The critical period of vision development is in infancy and early childhood, and many paediatric vision problems need to be addressed in a timely manner to avoid lifelong repercussions. The waiting lists at most public hospital paediatric ophthalmology departments in Australia and New Zealand are too long and children are at risk of not being seen within the appropriate timeframes. The Royal Children’s Hospital (RCH), Melbourne, is no exception.
Paediatric ophthalmologist Dr Anu Mathew provides an update on efforts within RCH to overcome this issue, by fostering collaborative care models.
Over recent years, the staff within the RCH Department of Ophthalmology have worked hard to increase capacity for paediatric patients through innovations relating to models of care, service delivery, and staffing profiles.
Orthoptist-led clinics and collaborative models of care with external providers have been shown to provide timely and appropriate paediatric ophthalmic care to children who meet set criteria, and these models have increased access to care for thousands of children in Victoria. However, we continue to struggle to meet demand.
Expanding service delivery within the walls of RCH is limited due to the barriers of funding, physical space, and the scarcity of paediatric ophthalmologists. Therefore, other community based paediatric ophthalmic options are essential. The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) has identified paediatric eye care as one of the key priorities in the Vision 2030 and beyond initiative1 and collaborative care models are among the strategies being pursued to provide sustainable, high-quality eye care services to the growing adult and paediatric populations.
Expanding service delivery within the walls of RCH is limited due to the barriers of funding, physical space, and the scarcity of paediatric ophthalmologists.
Development of Collaborative Care Programs
At RCH, a group of dedicated orthoptists is constantly triaging the waiting list to ensure that no child suffers irreversible vision loss while waiting for an appointment. Where possible, patients with non-urgent eye problems are often redirected to other services – either private ophthalmologists who are happy to see children, local optometrists, or our collaborative care programs.
Our first collaborative care program was with the La Trobe University Orthoptic Student-Led Eye Clinic (LTEC) to manage patients with strabismus, amblyopia, and nasolacrimal duct obstruction. Guidelines were created to ensure that all patients were treated according to evidence-based practice, and criteria were specified to redirect patients back to RCH for review.
Since then, we have developed programs with Melbourne University Optometry Student-Led Eye Clinic (MEC) to manage patients with chalazia, nasolacrimal duct obstruction, and craniosynostosis; and with the Australian College of Optometrists for patients with a healthcare care card, other systemic associations, and/or developmental delay.
Collaborative care also works well for young aphakic patients who see select optometrists that feel comfortable caring for this group of patients.
An audit of the program at MEC showed 95% clinician adherence to protocols and 100% family satisfaction.2 At all these teaching clinics, an added benefit is exposing student orthoptists and optometrists to more paediatric patients and increasing their comfort levels when dealing with this population. RCH is working on expanding these collaborative partnerships to other patient groups who need regular follow-up e.g. screening for drug toxicity and follow-up for pseudo-papilloedema.
Managing the Collaborative Workflow
A new, senior orthoptist role of ‘Collaborative Care Coordinator’ was created at the RCH to manage the collaborative workflow according to the protocols in place, audit the service, and ensure communication between all parties complies with agreed guidelines. Access to electronic medical records and increased availability of imaging technology has streamlined communication and enabled ophthalmic patients to be remotely reviewed.
Since these initiatives, the number of new patients waiting for appointments has significantly reduced, allowing more review appointments to be created. However, each new patient seen generates, on average, 12 follow-up appointments. Thus, more initiatives are required to help ease the demand on the public hospital system and ideally provide care for families, closer to where they live.
Community optometrists are ideal healthcare professionals as they are trained in eye care and well placed throughout the community. They can assess and start some treatments in children and make better informed referrals. However, many optometrists feel that they do not have the skills or do not feel comfortable assessing children, especially young children or children with developmental problems.
Queensland Children’s Hospital has been running an aligned optometry program to address its waiting list problem. This program creates a pathway for community optometrists to upskill and maintain their skills, while seeing patients in their local communities.3 An eight-year audit of the program showed that a majority of participating optometrists felt more confident with paediatric eye care delivery and the percentage of children waiting longer than the recommended time frames for an appointment had halved.
In Victoria, we hope to build on similar principals to expand on our collaborative care initiatives. Last year, Cathy Lewis, Chief Orthoptist at the RCH and myself were awarded the RCH Foundation, Professor Frank Billson Research Scholarship for our project to build online education modules for optometrists. The modules will aim to educate optometrists on examination techniques in young children as well as the management of common disorders and red flags to indicate need for referral. Alongside the education modules will be collaborative care guidelines and proformas for certain disorders to allow patients to be seen alternatively between their local optometrist and at RCH.
This will allow care closer to home, fewer requirements for follow-up appointments at RCH, and appointments within the appropriate time frames. Clear communication pathways will be developed to share patient information, expanding on the processes currently in place for our other collaborative pathways.
With sharing information and patient care, we hope to further build on our community partnerships to the benefit of all stakeholders.
Dr Anu Mathew is the Director of Ophthalmology at the Royal Children’s Hospital, Melbourne. She has special interests in retinopathy of prematurity, retinoblastoma and uveitis. She is passionate about education and improving access to paediatric ophthalmology services.
Over the past decade, Dr Mathew has been working with optometrists in the community, orthoptists, and other health care professionals to implement RCH collaborative models of care.
References
- Royal Australian and New Zealand College of Ophthalmology, Vision 2030 and beyond, available at: ranzco.edu/wp-content/uploads/2023/06/RANZCO-Vision-2030-and-beyond-v2.pdf [accessed Nov 2024].
- Huhtanen A. Profiling an Optometry-led Paediatric Shared Care Clinic Model [Conference presentation]. OMEGA23, Melbourne, Australia. 8-10 September 2023.
- Webber A, McKinlay L, Newcomb D, Dai S, Gole G. The paediatric optometry alignment program – a model of interprofessional collaborative eyecare. Clin Exp Optom; 2023 Mar;106(2):178-186.
