BREAKING DOWN BARRIERS A CASE FOR VISION CARE

BREAKING DOWN BARRIERS …. A CASE FOR VISION CARE IN NOVA SCOTIA AND CANADA ALLIANCES TO IMPROVE ACCESS TO SPECIALTY SERVICES Royal College NSS Summit Ottawa 2018 Ottawa, March 2018

THE CASE OF OPHTHALMOLOGY G. R. LA ROCHE MD FRCSC PROFESSOR AND DIVISION CHIEF PEDIATRIC OPHTHALMOLOGY AND ADULT STRABISMUS DEPARTMENT OF OPHTHALMOLOGY AND VISUAL SCIENCES DALHOUSIE UNIVERSITY

Know the players and potential allies ü Ophthalmology ü Optometry ü Family Medicine ü Technology, Megadata, AI ü Government Public Health ü NGOs like CNIB, Fight for Blindness etc

Two main routes of Referral to Ophthalmology o Optometrists: Many Surgical cases o Physicians: Family Doctors, Other specialists (Medical specialties) Medical Referral routes for ophthalmology are failing o Lacking Family Docs (see NS as example. . 10% without) o Lacking competent Family Docs for Eye Care (Curriculum issue) o Silent blinding conditions (D. Retinopathy, Mac. Degeneration, Amblyopia)

Know some issues of access o Vision restoration - Cataract surgery wait time: increasing again o Distant, and indigenous populations: neglected o Referral routes: deficient and changing o Evolving practices: insufficient in Ped. Ophth, Neuro-ophth o Pediatric vision primary care: under-utilized at 30% o Diabetic retinopathy screening and treatment: under-utilized at 40%

LOOKING THROUGH THE LENS OF CATARACT SURGERY… Proportion of patient’s accessing care within wait time benchmarks (2012 -2016) DECLINES (6 PROVINCES) INCREASES (4 PROVINCES) 100% 80% 60% 40% 20% 0% 2012 2013 2014 2015 2016 N. B. Que. Ont. N. L. P. E. I Source: CIHI, 2017, Wait Times for Priority Procedures in Canada, http: //waittimes. cihi. ca/All#year N. S. Sask.

NOVA SCOTIA – PEDIATRIC STRAB. SURGERY CASE EXAMPLE: STRABISMUS SURGERY ADULTS – WAIT TIMES DATA 12 Locations across Canada Dx to Sx (Surgical Wait) Referral to DX (Clinical Wait) Total Wait Canadian Average (months) 7. 7 9. 3 17. 25

Overarching value trumps care-givers’ turfs PATIENT/FAMILY NEED FOR ACCESS

Alliances to improve access o Scope of competence Ophthalmology complemented by Optometry o Education and participation Target population, Family Medicine, Optometry, Nursing o Government Quality and access at predictable costs

Ophthalmology solutions to improve access o COS Provincial Alliances (Eye Health Councils) Glaucoma Diabetic Retinopathy Pediatric ophthalmology o Many Telemedicine programs include First Nations o Senior Vision Rehabilitation Recommendations o Re-allocations of $$ to sub-specialty fees Pediatric and Neuro-ophthalmology

Figure 1 Nova. SPPEC Access Stream Protocol Nova. SPPEC Treatment Initiation Protocol For Optometrists Red eye reflex at birth bbirth Figure 2 Entry to Nova. SPPEC via Access Stream Protocol No Red Reflex < 1 week Refer to Ophthalmologist Abnormal Vision As per Nova. SPPEC Normative Standards Red eye reflex at each vaccination Control Visit 3/12 after Initiation of refractive Rx Normal VA Normal Alignment As per Nova. SPPEC Normative Standards Yearly Follow up To age 12 Normal Refraction As per Nova. SPPEC Normative Standard AND History to identify Children at risk < 6 months Positive History Of Risk EVSP vision screening program: failure (+) on screening, or failure to be screened Start Refractive Rx < 6 months Teacher’s suspicion of Vision problem Refer to Optometrist or Ophthalmologist For Nova. SPPEC Standard examination Refer to Optometrist or Ophthalmologist For Nova. SPPEC Confirmatory Standard examination Normal VA Abnormal Alignment < 12 months Routine Optometric or Ophthalmologic Eye examination Initiation of full time occlusion Refer to OMD < 2 months Continue with Refractive Tx Refer to OMD < 2 months Initiation of full time occlusion Follow up after 1 cycle* Development of abnormal alignment Continue with Tx Refer to OMD < 1 Month Children sent by parents for one (x 1) eye exam Before age 12 years Abnormal VA Abnormal alignment Abnormal VA Normal Alignment N o r m a l F o l l A l i g n m e n t + o w - u p s i m p r o v e m e n t i n x 2 c y c l V A e s Normal Alignment & Normal VA** Follow-up for recurrence q 1/12 x 2 Then q 4/12 x 2 then q 6/12 until age 12 Normal Alignment + NI or recurrence in abnormal VA Continue with Tx Refer to OMD < 1 Month

Future access Problems & Reliefs P 1: Aging population increases ophthalmology demand - Cataracts - Glaucoma - Retinal degenerative diseases - Acquired Strabismus with diplopia P 2: Aged Ophthalmologists of 2018 x 2 > 65 y/o --- x 1 < 35 y/o 2028 : 1/3 > 65 y/o Cataract patients = from 21% to 32 % New graduates/year : flat 40 R 1: Technology - Imaging - 5 G communications - A. I. / VR - Robotics R 2: Expanded Team - Fam. Docs - Optoms - Orthoptists

However … financial limitations o COS Yearly membership $500 One time vonluntary “gift” $700 o Doctors Nova Scotia Ophthal. Section : o Volunteers, time, dedication $250 Priceless

Thank you Shanna Di. Millo, Royal College Jennifer Brunet-Colvey, Canadian Ophthalmological Society Ken Rogers, Ophthalmologist, Fredericton, New Brunswick