugs are “FlomaxTM”, “FlomaxtraTM” and “DuodartTM” but there are others.
These drugs have been used very successfully but they do have side effects. Even one or two doses can mean the irises within your eyes are irreversibly weakened. This has no effect on your vision but if you need cataract surgery, there is a much greater chance your surgery will be more complicated with the possibility of iris damage and permanent glare after the operation. In fact, there is an increased rate of all cataract surgical complications in patients on these drugs
What can patients do? Tell your GPs or urologist if you are due to have cataract surgery as it may be possible to find an alternative drug therapy or delay treatment. If you are needing cataract surgery, inform your ophthalmologist if you are taking or have ever taken alpha-1 adrenergic blockers. Steps can be taken to reduce the risks of surgery in patients on these medications.
DAY SURGERY AND HOSPITAL CARE
Message 4: Intravitreal injections may be safely performed on an outpatient basis. Don’t perform routine intravitreal injections in a hospital or day surgery setting unless there is a valid clinical indication.
Explanation for patients: It is now very common for patients with the “wet” form of macular degeneration, retinal vein occlusions and diabetic eye disease to have injections of drugs into their eyes. These relatively new treatments have had a significant impact on reducing vision loss and blindness.
Most eye doctors give these injections to patients in their consulting rooms. Some doctors believe that admission to a hospital or day surgery facility is safer.
However, studies on thousands of patients all over the world have shown that if standard antiseptic protocols are followed, the rate of complications is no greater for injections done in the doctor’s rooms than they are if done in an operating theatre.
Even so, a patient with private health insurance might still reasonably prefer to have the injection in the operating theatre as the cost is often covered by their insurance with no gaps, a situation that may not be the case for injections given in the doctor’s rooms. The problem is that the overall cost borne by private health insurance for an injection given in an operating theatre is up to five times higher than the average price charged by ophthalmologists for conducting the procedure in their rooms.
Whilst a minority of ophthalmologists give their injections in the operating theatre, the additional cost of this practice to health insurance companies is many millions of dollars each year. These costs have to be recouped by other means and hence, a flow-on effect is being seen through higher premiums, reduced insurance benefits or no cover at all for patients who require other eye procedures. There is understandable concern that private health insurance premiums are continuing to increase at very high levels, out of proportion with other cost increases in medicine. There should not be any additional “excuses” for premium increases, which continue to reduce the affordability of private health insurance and its value to patients. RANZCO is committed to working with patient organisations, and with Government and the Health Funds, to find sustainable solutions which deliver affordable, high value care to patients.
In short, the practice of injecting eyes in operating theatres is too expensive for our health system to sustain, and research shows it is not associated with a lower rate of complications.
What can patients do? This is not an issue for patients to act upon. It is hoped that changes in health policy will allow more affordable and equitable access to injection treatments for all patients, whether they have private health insurance or not. In the meantime RANZCO trusts that its doctor members will provide affordable treatment for patients, and the overall health care system.
Message 5: In general there is no indication to perform prophylactic retinal laser or cryotherapy to asymptomatic conditions such as lattice degeneration (with or without atrophic holes), for which there is no proven benefit.
Information for patients: This recommendation is highly technical in nature, and is directed at ophthalmologists who may still be advocating laser treatment where there are no symptoms of retinal change. In such instances this treatment has not been shown to be of benefit.
What can patients do? Ask your ophthalmologist to clarify the reason for treatment.
Last updated: September 3, 2020