New NHS approach for people with eye disease

Clinical trial provides new approach for people with eye disease to increase NHS capacity: A UK-wide study, led by Queen’s University Belfast, has shown how a new surveillance pathway for people with stable diabetic eye disease is safe and cost-saving, freeing up ophthalmologists to evaluate and treat people requiring urgent care.

The new health care surveillance pathway may help ophthalmic units across the world to improve their capacity whilst saving patient’s sight. It is already having a positive impact on the re-design of NHS services across the UK, having been implemented successfully in several hospitals.

The research, funded by the National Institute for Health Research (NIHR), has been published in leading journals including Ophthalmology, BMJ and NIHR’s Health Technology Assessment.

The EMERALD (the Effectiveness of Multimodal imaging for the Evaluation of Retinal oedemA and new VesseLs in Diabetic retinopathy) diagnostic accuracy study tested a new “ophthalmic grader” pathway. Rather than ophthalmologists, this pathway involves trained graders monitoring people with previously treated and stable complications of diabetic eye disease, namely diabetic macular oedema (DMO) and proliferative diabetic retinopathy (PDR), based on the reading of images and scans of the back of their eyes.

The grader’s pathway can save £1390 per 100 patients, and the real savings are the ophthalmologist’s time, which can then be redirected to the evaluation of people at high risk of visual loss.

Professor Noemi Lois, lead researcher and Clinical Professor of Ophthalmology from the Wellcome-Wolfson Institute for Experimental Medicine at Queen’s University Belfast, explains: “Diabetic macular oedema and proliferative diabetic retinopathy, the main sight-threatening complications of diabetic retinopathy can cause blindness if left untreated. It is therefore important to diagnose them and to treat them timely.

“NHS hospitals eye units are under significant pressure given the extremely high number of people that need to be examined and treated and given the insufficient number of ophthalmologists in the UK. Currently, ophthalmologists need to evaluate all patients, even those that are stable after treatment and who are doing well.”

In EMERALD, trained ophthalmic graders were found to achieve satisfactory results when compared to standard care (i.e., ophthalmologists evaluating patients in clinic) while releasing ophthalmologist’s time.

Professor Lois added: “EMERALD showed trained ophthalmic graders are able to determine whether patients with diabetic macular oedema or proliferative diabetic retinopathy previously successfully treated remain stable or if on them the disease has reactivated.  Thus, they would be able to follow people that have been already treated, releasing ophthalmologists’ time. Ophthalmologists could then use this time to treat timely other patients, for example, those who have indeed diabetic macular oedema or active proliferative diabetic retinopathy and who have not yet received treatment saving their sight.”

Dr Clare Bailey, consultant ophthalmologist at the Bristol Eye Hospital, said: “The important data from the EMERALD study has helped us to significantly increase the numbers of people with diabetic retinopathy being seen in ‘imaging/grading’ pathways. This has hugely increased our follow-up capacity, whilst allowing ophthalmologists’ time to be directed to the people with diabetic retinopathy who need treatment or further assessment. This has helped us to deal with the capacity pressures as a result of Covid -19 as well as the longer-term capacity demands due to the increasing prevalence of diabetic retinopathy.”

Dr Caroline Styles, Consultant Ophthalmologist with NHS Fife, added: “Emerald provided us in NHS Fife with the relevant evidence that allowed us to redesign our pathways for people with diabetic eye disease. The involvement of people with diabetes in this study reassures our population that these are safe and appropriate changes, and not just based on cost.”

The EMERALD study was set in 13 National Health Service (NHS) hospitals across the UK and is a large multicentric, UK-wide, National Institute for Health Research (NIHR)-funded diagnostic accuracy study.

1. There have been several publications of the research: (I) The full study has been published as a Health Technology Assessment monograph (Health Technol Assess. 2021 May;25(32):1-104. doi: 10.3310/hta25320) (2) The summarised full study has been published in Ophthalmology (Ophthalmology. 2021 Apr;128(4):561-573. doi: 10.1016/j.ophtha.2020.10.030) (3) The cost-analysis has been published in the British Journal of Ophthalmology (Br J Ophthalmol. 2021 Jun 3:bjophthalmol-2021-318816. doi: 10.1136/bjophthalmol-2021-318816)
2. EMERALD Study Group includes: Ahmed Saad and Daniela Vaideanu-Collins, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust; Augusto Azuara-Blanco, Centre for Public Health, Queen’s University, and The Belfast Health and Social Care Trust, Belfast; Caroline Styles, Queen’s Margaret Hospital, Fife; Christine McNally, Andrew Jackson, and Rachael Rice, Northern Ireland Clinical Trials Unit; Clare Bailey, Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust; Danny McAuley, Queen’s University and Royal Victoria Hospital, Belfast H&SC Trust; David H. Steel, Clair Barbour, and Leontia Bell, Sunderland Eye Infirmary, City Hospitals Sunderland NHS Foundation Trust; Faruque D. Ghanchi and Zeid Madanat, Bradford Teaching Hospitals NHS Trust; Geeta Menon, Manju Chandran, Sely Mathews, and Mohammed Galal, Frimley Park Hospital NHS Foundation Trust; Haralabos Eleftheriadis and Stefanos Efraimidis, Kings College Hospital NHS Foundation Trust; Jonathan Cook, Ariel Wang, and William Sones, Centre for Statistics in Medicine, University of Oxford; Lindsay Prior, Centre for Public Health, Queens University, Belfast; Nachiketa Acharya, Sheffield Teaching Hospitals NHS Foundation Trust; Noemi Lois, The WellcomeWolfson Institute for Experimental Medicine, and the Belfast Health and Social Care Trust, Belfast; Norman Waugh, Hema Mistry, and Mandy Maredza, Warwick University; Samia Fatum and Janette Savage, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust; Sobha Sivaprasad, Moorfields Eye Hospital NHS Foundation Trust; Stephen Aldington, Peter H. Scanlon, and Katerina Ivanova, Gloucestershire Hospitals NHS Foundation Trust; Tariq M. Aslam and Zaria Ali, Manchester Royal Eye Hospital, Central Manchester University Hospitals NHS Foundation Trust; and Victor Chong, Royal Free Hospital NHS Foundation Trust, London.