The Royal Australian and New Zealand College of Ophthalmologists
Recommendations from the Royal Australian & New Zealand College of Ophthalmologists on visual fields, vitamins, alpha-1 blockers, intravitreal injections & retinal detachment. The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) is the leading medical eye specialist organisation in Australia and New Zealand. RANZCO’s mission is to drive improvements in eye health care through continuing exceptional training, education, research and advocacy.
In the absence of relevant history, symptoms and signs, ‘routine’ automated visual fields and optical coherence tomography are not indicated.
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, as screening or baseline for drug-related toxity, or as part of preparing a patient (pre-op for cataract assessment).
When testing for driving eligibility, the Estermann visual test for visual field defects is appropriate to screen for visual field defect. 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.
- American Academy of Ophthalmology. Choosing Wisely: Five Things Ophthalmologists and Patients Should Question. Recommendation 2: Imaging Tests 2013 [updated February 21, 2013] Available from: http://www.aao.org/choosing-wisely.
- American Academy of Ophthalmology. Advisory Opinion: One Network: Clinical Education 2014.
- Spaeth GL. Glaucoma Testing: Too Much of a Good Thing. Review of Ophthalmology [Internet] 2013. Available from: http://www.reviewofophthalmology.com/content/d/glaucoma/c/40136/.
- Augsburger JJ. Unnecessary clinical tests in ophthalmology. Transactions of the American Ophthalmological Society 2005;103:143-7.
- Austroads, NTC Australia. Assessing fitness to drive for commercial and private vehicle drivers March 2012. Available from: https://www.onlinepublications.austroads.com.au/items/AP-G56-13.
- American Academy of Ophthalmology. Preferred Practice Pattern: Comprehensive Adult Medical Eye Evaluation: Elsevier; 2015. Available from: http://www.aaojournal.org/pb/assets/raw/Health%20Advance/journals/ophtha/ophtha_8949.pdf.
- Bussel II, Wollstein G, Schuman JS. OCT for glaucoma diagnosis, screening and detection of glaucoma progression. British Journal of Ophthalmology 2013;2013(98):ii15 - ii9.
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.
- 1 In the absence of relevant history, symptoms and signs, ‘routine’ automated visual fields and optical coherence tomography are not indicated.
- 2 AREDS-based vitamin supplements only have a proven benefit for patients with certain subtypes of age-related macular degeneration. There is no evidence to prescribe these supplements for other retinal conditions, or for patients with no retinal disease.
- 3 Don't prescribe tamsulosin or other alpha-1 adrenergic blockers without first asking the patient about a history of cataract or impending cataract surgery.
- 4 Intravitreal injections may be safely performed on an outpatient basis. Don't perform routine intravitreal injections in a hospital or day surgery setting unless there is a valid clinical indication.
- 5 In general there is no indication to perform prophylactic retinal laser or cryotherapy to asymptomatic conditions such as lattice degeneration (with or without atrophic holes), for which there is no proven benefit.
- 6 Do not use corneal cross linking for every patient with keratoconus.
- 7 Do not use topical antibiotics pre or post intravitreal injections.
- 8 Do not investigate systemically well patients with a first, uncomplicated episode of acute anterior uveitis.
- 9 Topical steroids should not be used unless infection has been ruled out in any patient with red eye.