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RANZCO Developing Injections Guidelines for Non Ophthalmologists

The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) is developing guidelines for health professionals other than ophthalmologists to give anti-VEGF injections in hospitals in Australia and New Zealand.

The move would open the way for ophthalmologists to train optometrists, nurses and GPs to give intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) in hospital clinics.

Injecting would likely be under strict conditions, including being under the direct supervision of an ophthalmologist, making no clinical decisions and being trained in phlebotomy, sterile techniques and first aid.

If optometrists meet those requirements then there is nothing to stop them doing injections

Currently ophthalmologists inject this treatment into the eyes of patients with neovascular age-related macular degeneration, diabetic macular oedema and retinal vein occlusion.

CEO of the Royal Australian and New Zealand College of Ophthalmologists Dr David Andrews confirmed today, August 1, 2019, that guidelines were being developed.

“The guidelines aren’t finished yet, we have a few more rounds to go and at this stage we expect they will not go to the board until October,” he told Optometry Australia.

“The medical system is different in Australia and New Zealand because most clinics in New Zealand are public, but we don’t want two sets of guidelines, we prefer one (to cover both countries.)”

Dr Andrews said RANZCO had been asked by its Fellows to produce guidelines for intravitreal anti-VEGF injections in hospitals by non-ophthalmologists.

Nurses Giving Injections

“In Australia and New Zealand, a number of nurses (nurse practitioners) are giving the injections, plus some GPs in New Zealand, and there has been a request for guidelines for an orthoptist already trained to inject in the UK,” he said.

“The guidelines would cover what we believe should be the standard, the level of training that people require, and other skills such as resuscitation and injecting skills, the standards everyone giving these injections needs to meet. It will also cover what re-credentialling needs to be done and how often.

“If optometrists meet those requirements then there is nothing to stop them doing injections.”

Dr Andrews said that if RANZCO gave the green light, it would then be up to optometry’s regulatory bodies, the Optometry Board of Australia and the Optometrists and Dispensing Opticians Board of New Zealand to specify and prescribe qualifications for change in optometrists’ scope of practice.

He said he had raised this with the Optometrists and Dispensing Opticians Board of New Zealand.

“It has had a number of requests from district health bodies for hospital optometrists to give the injections, and said New Zealand would run a trial if given the go ahead.

‘I am unaware of similar requests in Australia although I believe there has been a trial using nurses at Melbourne’s Alfred hospital.’

Dr Andrews said it may be nurses, who are trained in injection techniques, who do the majority of injections but optometrists who staff hospital clinics might also give the injections.

He said most anti-VEGF treatment in New Zealand was through the public system, whereas in Australia, most was through the private system.

Dr Andrews spoke to Optometry Australia after New Zealand’s Eyeonoptics newspaper reported that demand was outstripping the health service’s ability to provide timely treatments, leading to some patients going blind unnecessarily.

The report said that in some areas nurse practitioners had been trained to give injections but Gisborne ophthalmologist Dr Graham Wilson said this was not enough to cope with demand in poorer regions such as Gisborne.

Eyeonoptics reported that to cope with demand, Dr Wilson had employed four optometrists whom he began to train to inject but this had led to some criticism relating to optometrists’ lack of training with needles and sterile techniques.

“The rate of endophthalmitis after these injections is about one in 3,000 and that doesn’t relate to the skill of the practitioner,’ he said in Eyeonoptics. ‘I’ve trained nine registrars to inject. I’ve trained a nurse to inject, who’s done well over 1,000 injections now, so surely I can train an optometrist who knows the anatomy and physiology of the eye well.”

Great Potential for Optometrists

Optometry Australia’s National CEO Lyn Brodie said, “We are very pleased to see this recognition that the skills and expertise of optometrists can be used in different ways to help meet community need.

“We applaud RANZCO for supporting this approach to enhancing patient access to anti-VEGF treatment.

“We think there is great potential for optometrists and ophthalmologists to work collaboratively in the interests of ensuring more Australians have timely access to the eye care they need.”

As part of its Optometry 2040 project, Optometry Australia has a priority commitment to continue evolving scope of practice in Australia to ensure community need is met.

Some optometrists in America can already give injections. In March 2019, Arkansas became the latest state in the USA to enact legislation to increase the scope of optometry practice to include surgical procedures.

Enacted on March 27 2019, the bipartisan-supported legislation (HB 1251) amends the state’s optometric scope of practice act to permit new procedures including selective laser trabeculoplasty and YAG laser capsulotomy, certain injections (excluding intravenous and intraocular), removal of lid lesions and chalazion incision and curettage

Optometry Australia reported on a study in 2014 which claimed that about 5,000 Australians a year with wet AMD may be missing out on injections to delay AMD progression.

The study by CERA ophthalmologist Dr Robert Finger and the Macular Disease Foundation Australia found a ‘large discrepancy’ between the number of people expected to receive Lucentis injections and the number who actually received them.

Article republished with permission from Optometry Australia, (It already has Helen Carter as journalist)