A Sydney ophthalmologist has urged colleagues to think outside the box and consider taking sight-saving intravitreal eye injection (IVI) therapy out of the clinic when circumstances demand it.
Every six weeks, prominent medical retinal specialist Dr Paul Beaumont shuts his clinic, at Mona Vale on Sydney’s northern beaches, a little earlier in the day. His ophthalmic nurse has already packed a medical kit, and together they head to a nearby nursing home.
They are there to provide an intravitreal eye injection (IVI) to an elderly patient, who has neovascular age-related macular degeneration (nAMD) but who is unable to leave her bed.
“We shouldn’t have elderly Australians go blind just because they’re in a nursing home,” Dr Beaumont told mivision.
During COVID, when many nursing home patients were unable to leave their premises, Dr Beaumont would provide in-room treatment to “six or seven” patients.
“At the moment, we’re doing only two but that’s probably taken us – in terms of time out of the clinic – about three to four hours,” he said.
His patient on the day mivision accompanied him to the nursing home was 103-year-old Norma Tory (see breakout), who receives an anti-VEGF injection in her right eye. She is legally blind in the other.
LOGISTICS
“It is a logistical problem when you’re running a practice, because you have all the staff in the practice and you have high overheads, so you can’t afford to do it every week,” Dr Beaumont said.
“But I do it once every six weeks. So, for some people that might be a slight overtreatment; for some people it might be a slight under-treatment. But what we are finding is that it keeps them watching TV and reading books.
“In the last years of your life, this is what you do to entertain yourself so it’s critically important.
“Really, being in a nursing home and having a lot of your independence taken, at least if you can see, you can watch TV, you can dial your phone, you can read books, you can read the paper. It keeps you in contact with the world.”
PATIENT SELECTION
Dr Beaumont said he offers the in-room procedure only to patients who are mentally alert and unable to travel.
“If a person is too demented to read and watch TV, they’re usually too demented to cooperate, so they are the one group of patients that you can’t treat.
“But, I mean, look at Norma. She’s 103. When she had her 99th birthday she was mobile, and she had her injections in the practice. We actually broke out a bottle of champagne with her.”
Of course, as Mrs Tory is unable to leave her bed, Dr Beaumont can’t perform the usual battery of tests to check her macula. Instead, he relies on “functional testing” to determine whether the treatment is working.
“I ask, ‘How’s your reading going?’. She reads two books a week, so I know I’m on the right track.”
INFECTION CONTROL
Dr Beaumont conceded sterility was a problem, “but it is a matter of informed consent”.
“Norma would rather take the risk of infection than lose her vision so we do what we can to minimise the extent of it. Over the years we’ve never had an infection whilst doing it in the nursing home.
“It would have to be less sterile than, say, in your rooms where you have got control of the environment. But the alternative, blindness, is unacceptable,” he said.
Dr Beaumont said he takes extra precautions, taking time to bathe a patient’s eye with an antiseptic solution before the injection. Everyone in the room is masked during the procedure, and the patient’s eyes are bandaged for four hours afterwards.
Every time the procedure is performed, instructions are left with nursing staff, in case new nursing home staff attend to the patient. Staff also have Dr Beaumont’s numbers to contact in case of emergency.
“It is time intensive, but I think people (other ophthalmologists) don’t think about doing it.
“They’re worried about infections, but it’s not their worry. It is the person in there (the nursing home) who has to choose between the risk of infection and the loss of vision.
“I think we have to let people know that this is a reasonable thing to do and that the elderly want it.
“So, I just encourage other doctors to think about their patients who go into a nursing home and can’t come into the surgery – go to them.
“It’s a bit of a loss leader. It’s not going to be cost effective, but in terms of what it does spiritually, keeping someone in their last years of life seeing, I think it’s worth buckets, isn’t it?”
Maintaining a Lifeline
For centenarian Norma Tory, her sight is one of the last few links to the outside world, allowing her to escape the confines of her bed and jump into the worlds created in the books she consumes so voraciously.
Her room in the nursing home on Sydney’s northern beaches has bookshelves and cupboards crammed with biographies, literary classics, and a few Agatha Christie detective novels.
She regards her regular in-room visits by Dr Beaumont – for neovascular age-related macular degeneration, discovered when she was in her late 90s – as her lifeline. Legally blind in her left eye, her right eye has responded to treatment, maintaining her functional vision.
“In the beginning, we would take Norma to Dr Beaumont in his surgery, and he would do all the tests and the injections,” Ms Tory’s son, David Tory, explained.
“But, in September 2020, Norma unfortunately had to come in here (to the nursing home) … so Dr Beaumont decided to do the injections in her bed,” he said.
“Visits to the surgery at Mona Vale would be an ambulance ride every time. It would be a major event. Getting Norma out of bed, into an ambulance to the surgery and back… if it came to the crunch, it would be possible, but it would take a day and it would be very hard to do. And their surgery is not set up for someone on a gurney.”
Instead, every six weeks, Dr Beaumont and his ophthalmic nurse pack a medical kit and visit Mrs Tory. It’s because of these eye injections that she can still read, watch television, and see the faces of her two children, five grandchildren, and three great-grandchildren.
“I couldn’t do without them (the eye injections), could I? It’s very nice of him to come,” Ms Tory told mivision.
“I like sensible books about artists. I’m currently reading about Dorothea Mackeller. I’ve just read the Secret River series (an historical trilogy) by Kate Grenville.”
Norma, who is also hard-of-hearing, explained that she sees well enough to be able to read the captions on her television, which keeps her entertained in the evenings.
Mr Tory said the in-room visits have “enabled Norma to continue reading, which is her great passion and her only real link – apart from her family visiting very regularly – with the outside world”.
“In doing so, he (Dr Beaumont) has saved her sight. But he’s also saved her life in a way because she’s able to read and have a continual interest in the world. It’s wonderful.
