**3. Eye care in mobile vans in urban and rural populations for macular disease and diabetic retinopathy**

As the wet macular service continues to exponentially multiply the capacity issues in per‐ forming OCT scans (instrumental in the management of this condition) are becoming a limiting factor in this service. The use of transport mobile vans that perform these scans with technicians and nurses is now becoming a more viable option.

Mobile van units have been used successfully to deliver eye service in the community in York, Exeter and Wales. In Wales there is the National Diabetic Retinopathy Screening Service, where vans are used throughout the country to take fundus photos of diabetics. Images are then transferred to a grading centre in Cardiff. In Exeter there is a mobile glaucoma service which has been developed to provide additional clinic capacity, run by Glaucoma Nurse Practition‐ ers. In York there is a Box Van where patients are seen to have OCT scanning and lucentis injections in the van.

#### **3.1. Diabetic retinopathy screening service for Wales**

In Wales all diabetic patients undergo annual screening in local community hospitals or GP surgeries depending on the rural location. Digital fundus imaging is carried out with dilated pupils. The photographs are saved onto laptops with strict security access codes. Images are stored in data centres in North Wales, (Canaervon), Mid and South West Wales (Carmarthen) and Trefforest near Cardiff at Fairway Court which is the main centre to which all images are sent for data backup. These centres are linked through a DAWN2METRO VPN. Graders at Trefforest carry out primary and secondary retinal screening.

Any patients with sight threatening diabetic retinopathy are referred to their local eye clinic by a fax or letter referral depending on the urgency and the patients are seen appropriately in specialised diabetic eye clinics within the hospital eye service. Patients with background diabetic retinopathy or no retinopathy at all have annual follow up screening assessments. This has proved to be a world class, efficient and well coordinated screening service for all diabetics in Wales. Consultant Ophthalmologists throughout Wales have regular group meetings to discuss how the service is to be delivered and improved, and provide regular training for all the Graders at Trefforest. In addition, it has standardised ophthalmic care for diabetics throughout the whole country. Consultants may view images at the local Screening Centre. There are now developments in place to allow the images to be digitally transferred to individual clinics from the main centre, so Consultants can visualise them in the clinic setting

#### **3.2. Exeter mobile glaucoma service**

This service was set up to screening for new referrals and follow up care of stable patients according to NICE standards The Royal Devon & Exeter Hospital Wonford have a dedicated Mobile Eye Unit which goes out across the community which screens new referrals and provides follow up care of stable patients. It is Nurse led, the Specialist Glaucoma Nurses carrying out investigations in the mobile unit including:


In the last few years wet age related macular degeneration (AMD) and the intravitreal anti-VEGF injection treatment has put unprecedented strain on the ophthalmology services worldwide. Even when the patients do not need treatment they have to be followed up on monthly basis, because of the possibility of recurrence. Stable wet AMD patients can be followed up locally with their community optometrist. Optometrists can examine the patients; take OCT scans and fundus photos and all this information can be transferred digitally via secure connection to the eye clinic. Consultants or other trained staff at the HES virtual AMD clinic can assess the information and manage the patients appropriately. In this way the current

Many of the patients with eye complaints present initially at the optometrists practices. Sometimes the cases can be solved just with the advice of the ophthalmologist. The percentage of these cases can be increased significantly by using the opportunities of teleophthalmology. In this way unnecessary appointments at the HES and travel can be avoided. If emergency phone calls from the optometrists are accompanied by anterior segment photo or fundus photo the hospital ophthalmologist will receive much more information and can take immediate decision in most of the cases, whether to see the patient as an emergency or even to give

Most of the referral to the HES, even if they come from the GP are seen prior by their optom‐ etrists. If most of the referrals are accompanied by digital information received at the hospital the prioritisation consultant can more easily detect urgent cases, so they can receive sooner

Optometrists have the expertise to manage ophthalmology patients and with the help of teleophthalmology technology these skills can be expanded. The variety of patients managed in the community setting under the direct teleophthalmology supervision of a hospital consultant can be increased. In this way more resources at the hospitals can be spared for more challenging cases. On the other hand patients can receive high quality hospital service at their

**3. Eye care in mobile vans in urban and rural populations for macular**

As the wet macular service continues to exponentially multiply the capacity issues in per‐ forming OCT scans (instrumental in the management of this condition) are becoming a limiting factor in this service. The use of transport mobile vans that perform these scans with technicians

Mobile van units have been used successfully to deliver eye service in the community in York, Exeter and Wales. In Wales there is the National Diabetic Retinopathy Screening Service, where vans are used throughout the country to take fundus photos of diabetics. Images are then

capacity of the eye clinics can be increased.

appropriate management plan to the optometrist.

**disease and diabetic retinopathy**

and nurses is now becoming a more viable option.

appointment.

12 Telemedicine

local community.

**2.4. Teleophthalmology and urgent ophthalmology referrals**


The Specialist Nurses also drive the mobile units around the area

The Nurse Practitioners work closely with the consultants and other members of the health service such as Opticians and GPs to provide screening and follow-up care for glaucoma patients. Glaucoma Practitioners undergo MSc Glaucoma modules in assessment and man‐ agement of Glaucoma and non medical independent prescribing qualifications.

**3.4. Setting up a mobile ophthalmology service: Rural Wales**

(RVO) etc.

fordwest.

Board.

community locations at a later stage.

The aim of the Project is to improve the quality and convenience of care for Ophthalmolo‐ gy patients by providing clinical reviews in the community by setting up a mobile assess‐ ment service with the capability of performing OCTs, automated visual fields, and slitlamp based clinical examinations. This mobile assessment service will assist in overcoming current clinic capacity issues experienced by the general ophthalmology service (especially the wet AMD and glaucoma service) within the Hywel Dda Health Board Ophthalmology Department and reduce the requirement for extra out-of-hours / weekend clinics. The Mobile Ophthalmic Review Service (The Review Van) will be used in varying locations for pa‐ tients to visit and receive their follow up wet AMD assessments (OCT scan and fundosco‐ py), and glaucoma assessments (optic disc imaging via the OCT machine, visual field analysis, and intraocular pressure check). Two possible models may be used. 1. Decisions can be made immediately in the van by an appropriate doctor or nurse practitioner. 2. The images can be transferred to the Department of Ophthalmology to be reviewed by clinicians at Hywel Dda Health Board. The mobile unit could be used to monitor other ophthalmic conditions such as pre-op and post-op cataracts, diabetic macular oedema (DMO), retinal vein occlusion

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In West Wales, there are a number of community hospitals in rural areas, where elderly people find it difficult to access care. We are in the process of piloting an OCT Scan Van which will provide local OCT scanning for macular patients undergoing lucentis therapy. This will reduce the travel burden for these elderly patients who would otherwise have to access this care at District General Hospitals which are more than 1 hour away. It will also provide OCT scanning of the Optic Disc for Glaucoma patients. Some of the local community hospitals have injection facilities/theatres which could be used at a later stage to provide a one stop service. There will also be the option of providing an Injection van for carrying out Lucentis injections at certain

Hywel Dda Health Board is the operational name of Hywel Dda Local Health Board.

Hywel Dda Local Health Board provides healthcare services to a total population of around 372,320 throughout Carmarthenshire (178,119), Pembrokeshire (116,001), and Ceredigion (78,200). It provides Acute, Primary, Community, Mental Health and Learning Disabilities services via General and Community Hospitals, Health Centres, GP's, Dentists, Pharmacists, Optometrists and other sites. The Headquarters is at Merlin's Court, Winch Lane, Haver‐

The map below provides a visual overview of the wide area covered by Hywel Dda Health

The map shows the site of the 4 general hospitals (white circles 1-4) within Hywel Dda Health Board. For geographic reasons the ophthalmology service for Hywel Dda has historically developed as 2 separate departments each with its own separate group of staff. The wet AMD and glaucoma services that the Hywel Dda Health Board Mobile Outreach Joint Working Project Group applies to are delivered by the department serving Carmarthenshire and Pembrokeshire (and some patients from Ceredigion) serving a total population of approxi‐

Glaucoma Imaging Technicians provide technical support for Glaucoma Practitioners in carrying out Glaucoma screening and follow-up clinics. They record patients' visual acuities, carry out Humphrey visual field assessments, perform digital stereoscopic optic disc photog‐ raphy, retinal topography scans and optical coherence tomography images of the optic disc

#### **3.3. York mobile service**

AMD is the leading cause of blindness in the UK, and predominantly affects those aged 55 and over. It currently affects an estimated 500,000 people in the UK and approximately 26,000 new cases of the more severe wet form are reported each year. This includes over 10,000 people across the North and East of Yorkshire.

Eye patients based in East Yorkshire are now able to reap the benefits of a newly launched Mobile Community Eye Care Centre based at Bridlington and District Hospitals. Previously over 140, mostly elderly, patients from the Bridlington, Scarborough and Whitby area had to make a round trip of 80 miles or more to receive treatment at York Hospital once a month. This meant that a clinic visit which should not take longer than two hours could sometimes take a whole day.

Designed as a dedicated service for local people with wet Age-related Macular Degeneration (AMD), the new clinic has slashed patient travelling times by over half, also relieving local health services of some of the capacity issues currently being faced.

The York Mobile Unit is a large Box van in which there is a waiting area, visual acuity assessment, OCT scanning and injection facilities.

The mobile clinic has saved the local NHS money in transport costs, as patients will be able to receive treatment closer to home. On average, 50 patients required hospital transport to their AMD clinic appointments over a 3 month period previously.

Incorporation of" Iris software" into the van has enabled the development of an electronic patient record in the mobile unit and has the potential to transmit image data wirelessly to a smart phone or tablet, allowing remote teleophthalmology assessment of images to take place. The unique thing about iris is that it uses the cloud to store data so can be accessed more easily in peripheral locations than Stand alone systems. It's is connected via the National Health Service n3 secure network via a password that is sent to the users mobile phone on logging in. It is a paperless system that mails a summary to the General Practitioner direct.

#### **3.4. Setting up a mobile ophthalmology service: Rural Wales**

**•** Digital fundus photography

14 Telemedicine

**•** Optic nerve head assessments

**3.3. York mobile service**

whole day.

across the North and East of Yorkshire.

The Specialist Nurses also drive the mobile units around the area

The Nurse Practitioners work closely with the consultants and other members of the health service such as Opticians and GPs to provide screening and follow-up care for glaucoma patients. Glaucoma Practitioners undergo MSc Glaucoma modules in assessment and man‐

Glaucoma Imaging Technicians provide technical support for Glaucoma Practitioners in carrying out Glaucoma screening and follow-up clinics. They record patients' visual acuities, carry out Humphrey visual field assessments, perform digital stereoscopic optic disc photog‐ raphy, retinal topography scans and optical coherence tomography images of the optic disc

AMD is the leading cause of blindness in the UK, and predominantly affects those aged 55 and over. It currently affects an estimated 500,000 people in the UK and approximately 26,000 new cases of the more severe wet form are reported each year. This includes over 10,000 people

Eye patients based in East Yorkshire are now able to reap the benefits of a newly launched Mobile Community Eye Care Centre based at Bridlington and District Hospitals. Previously over 140, mostly elderly, patients from the Bridlington, Scarborough and Whitby area had to make a round trip of 80 miles or more to receive treatment at York Hospital once a month. This meant that a clinic visit which should not take longer than two hours could sometimes take a

Designed as a dedicated service for local people with wet Age-related Macular Degeneration (AMD), the new clinic has slashed patient travelling times by over half, also relieving local

The York Mobile Unit is a large Box van in which there is a waiting area, visual acuity

The mobile clinic has saved the local NHS money in transport costs, as patients will be able to receive treatment closer to home. On average, 50 patients required hospital transport to their

Incorporation of" Iris software" into the van has enabled the development of an electronic patient record in the mobile unit and has the potential to transmit image data wirelessly to a smart phone or tablet, allowing remote teleophthalmology assessment of images to take place. The unique thing about iris is that it uses the cloud to store data so can be accessed more easily in peripheral locations than Stand alone systems. It's is connected via the National Health Service n3 secure network via a password that is sent to the users mobile phone on logging in.

It is a paperless system that mails a summary to the General Practitioner direct.

health services of some of the capacity issues currently being faced.

AMD clinic appointments over a 3 month period previously.

assessment, OCT scanning and injection facilities.

agement of Glaucoma and non medical independent prescribing qualifications.

The aim of the Project is to improve the quality and convenience of care for Ophthalmolo‐ gy patients by providing clinical reviews in the community by setting up a mobile assess‐ ment service with the capability of performing OCTs, automated visual fields, and slitlamp based clinical examinations. This mobile assessment service will assist in overcoming current clinic capacity issues experienced by the general ophthalmology service (especially the wet AMD and glaucoma service) within the Hywel Dda Health Board Ophthalmology Department and reduce the requirement for extra out-of-hours / weekend clinics. The Mobile Ophthalmic Review Service (The Review Van) will be used in varying locations for pa‐ tients to visit and receive their follow up wet AMD assessments (OCT scan and fundosco‐ py), and glaucoma assessments (optic disc imaging via the OCT machine, visual field analysis, and intraocular pressure check). Two possible models may be used. 1. Decisions can be made immediately in the van by an appropriate doctor or nurse practitioner. 2. The images can be transferred to the Department of Ophthalmology to be reviewed by clinicians at Hywel Dda Health Board. The mobile unit could be used to monitor other ophthalmic conditions such as pre-op and post-op cataracts, diabetic macular oedema (DMO), retinal vein occlusion (RVO) etc.

In West Wales, there are a number of community hospitals in rural areas, where elderly people find it difficult to access care. We are in the process of piloting an OCT Scan Van which will provide local OCT scanning for macular patients undergoing lucentis therapy. This will reduce the travel burden for these elderly patients who would otherwise have to access this care at District General Hospitals which are more than 1 hour away. It will also provide OCT scanning of the Optic Disc for Glaucoma patients. Some of the local community hospitals have injection facilities/theatres which could be used at a later stage to provide a one stop service. There will also be the option of providing an Injection van for carrying out Lucentis injections at certain community locations at a later stage.

Hywel Dda Health Board is the operational name of Hywel Dda Local Health Board.

Hywel Dda Local Health Board provides healthcare services to a total population of around 372,320 throughout Carmarthenshire (178,119), Pembrokeshire (116,001), and Ceredigion (78,200). It provides Acute, Primary, Community, Mental Health and Learning Disabilities services via General and Community Hospitals, Health Centres, GP's, Dentists, Pharmacists, Optometrists and other sites. The Headquarters is at Merlin's Court, Winch Lane, Haver‐ fordwest.

The map below provides a visual overview of the wide area covered by Hywel Dda Health Board.

The map shows the site of the 4 general hospitals (white circles 1-4) within Hywel Dda Health Board. For geographic reasons the ophthalmology service for Hywel Dda has historically developed as 2 separate departments each with its own separate group of staff. The wet AMD and glaucoma services that the Hywel Dda Health Board Mobile Outreach Joint Working Project Group applies to are delivered by the department serving Carmarthenshire and Pembrokeshire (and some patients from Ceredigion) serving a total population of approxi‐

transport. A public transport journey is complicated, exceptionally long, and not practical for patients, and is never undertaken. The above example (the catchment area for Withybush Hospital in Haverfordwest) applies to approximately one third of the departmental catchment area (serving 116,000 people). There are currently 460 wet AMD patients in this service for regular follow up and treatment, approximately 1/3 of this population each lives in the catchment area of PPH (Llanelli), WWGH (Carmarthen), Withybush (Haverfordwest, Pem‐ brokeshire). This represents a significant travel burden on patients and their relatives, especially for the patients from Pembrokeshire. Costs of travel are met by patients and family (75% of journeys), and Hywel Dda Health Board via the Welsh Ambulance Service (25% of

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An audit of 26 recent clinics (June, July 2011) has shown that the number of patients injected per clinic has fallen from 75-80% in 2009, to 50% currently (due to the increased proportion of stable wet age related macular disease patients as the macular service service has matured). This has resulted in an inefficient use of the injection facilities available, and unnecessary travel for the 50% of patients who do not receive injections. Not all 'non-injection' decisions can be predicted, but many can, especially those patients who have been recently dry for 4 months

The Ophthalmology service is currently operating beyond capacity and the expected increase in patient numbers would mean the service would be further stretched. An increased time interval between intravitreal treatments has been proven to reduce visual outcomes. The service currently requires a combination of extra Saturday clinics or volunteers to cross-cover for colleagues when they take annual leave from the service. The current guidelines from the Royal College of Ophthalmologists on the standard of care for the management of wet AMD is that initial treatment be given within two weeks of presentation and that patients be followed up four weekly. The current average follow up time at Hywel Dda Health Board is 5 weeks for patients with active wet AMD, longer for those patients who have been 'dry' for successive visits, as long as extra clinics and cross-cover can be arranged. The extra out-of-hours clinics

New treatment modalities have recently been approved for Diabetic Macular Oedema (DMO)and Retinal Vein Occlusion (RVO). These developments will increase the burden on theintravitreal service over and above the burden from the wet AMD service. The wet AMDservice continues to accumulate patients at a rate of 11-14 new patients per month, thiscontinues to far exceed the number of discharges from the service despite now entering its 4th year. Experience from around the UK is showing only a 5% discharge at year one, only 25% at year two, the predicted service plateau at end of year three has not materialised.

Within the Department of Ophthalmology, the medical retina service has been a priority due its immediate capacity needs. However, the service cannot keep up with the demand, and the new treatment modalities now available for DMO and RVO will impact this service further. This growth in demand for intravitreal treatments has had a major impact on the ability and capacity to deliver the general ophthalmic service, especially the glaucoma and cataract

and volunteer based cross-cover is no longer sustainable.

journeys).

or more.

services.

**Figure 1.** Map of Wales with locations of Hospitals served by Hywel Dda Health Board

mately 300,000. The intravitreal service for this area currently operates out of Amman Valley Hospital (yellow circle 2). The day surgery unit at this community hospital accepts patients for its intravitreal service from the catchment areas of 3 general hospitals: Withybush Hospital (WBH) in Haverfordwest (white circle 3), West Wales General Hospital (WWGH) in Car‐ marthen (white circle 2), Prince Phillip Hospital (PPH) in Llanelli (white circle 4). Thus Amman Valley Hospital provides a wet AMD service for Carmarthenshire, Pembrokeshire and parts of Ceredigion which covers a population of approximately 300,000 drawing patients from a wide geographical area.

The AA route finder shows that a return journey from Haverfordwest to Amman Valley Hospital is 110 miles taking 2 hours and 50 minutes, from Fishguard it is 140 miles with an estimated return travel time of 3.5 hours. Only a proportion of this journey has a dual carria‐ geway, patients often have longer travel times than this, especially when using hospital transport. A public transport journey is complicated, exceptionally long, and not practical for patients, and is never undertaken. The above example (the catchment area for Withybush Hospital in Haverfordwest) applies to approximately one third of the departmental catchment area (serving 116,000 people). There are currently 460 wet AMD patients in this service for regular follow up and treatment, approximately 1/3 of this population each lives in the catchment area of PPH (Llanelli), WWGH (Carmarthen), Withybush (Haverfordwest, Pem‐ brokeshire). This represents a significant travel burden on patients and their relatives, especially for the patients from Pembrokeshire. Costs of travel are met by patients and family (75% of journeys), and Hywel Dda Health Board via the Welsh Ambulance Service (25% of journeys).

An audit of 26 recent clinics (June, July 2011) has shown that the number of patients injected per clinic has fallen from 75-80% in 2009, to 50% currently (due to the increased proportion of stable wet age related macular disease patients as the macular service service has matured). This has resulted in an inefficient use of the injection facilities available, and unnecessary travel for the 50% of patients who do not receive injections. Not all 'non-injection' decisions can be predicted, but many can, especially those patients who have been recently dry for 4 months or more.

The Ophthalmology service is currently operating beyond capacity and the expected increase in patient numbers would mean the service would be further stretched. An increased time interval between intravitreal treatments has been proven to reduce visual outcomes. The service currently requires a combination of extra Saturday clinics or volunteers to cross-cover for colleagues when they take annual leave from the service. The current guidelines from the Royal College of Ophthalmologists on the standard of care for the management of wet AMD is that initial treatment be given within two weeks of presentation and that patients be followed up four weekly. The current average follow up time at Hywel Dda Health Board is 5 weeks for patients with active wet AMD, longer for those patients who have been 'dry' for successive visits, as long as extra clinics and cross-cover can be arranged. The extra out-of-hours clinics and volunteer based cross-cover is no longer sustainable.

New treatment modalities have recently been approved for Diabetic Macular Oedema (DMO)and Retinal Vein Occlusion (RVO). These developments will increase the burden on theintravitreal service over and above the burden from the wet AMD service. The wet AMDservice continues to accumulate patients at a rate of 11-14 new patients per month, thiscontinues to far exceed the number of discharges from the service despite now entering its 4th year. Experience from around the UK is showing only a 5% discharge at year one, only 25% at year two, the predicted service plateau at end of year three has not materialised.

mately 300,000. The intravitreal service for this area currently operates out of Amman Valley Hospital (yellow circle 2). The day surgery unit at this community hospital accepts patients for its intravitreal service from the catchment areas of 3 general hospitals: Withybush Hospital (WBH) in Haverfordwest (white circle 3), West Wales General Hospital (WWGH) in Car‐ marthen (white circle 2), Prince Phillip Hospital (PPH) in Llanelli (white circle 4). Thus Amman Valley Hospital provides a wet AMD service for Carmarthenshire, Pembrokeshire and parts of Ceredigion which covers a population of approximately 300,000 drawing patients from a

4 General Hospitals

14 Health Centres

Health Services

8 Community Hospitals

Comprehensive Mental

Residences & Offices

**Figure 1.** Map of Wales with locations of Hospitals served by Hywel Dda Health Board

The AA route finder shows that a return journey from Haverfordwest to Amman Valley Hospital is 110 miles taking 2 hours and 50 minutes, from Fishguard it is 140 miles with an estimated return travel time of 3.5 hours. Only a proportion of this journey has a dual carria‐ geway, patients often have longer travel times than this, especially when using hospital

wide geographical area.

16 Telemedicine

Within the Department of Ophthalmology, the medical retina service has been a priority due its immediate capacity needs. However, the service cannot keep up with the demand, and the new treatment modalities now available for DMO and RVO will impact this service further. This growth in demand for intravitreal treatments has had a major impact on the ability and capacity to deliver the general ophthalmic service, especially the glaucoma and cataract services.

The glaucoma service for this department currently operates out of the 3 main district general hospitals described above (WBH, WWGH and PPH – white circles 3, 2 and 4 respectively). The extra capacity demands placed on the Ophthalmology department following the development of the new wet age related macular disease service in 2008 has resulted in a lack of building space and staff to cope with the increased demands placed on the glaucoma service via recent NICE guidelines and the new National (NHS Wales) Glaucoma pathway. The glaucoma service cannot currently meet these guidelines predominantly due to capacity issues, created by recent intravitreal service development

into in any of the above 3 district general hospitals (WBH, WWGH, PPH – white circles 3,

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**•** There are demands on the Ophthalmology service to follow up patients at regular intervals

**•** Adherence to National Institute of Clinical Excellence guidelines (for both wet age related macular disease and glaucoma) and the new NHS Wales 'Focus on Ophthalmology' Pathways (for both wet age related macular diseases and glaucoma) cannot be guaranteed

The proposed project is to set up a mobile assessment unit (review van) complete with an OCT machine, visual field machine and slit-lamp to follow-up recently 'dry' macular disease patients nearer to their home rather than in Amman Valley Hospital; plus follow-up glaucoma patients at an approved interval near to or at their local district general hospital thereby:

**•** Reducing the number of unused injection slots in the Amman Valley Hospital (AVH) theatre

**•** Reducing considerably the travel cost burden on the Health Board, patients and their

**•** Reducing the time interval between reviews in wet age related macular disease, thus facilitating improved visual outcomes due prompt recognition of the requirement for

**•** Reduce the time interval between glaucoma follow-up reviews to that required by NICE guidelines and NHS Wales 'Focus on Ophthalmology' Pathways, thus facilitating enhanced

The 'Review Van' will be used in varying locations for patients to visit and receive their follow

**•** Data (intraocular pressure and images for glaucoma, images for macular assessment) can be transferred to the Department of Ophthalmology at Hywel Dda Health Board to be

**•** The assessments can be reviewed in real-time by a doctor or nurse practitioner present

For macular disease, the first locations for the mobile unit to provide follow up appointments have been identified in Pembrokeshire. There is an aspiration to achieve further locations

For glaucoma, WWGH Carmarthen has been identified as the primary area of interest due to acute constraints of available building space and staff. There is an aspiration to pilot the review van for glaucoma reviews in WBH and PPH (both also have constraints on available building

up macular and glaucoma assessments. 2 models are available:

within twelve months in/near Carmarthen and Llanelli.

**•** Reducing considerably the travel time burden on patients and their family to AVH

which cannot be achieved with current staff / service logistics / capacity.

2, 4 above).

families

further intravitreal therapy.

reviewed by clinicians, or

visual outcomes.

within the van

space and staff).

with current demands and activities

Delivering a health system focused on care closer to home will require support from the population of Carmarthenshire, Ceredigion and Pembrokeshire, as well as stakeholders. The key driver for change is the opportunity to improve the quality and the safety of health services. This project fits perfectly with the stated aims of the Health Board by moving wet age related macular disease consultations from a day surgery unit hospital environment into the com‐ munity, and nearer to the home of the patient. As stated above there is a considerable travel burden for one third of the intravitreal population, and in comparison to a non-rural region there is still a significant travel burden for the other two thirds of the population. The costs for 25% of journeys are met by the Health Board; costs for 75% of journeys are met by patients and their families. The table below provides a snapshot of the travel burden.


\*AA route finder quote

NB: Carmarthen to AVH is the only journey which is predominantly dual carriageway, the other 2

**Table 1.** journeys are predominantly single carriageway roads

**•** The Health Board has limited buildings and infrastructure to grow and develop the Ophthalmology service. This has significant implications for the intravitreal service (wet age related macular disease, Diabetic macular oedema and retinal vein occlusion), and the Glaucoma service, both of which have NICE guidelines and new NHS Wales pathways to adhere to. The Glaucoma service does not have the required buildings / space to expand into in any of the above 3 district general hospitals (WBH, WWGH, PPH – white circles 3, 2, 4 above).

The glaucoma service for this department currently operates out of the 3 main district general hospitals described above (WBH, WWGH and PPH – white circles 3, 2 and 4 respectively). The extra capacity demands placed on the Ophthalmology department following the development of the new wet age related macular disease service in 2008 has resulted in a lack of building space and staff to cope with the increased demands placed on the glaucoma service via recent NICE guidelines and the new National (NHS Wales) Glaucoma pathway. The glaucoma service cannot currently meet these guidelines predominantly due to capacity issues, created

Delivering a health system focused on care closer to home will require support from the population of Carmarthenshire, Ceredigion and Pembrokeshire, as well as stakeholders. The key driver for change is the opportunity to improve the quality and the safety of health services. This project fits perfectly with the stated aims of the Health Board by moving wet age related macular disease consultations from a day surgery unit hospital environment into the com‐ munity, and nearer to the home of the patient. As stated above there is a considerable travel burden for one third of the intravitreal population, and in comparison to a non-rural region there is still a significant travel burden for the other two thirds of the population. The costs for 25% of journeys are met by the Health Board; costs for 75% of journeys are met by patients and

their families. The table below provides a snapshot of the travel burden.

33% 2 hrs 50mins

**Minimum return journey time\***

NB: Carmarthen to AVH is the only journey which is predominantly dual carriageway, the other 2

**Frequently quoted return journey time**

4 hrs WBH 5 hrs Fishguard

33% 80 mins 80 mins 52 miles

33% 60 mins 60 mins 31 miles

**•** The Health Board has limited buildings and infrastructure to grow and develop the Ophthalmology service. This has significant implications for the intravitreal service (wet age related macular disease, Diabetic macular oedema and retinal vein occlusion), and the Glaucoma service, both of which have NICE guidelines and new NHS Wales pathways to adhere to. The Glaucoma service does not have the required buildings / space to expand

**Return mileage from district general hospital to intravitreal centre (AVH, Glanamman)**

110 miles

by recent intravitreal service development

**Approx proportion of population (Total 300,000)**

**Table 1.** journeys are predominantly single carriageway roads

**Catchment area**

Pembrokeshire

\*AA route finder quote

WBH,

18 Telemedicine

WWGH, Carmarthen

PPH, Llanelli


The proposed project is to set up a mobile assessment unit (review van) complete with an OCT machine, visual field machine and slit-lamp to follow-up recently 'dry' macular disease patients nearer to their home rather than in Amman Valley Hospital; plus follow-up glaucoma patients at an approved interval near to or at their local district general hospital thereby:


The 'Review Van' will be used in varying locations for patients to visit and receive their follow up macular and glaucoma assessments. 2 models are available:


For macular disease, the first locations for the mobile unit to provide follow up appointments have been identified in Pembrokeshire. There is an aspiration to achieve further locations within twelve months in/near Carmarthen and Llanelli.

For glaucoma, WWGH Carmarthen has been identified as the primary area of interest due to acute constraints of available building space and staff. There is an aspiration to pilot the review van for glaucoma reviews in WBH and PPH (both also have constraints on available building space and staff).

There is also the potential for the review and monitoring of other patients that require OCT scanning and slit-lamp review as part of their regular monitoring eg diabetic macular oedema, retinal vein occlusion, pre and post-op cataract assessments.

about to hit the road, and has had a successful demonstration using the Mobile van for optical

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The diagnosis of non-accidental injuries in children and babies frequently requires the presence of retinal haemorrhages. Court conviction depends on the testimony of the ophthalmologist who has to rely only on clinical notes as evidence. Having retcam video and photographs carry

Babies born prematurely or underweight are at risk of developing a devastating proliferative retinopathy of prematurity (RoP) that can be blinding. It remains a major cause of visual loss worldwide and there is approximately 50 000 babies annual rate of global blindness from RoP. This is potentially a treatable condition and therefore requires thorough and extensive screening. Unfortunately screening is dependant on the presence of highly skilled paediatric ophthalmologists. Most babies with RoP are in developing countries where there is a lack of properly trained paediatric ophthalmologists. Having a device that can photograph the fundus appearance and then either email or share these pictures with a central resource where trained ophthalmologists can grade them will obviously save sights. The answer has been in the use of the retcam, which can photograph and even video the fundi of such babies. The retcam images are now increasingly replacing the indentation indirect approach of fundoscopy.

Another source of problems is intra and inter grader variability. To overcome this issue software are in the process of development for "Automated Quantification of Retinal Vessel Morphology". Human input is still required, but the aim of development is to make screening

Retcam images are similarly used for screening of premature or low birth weight babies for Retinopathy of Prematurity (ROP) using ophthalmoscopy and image-based telemedicine examinations. The number of premature infants is increasing throughout the world, and a larger percentage of them are surviving. A Telemedicine examination from images obtained from a Retcam may be more reproducible than if you see an infant's retina only briefly during ophthalmoscopy. These are manufactured by Spectrum and Clarity Medical systems. There is a rationale that image-based examination may be better because findings are documented photographically, rather than an indirect ophthalmoscopic examination, which may also be more uncomfortable for the baby. In many other ophthalmic diseases, definitions are based on standard images, so this has implications for the way we might deliver the best care to patients

coherence tomography scanning

huge weight age in such proceedings.

**4.2. Retinopathy of prematurity**

entirely computerized.

**4.3. Retcam images**

in the future.

**4.1. Medico legal issues**

**4. Eye care to the paediatric population**

By moving a proportion of the wet AMD service and glaucoma service out of the main unit it is proposed that there will be more capacity to meet the current and immediate future demands for intravitreal therapies. It is proposed that after 3-4 months of 'dry' status patients could be seen in the review van for follow up.

The lucentis service at Aberystwyth caters for the population of Ceredigion (90,000), South Gwynedd (50,000 of a total of 130,000 for Gwynedd county and Powys (120,000). Some patients in Powys are managed by the medical retina teams of Shrewsbury and Hereford.

All patients undergo OCT scanning at North Road Eye Clinic, and lucentis injection at Bronglais Hospital at a separate booked appointment. Currently up to 20-25 patients are booked for lucentis injection from North Road onto one injection list at Bronglais Hospital as a two stop service.

Patients are seen at local community clinics of Tywyn (South Gywnedd), Machynlleth (North Powys), Llanidloes (North Powys), Newtown (Mid Powys), Aberaeron (South Ceredigion) and Cardigan (South Ceredigion). All patients from these community clinics therefore have to travel twice per month when undergoing review of lucentis therapy for OCT scanning at North Road and subsequent injection at Bronglais. Provision of local Optical Coherence Tomography scanning in the van in the community will allow this travel burden to be halved.

Patients from Aberaeron, Machynlleth are within 30 minutes of Aberystwyth and can therefore continue to have their injections in Bronglais. Patients from South Gwynedd and Mid Powys may have to travel in excess of 1 hour to access the theatre facilities in Aberystwyth. This travelling time can be up to 1.5 or 2 hours in snowy winter conditions, where the roads are full of traffic from holiday makers from the Midlands in the summer or in rare instances where there has been a road traffic accident

This group of patients can potentially have injections in theatre facilities within Tywyn for South Gwynedd patients and Llandrindod Wells Hospital for Mid Powys patients. Cardigan patients are over 1 hour from Aberystwyth, and they may have the travel burden reduced by having both the OCT scan and injection facilities to be made available in two separate vans. It would be possible therefore, for certain sited to have a one stop service (Tywyn, Llandrindod Wells, Cardigan) and some to remain as a two stop (Aberaeron, Machynlleth) depending on the facilities available on each site.

There remains scope to reduce the travel burden on patients from Powys who currently are scanned in Shrewsbury or Hereford to have local OCT scanning and/or injections in the community at Welsh Community Hospitals in the future to reduce their travel burden. This may be incorporated into the project once the project has been established within Hywel Dda Health Board.

In order to set this develop this project, an Ophthalmic Mobile Unit team was set up to discuss development of a business case with regular meetings monthly for a year. The Project is now about to hit the road, and has had a successful demonstration using the Mobile van for optical coherence tomography scanning
