The Royal Australian and New Zealand College of Ophthalmologists: tests, treatments and procedures clinicians and consumers should question

When a patient’s visual symptoms can be explained by simple refractive error and a comprehensive eye examination including slit lamp, extraocular movements, intraocular pressures, fundoscopy and confrontation visual fields is normal, there is no need for further tests. There are occasional exceptions – eg if the patient is specifically being reviewed in relation to an inherited retinal or optic nerve disorder, or as screening or baseline for drug-related toxity.

When testing for driving eligibility, the confrontation method is acceptable to screen for visual field defects. Automated perimetry is only required when significant field defects are suspected.

As in almost all branches of medicine, history and examination precede investigations and not the other way around.

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The AREDS studies were randomised controlled trials which demonstrated benefit for specific combinations of supplements for certain subtypes of age-related macular degeneration (AMD). They did not show benefit for patients without AMD, and have not been tested for retinal conditions other than AMD. There is no high-level evidence to support the use of dietary supplements for the prevention or treatment of other retinal conditions, assuming a normal diet and the absence of specific vitamin or other nutrient deficiency. Despite this, there is widespread promotion and use of dietary supplements perceived to have benefits for other retinal diseases.

Supporting evidence

  • Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Archives of Ophthalmology 2001;119(10):1417-36.
  • Chew EY, Clemons TE, Agrón E, Sperduto RD, SanGiovanni JP, Kurinij N, et al. Long-Term Effects of Vitamins C and E, β-Carotene, and Zinc on Age-related Macular Degeneration. Ophthalmology 2013;120(8):1604-11.e4. 
  • The Age-Related Eye Disease Study 2 Research Group. Lutein + Zeaxanthin and Omega-3 fatty acids for Age-Related Macular Degeneration: The Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial. Journal of the American Planning Association 2013;309(19):2005-15. 

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Alpha-1 adrenergic blockers such as tamsulosin nearly always affect the structural integrity of the iris and this can be permanent after only a few doses of the drug. As a result, “intraoperative floppy-iris syndrome” often results when intraocular surgery, especially cataract surgery, is performed. This can lead to iris damage and post-operative glare problems but also increase the risk of more serious complications such as posterior capsule rupture, vitreous loss, macular oedema and retinal detachment. This risk is up to ten times greater in some series.

Surgeons can minimise the risk if they know a patient has taken the drug. Patients on long waiting lists can sometimes forget to tell the ophthalmologist they have been prescribed it whilst waiting for surgery. Better still, if the need for taking tamsulosin is not absolute and immediate, delaying its prescription until after any impending cataract surgery is performed would be in the patient’s best interest.

Supporting evidence

  • Doss EL, Potter MB, Chang DF. Awareness of intraoperative floppy-iris syndrome among primary care physicians. Journal of Cataract & Refractive Surgery 2014;40(4):679-80.
  • Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. Journal of Cataract & Refractive Surgery 2005;31(4):664-73. 
  • Ng DT, Rowe NA, Francis IC, Kappagoda MB, Haylen MJ, Schumacher RS, et al. Intraoperative complications of 1000 phacoemulsification procedures: a prospective study. Journal of Cataract & Refractive Surgery 1998;24(10):1390-5. 
  • Chen AA, Kelly JP, Bhandari A, Wu MC. Pharmacologic prophylaxis and risk factors for intraoperative floppy-iris syndrome in phacoemulsification performed by resident physicians. Journal of Cataract & Refractive Surgery 2010;36(6):898-905. 
  • Chang DF, Osher RH, Wang L, Koch DD. Prospective multicenter evaluation of cataract surgery in patients taking tamsulosin (Flomax). Ophthalmology 2007;114(5):957-64. 
  • Manvikar S, Allen D. Cataract surgery management in patients taking tamsulosin staged approach. Journal of Cataract & Refractive Surgery 2006;32(10):1611-4.
  • Chang DF. Use of Malyugin pupil expansion device for intraoperative floppy-iris syndrome: results in 30 consecutive cases. Journal of Cataract & Refractive Surgery 2008;34(5):835-41. 

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Studies show that giving intravitreal injections, most commonly anti-VEGF agents for “wet” macular degeneration, can be safely done in an outpatient setting if standard, well published protocols are followed. These protocols include the use of standard aseptic technique, topical antiseptic in the conjunctival sac, and a face mask. Performing these injections in a hospital or day surgery adds enormous cost to the procedure for no clinical benefit. This cost, initially borne by private health funds, clearly puts pressure on the sustainability of the private health system and contributes to the need to increase health insurance premiums and to reduce benefits for other procedures.

Supporting evidence

  • Shimada H, Hattori T, Mori R, Nakashizuka H, Fujita K, Yuzawa M. Minimizing the endophthalmitis rate following intravitreal injections using 0.25% povidone-iodine irrigation and surgical mask. Graefe's Archive for Clinical and Experimental Ophthalmology 2013;251(8):1885-90.
  • Tabandeh H, Boscia F, Sborgia A, Ciraci L, Dayani P, Mariotti C, et al. Endophthalmitis associated with intravitreal injections: office-based setting and operating room setting. Retina 2014;34(1):18-23.
  • Merani R, Hunyor AP. Endophthalmitis following intravitreal anti-vascular endothelial growth factor (VEGF) injection: a comprehensive review. International Journal of Retina and Vitreous [Internet] 2015; 1(9). 
  • Fagan XJ, Al-Qureshi S. Intravitreal injections: a review of the evidence for best practice. Clinical & Experimental Ophthalmology 2013;41(5):500-7.
  • The Royal Australian and New Zealand College of Ophthalmologists. Guidelines for performing intravitreal therapy 2006/2012. Available from: http://www.ranzco.edu/images/documents/policies/CPG004_Intravitreal_Injections.pdf.

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Lattice degeneration and related asymptomatic retinal conditions are frequently found in eyes with retinal detachment. Intuitively one would expect that prophylactic treatment of such visible areas of abnormality would reduce the risk of retinal detachment, and such treatments used to be commonplace. The available evidence has however failed to demonstrate any convincing benefit, and there are also significant potential side effects to such treatment. One reason for the absence of demonstrated benefit is the frequent occurrence of retinal breaks outside areas of visible abnormality. With occasional exceptions, there is no justification for such treatment in asymptomatic eyes, and it has been a recommendation of the American Academy of Ophthalmology for many years that such treatment is not indicated. Counselling and follow-up of at-risk patients is likely more effective, and far more cost-effective, in preventing loss of vision due to retinal detachment.

Supporting evidence

  • Blindbaek S, Grauslund J. Prophylactic treatment of retinal breaks- a systematic review. Acta Ophthalmologica 2014;93(1):3-8.
  • Wilkinson CP. Evidence-based analysis of prophylactic treatment of asymptomatic retinal breaks and lattice degeneration. Ophthalmology 2000;107(1):12-5; discussion 5-8. 
  • Chauhan DS, Downie JA, Eckstein M, Aylward GW. Failure of prophylactic retinopexy in fellow eyes without a posterior vitreous detachment. Archives of Ophthalmology 2006;124(7):968-71. 
  • Lewis H. Peripheral retinal degenerations and the risk of retinal detachment. American Journal of Ophthalmology 2003;136(1):155-60. 
  • Kazahaya M. Prophylaxis of retinal detachment. Seminars in Ophthalmology 1995;10(1):79-86. 
  • Folk JC, Bennett SR, Klugman MR, Arrindell EL, Boldt HC. Prophylactic treatment to the fellow eye of patients with phakic lattice retinal detachment: analysis of failures and risks of treatment. Retina 1990;10(3):165-9. 
  • Folk JC, Arrindell EL, Klugman MR. The fellow eye of patients with phakic lattice retinal detachment. Ophthalmology 1989;96(1):72-9. 
  • Mastropasqua L, Carpineto P, Ciancaglini M, Falconio G, Gallenga PE. Treatment of retinal tears and lattice degenerations in fellow eyes in high risk patients suffering retinal detachment: a prospective study. British Journal of Ophthalmology 1999;83(9):1046-9. 
  • American Academy of Ophthalmology Preferred Practice Pattern: Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration - 2014.  Available at:   http://www.aao.org/preferred-practice-pattern/posterior-vitreous-detachment-retinal-breaks-latti-6 

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RANZCO has undertaken a multi-stage consultation process to ensure that the entire spectrum of medical eye specialists in Australia and New Zealand can contribute to the process of identifying and refining the top five recommendations. The first stage included a survey of fellows to identify possible recommendations, which were then narrowed down and by a dedicated “Choosing Wisely” committee of RANZCO members. A second survey was then sent to all members to provide feedback on the list of five and received a high response rate. Based on the extensive feedback received via the survey, RANZCO’s “Choosing Wisely” committee crafted the final wording of the top five recommendations. Finally, the RANZCO board discussed and approved the recommendations.

Last reviewed 01 March 2016