Collaborative Care and Consensus Guidelines

As part of the implementation of Vision 2030 and beyond, five working groups were formed, including the Paediatric Collaborative Care Working Group comprising paediatric ophthalmologists from across Australia. The aim of this working group was to improve outcomes and access to eye health care for children, especially those not currently accessing services, for example children who reside in rural and remote areas and Indigenous communities.

Specifically, the Paediatric Collaborative Care Working Group identified four key focus areas:

• Discrepancies in children’s vision screening programs across jurisdictions with some areas having excellent coverage and some not,

• Increasing awareness of myopia among general practitioners (GPs), parents, carers, and educators,

• Increased need for retinopathy of prematurity (ROP) screening, and

• Workforce shortages, as currently there are not enough paediatric ophthalmologists and some public hospital appointments remain unfilled.

Given that a shortage of paediatric ophthalmologists has created unmet demand for services, it was agreed that finding ways to work with other eye health care providers could help address this gap. This approach is known as collaborative care.

Collaborative care is defined as an integrated approach, where ophthalmologists work, not only together with optometrists and orthoptists in a traditional manner, but also with other health care providers such as non-ophthalmic physicians; GPs; paediatricians; nurse specialists; and Aboriginal Medical Services, to provide safe and effective eye care.

Collaborative care can take various forms; for example, eye care professionals may work together at one site, or at different locations at the same time or asynchronously, using the same or different medical record systems.

Regardless of the form, the goal is to direct appropriate care of a select group of patients away from tertiary-level paediatric public ophthalmology departments, without sacrificing quality of care or patient safety.

… the goal is to direct appropriate care… away from tertiary-level paediatric public ophthalmology departments, without sacrificing quality of care or patient safety…

Paediatric Collaborative Care Workshop

Supported by an education grant from Roche and Bayer, between May and September 2024, RANZCO led four collaborative care stakeholder workshops.

The Paediatric Collaborative Care Workshop was the first of these events. RANZCO’s paediatric ophthalmologists led the workshop, inviting eye care professionals including ophthalmologists, optometrists, orthoptists, and representatives from advocacy peak bodies to join. The aim of the workshop was to canvass opinion by having candid discussion on the best strategies to advocate for children’s eye health, facilitate improved access to an appropriate level of eye health services for timely intervention, and to ensure early referral occurs for sight and life-threatening conditions (‘red flags’).

Consensus Guidelines

As part of RANZCO’s advocacy platform, Vision 2030 and beyond,¹ specialist working groups were set up to focus on the four focus areas outlined above.

Retinopathy of prematurity (ROP) is a severe sight-threatening condition that impacts three out of every four babies born before 32 weeks’ gestation or weighing less than 1,250 g. Due to an increase in the survival rate of very premature babies, the incidence of ROP is increasing, coincident with a reduction in the number of ophthalmologists committed to delivering weekly care to this population.

A very small number of ophthalmologists, usually paediatric ophthalmologists, provide screening and treatment services across multiple health care services and in some cases, across an entire state. Given this, RANZCO identified ROP as a priority area within paediatric ophthalmology and assigned a specialist working group the task of reviewing the evidence and updating its ROP guidelines. In 2023, the Australian and New Zealand Neonatal Network (ANZNN) endorsed RANZCO’s Retinopathy of prematurity (ROP) screening and treatment guidelines2 as a best practice standard for screening and diagnosing babies at risk.

Based on emerging evidence, and in consultation with Optometry Australia, RANZCO updated its position statement, Progressive myopia in childhood in 2023.³ Reflective of the collaborative relationship and genuine efforts to reach consensus, in 2024, RANZCO reviewed and provided input into Optometry Australia’s Position statement on myopia management.⁴

A specialist working group was formed to develop new RANZCO Referral guidelines for eye and vision problems in infants and children.⁵ These guidelines are to be used by primary health care professionals to inform screening and triage of children with myopia and other eye conditions.

Given that the limited numbers of paediatric ophthalmologists working within public hospitals and rural and remote locations has resulted in long wait lists, the aim of this referral pathway is, in less serious cases, to identify conditions like myopia early, so that vision loss can be prevented.

When using the referral guidelines, it is also important that the pathway is referenced along with RANZCO’s Progressive myopia in childhood position statement,³ so that eye health care professionals can discern when myopia is progressing, despite treatment.

Health promotion resources targeting parents and carers are recommended to increase health literacy so that they know when to ask for a referral to an ophthalmologist.

Health promotion resources targeting parents and carers are recommended to increase health literacy…

Stakeholder Feedback

Overall, eye health care professionals who participated in the Paediatric Collaborative Care workshop endorsed the relevance, usability, and applicability of the RANZCO guidelines for diagnosis, referral, treatment and management of eye conditions in children.⁵ However, participants highlighted the need for more effective promotion of the RANZCO guidelines, ensuring they are easily accessible and widely available.

It was agreed that translating and adapting evidence-based clinical guidelines for key audiences, such as busy clinicians, will ensure they are used more widely and have greater impact. Suggestions for varying the format to suit the audience included summarising key information into reference sheets, and checklists to be accessed as a laminated sheet, which is wearable or can be displayed on a pin board.

Margaret Lum is Manager, Policy and Advocacy at RANZCO and provides support to the Vision 2030 and beyond Paediatric and Diabetic Retinopathy and Working Groups. Ms Lum is responsible for working with specialist ophthalmologists and other eye care professionals to develop and implement advocacy strategies for patient-centred models of care, highlighting gaps in services especially for children, Aboriginal and Torres Strait Islander and rural/remote populations with the goal of preventing vision loss.

Dr Caroline Catt is a paediatric eye surgeon with experience caring for premature babies through to older children and adults. She operates in both private and public settings including at the Westmead Children’s Hospital. Dr Catt is the Chair of the Australian and New Zealand Paediatric Ophthalmology Society (ANZPOS), co-Chair, Vision 2030 and beyond Paediatric Ophthalmology Working Group, and is Principal Investigator of the Fight Childhood Blindness! ROP Registry, a Save Sight Registry.

Professor Shuan Dai is the Director of Ophthalmology at Children’s Health Queensland Hospital and Health Services and the Queensland Children’s Hospital in Brisbane, Australia. He currently serves as the Chair of the Royal Australian and New Zealand Strabismus Society and co-Chair Vision 2030 and beyond Paediatric Working Group. Additionally, he is the Paediatrics and Strabismus Section Editor for the RANZCO journal, Clinical and Experimental Ophthalmology. Prof Dai is an active member of the American Academy of Ophthalmology, the American Association for Paediatric Ophthalmology and Strabismus, and a Council Member of the Asia Pacific Strabismus and Paediatric Ophthalmology Society. He specialises in paediatric ophthalmology and adult strabismus and is widely recognised for his expertise in paediatric neuro-ophthalmology, strabismus, paediatric low vision, and retinopathy of prematurity (ROP) telemedicine. He plays a key role in shaping government health policies related to paediatric eye care, collaborating with various healthcare professionals.

References

1. Royal Australian and New Zealand College of Ophthalmologists, Vision 2030 and beyond. Available at ranzco.edu/home/community-engagement/vision2030-beyond [accessed Nov 2024].
2. Royal Australian and New Zealand College of Ophthalmologists, Retinopathy of prematurity (ROP) sScreening and treatment guidelines. Available at ranzco.edu/policies_and_guideli/retinopathy-of-prematurity-rop-screening-and-treatment-guidelines [accessed Dec 2024].
3. Royal Australian and New Zealand College of Ophthalmologists, RANZCO position statement: Progressive myopia in childhood. 2023. Available at: ranzco.edu/wp-content/uploads/2022/05/RANZCO-Position-Statement-%E2%80%93-Progressive-Myopia-in-Childhood_2023.pdf [accessed Nov 2024].
4. Optometry Australia, Position statement on myopia management. Available at: optometry.org.au/wp-content/uploads/Professional_support/Guidelines/Myopia-Position-Statement-2024-v2.pdf [accessed Dec 2024].
5. Royal Australian and New Zealand College of Ophthalmologists, Referral guidelines for eye and vision problems in infants and children. Available at ranzco.edu/policies_and_guideli/referral-guidelines-for-eye-and-vision-problems-in-infants-and-children [accessed Dec 2024].