Clinical Commissioning Group (CCG) Governing Body 2015/2016

Transcription

1 Clinical Commissioning Group (CCG) Governing Body 2015/2016 Date of Meeting: 20 November 2015 Agenda Item: 8b Subject: Greater Manchester Effective Use of Resources Policies Reporting Officer: Dr C Duffy Aim of Paper: Ratification of GM EUR Policy Removal of Common Benign Skin Lesions of the Eyelid. Governance route prior to Governing Body Meeting Date Objective/Outcome CCG Governing Body Quality and Safety Committee Clinical Commissioning Committee Patient Experience Assurance Committee Finance, Performance and Risk Committee Audit Committee Remuneration Committee Locality Engagement Group Health and Wellbeing Board Other: Greater Manchester EUR Steering Group 20 May 2015 Approved Greater Manchester Chief Finance Officers Virtually August 2015 Approved Greater Manchester Heads of Commissioning Virtually August 2015 Approved Greater Manchester Association Governing Group 15 th September 2015 Approved Governing Body Resolution Required: Recommendation The Governing Body is asked to ratify the Greater Manchester EUR Policy on Removal of Common Benign Skin Lesions of the Eyelid.. Link to Strategic Objectives SO1: To secure additional years of life for people of the Borough with treatable mental and physical health conditions SO2: To improve the health related quality of life for people with long term condition(s) including mental health conditions SO3: To reduce the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside hospital SO4: To increase the proportion of older people living independently at home following discharge from hospital SO5: To increase the number of people with mental and physical health conditions having a positive experience of hospital care and care outside of hospital (including General Practice and the Community) SO6: To make significant progress towards eliminating avoidable deaths in our hospitals, and all care settings, caused by problems in care. SO7: To develop integrated working and partnerships to ensure the best possible care for the borough SO8: To be a high performing CCG, deliver our statutory duties and use our Contributes to: (Select Yes or No) Yes Yes Yes Yes Yes Yes Yes Yes 1

2 available resources innovatively to deliver the best outcomes for our population. Risk Level: (To be reviewed in line with Risk Policy) Comments (Document should detail how the risk will be mitigated) Content Approval/Sign Off: The contents of this paper have been reviewed and approved by: Clinical Content signed off by: Not Applicable CCG Chair, Dr Chris Duffy Financial content signed off by: Clinical Engagement taken place Patient and Public Involvement Patient Data Impact Assessment Equality Analysis / Human Rights Assessment completed Completed: Yes Yes Not Applicable Yes Executive Summary The attached policy document outlines the arrangements for the funding of Removal of Common Benign Skin Lesions of the Eyelid for the population of Greater Manchester. This has been produced in order to provide and ensure equity, consistency and clarity in the commissioning of Removal of Common Benign Skin Lesions of the Eyelid. Adoption of this policy will alleviate any disparity faced by patients within Greater Manchester, (dependent on their registered GP/CCG) when requesting funding for Removal of Common Benign Skin Lesions of the Eyelid. Adoption of Greater Manchester EUR policies will also ensure that all acute trusts within Greater Manchester are working to the same policy, which will also relieve any possible differences in accessing this treatment dependent on where the patient is referred. Commissioning Recommendation: Removal of Common Benign Skin Lesions of the Eyelids The removal of common benign eyelid lesions for aesthetic reasons is not commissioned. All suspected malignant lesions are excluded from this policy - these should be managed via the 2 week wait. 4 A) Referrals for the treatment of common benign eyelid lesions may be made if there is any indication that these indicate underlying disease, sight threatening issues with the eye or there is doubt of the diagnosis and the lesion may not be benign in nature. Examples of reasons for referral include but are not exclusive to: 2

3 Significant preseptal cellulitis / orbital cellulitis Atypical presentation, re-occurrence in same site, may require cancer exclusion Protrusion of the eye Rapidly growing Visual field affected Ocular symptoms indicating either an underlying condition or the potential for serious damage to the eye New and unexpected visual problems (e.g. double vision) Reduced light reflexes or abnormal swinging light test Symptomatically unwell CNS symptoms or signs 4 B) Where the eyelid lesion is symptomatic referrals can be made using the prior approval through IFR route for the following criteria: Persistent (more than 6 months and not responded to conservative treatment) There is significant pain as a direct result of the lesion There is a confirmed history of recurrent infection / inflammation Significant redness of the eye in the absence of an obvious cause This policy has been developed and approved by the Greater Manchester EUR Steering Group. The Greater Manchester EUR Steering Group is quorate when all 12 CCGs are represented. Decisions taken by the Steering Group are by consensus. Consultation on the policy has also taken place, with feedback being reviewed by the Greater Manchester EUR Steering Group prior to approval of the final attached policy. 3

4 GREATER MANCHESTER ASSOCIATION GOVERNING GROUP MEETING Date of Meeting 18 th August 2015 Issue under Consideration Brief Paragraph Summary Greater Manchester Effective Use of Resources (EUR) Policy Removal of Common Benign Eyelid Lesions This policy document outlines the conditions under which the removal of common benign eyelid lesions will be routinely commissioned by Clinical Commissioning Groups (CCGs) in Greater Manchester. It has been produced in order to provide and ensure equity, consistency and clarity in the commissioning of the removal of common benign eyelid lesions by all CCGs in Greater Manchester. Adoption of this policy will alleviate any disparity faced by patients within Greater Manchester, (dependent of their registered GP/CCG) in accessing the removal of common benign eyelid lesions. Adoption of Greater Manchester EUR policies will ensure that all NHS acute trusts/providers within Greater Manchester are working to the same policy, which will also relieve any possible differences in accessing this treatment dependent on where the patient is referred. Commissioning Recommendation The removal of common benign eyelid lesions for aesthetic reasons is not commissioned. All suspected malignant lesions are excluded from this policy - these should be managed via the 2 week wait. 4 A) Referrals for the treatment of common benign eyelid lesions may be made if there is any indication that these indicate underlying disease, sight threatening issues with the eye or there is doubt of the diagnosis and the lesion may not be benign in nature. Examples of reasons for referral include but are not exclusive to: Significant preseptal cellulitis / orbital cellulitis Atypical presentation, re-occurrence in same site, may require cancer exclusion Protrusion of the eye Rapidly growing Visual field affected Ocular symptoms indicating either an underlying condition or the potential for serious damage to the eye New and unexpected visual problems (e.g. double vision) Reduced light reflexes or abnormal swinging light test Symptomatically unwell CNS symptoms or signs

5 GREATER MANCHESTER ASSOCIATION GOVERNING GROUP MEETING 4 B) Where the eyelid lesion is symptomatic referrals can be made using the prior approval through IFR route for the following criteria: Persistent (more than 6 months and not responded to conservative treatment) There is significant pain as a direct result of the lesion There is a confirmed history of recurrent infection / inflammation Significant redness of the eye in the absence of an obvious cause Funding Mechanism The Greater Manchester EUR Steering Group has recommended the following funding mechanism for this policy:- Funding will be via monitored approval for referrals made and accepted in line with the criteria detailed in 4 A. Funding will be by prior approval via the IFR route for the criteria detailed in 4 B. Decision/Opinion Required The Association Governing Group is asked to review the attached policy and supporting documentation and approve for ratification by Greater Manchester CCG Governing Bodies. Item is for Information Author of Paper and contact details Lynne Duxbury, Head of Effective Use of Resources, Telephone: , Mobile , lynneduxbury@nhs.net. The item has been discussed previously at these meetings including the outcome This policy has been developed and approved by the Greater Manchester EUR Steering Group. The Greater Manchester EUR Steering Group is quorate when all 12 CCGs are represented. Decisions taken by the Steering Group are by consensus. Consultation on the policy has taken place from 16 th February to 27 th March 2015, with feedback being reviewed by the Greater Manchester EUR Steering Group prior to approval of the final attached policy. Notification of the policy consultation was disseminated to:- Within Greater Manchester Clinical Commissioning Groups (GMCCG); CCG Chief Operating Officers; CCG Heads of Commissioning; CCG EUR Leads; CCG IFR Panel/Process Review Panel Members; Greater Manchester EUR Steering Group Members;

6 GREATER MANCHESTER ASSOCIATION GOVERNING GROUP MEETING Within the Greater Manchester Commissioning Support Unit (GMCSU); Executive Team; Medicines Management; Contracts and Performance; Service Redesign; Patient Services; Equality and Diversity; EUR Team, including Clinical Triage GP members; CCG Communication Teams to be disseminated to GPs; Practice Managers; Patient Representative Groups through existing CCG communication mechanisms; The policy consultation was also sent to named contacts with each Greater Manchester Acute Trust to disseminate to appropriate clinicians/managers within each organisation. This policy has been reviewed by the Greater Manchester Heads of Commissioning (HOC) and Greater Manchester Chief Finance Officers (CFO), virtually in August Feedback had been requested by the 17 th August 2015 for final agreement and recommendation to CCG Governing Bodies by the Greater Manchester Association Governing Group.

7 Greater Manchester Clinical Commissioning Groups Cost and Activity for Common Benign Eyelid Lesions 2011/12 to 2014/15

8 Introduction Clinical Commissioning Groups (CCGs) across Greater Manchester have inherited Effective Use of Resources (EUR) policies from their predecessor Primary Care Trusts (PCTs). Consequently, there are varying positions regarding the commissioning of certain procedures/treatments across Greater Manchester. Work is now being undertaken by the North West Commissioning Support Unit s (NWCSU) Policy Team, led by the Greater Manchester EUR Steering Group to align EUR policies across Greater Manchester. Purpose of the Report This report aims to inform the Greater Manchester EUR Steering Group of the activity and spend on common benign eyelid lesions during financial years 2011/12, 2012/13, 2013/14 and 2014/15 for each CCG. Body of the Report The table attached at Appendix 1 provides details of each CCG s activity and costs on common benign eyelid lesions (Source Data: Inpatient Spell PbR, Primary Procedures). The following procedures were selected to inform the report: C11.1 Excision of lesion of canthus C11.2 Destruction of lesion of canthus C12.1 Excision of lesion of eyelid NEC C12.2 Cauterisation of lesion of eyelid C12.3 Cryotherapy to lesion of eyelid C12.4 Curettage of lesion of eyelid C12.5 Destruction of lesion of eyelid NEC C12.6 Wedge excision of lesion of eyelid C12.8 Other specified C12.9 Unspecified Conclusion The information contained in Appendix 1 has been produced in order to support the policy decision making process across Greater Manchester. The Greater Manchester EUR Steering Group is asked to review this information to assist the policy decision taken for the removal of common benign eyelid lesions across Greater Manchester.

9 Appendix 1 Activity Reports for Common Benign Eyelid Lesions procedures OPCS Codes Used : C11.1, C11.2, C12.1, C12.2, C12.3, C12.4, C12.5, C12.6, C12.8, C12.9. Source used : InpatientPbR Procedure Group Primary Procedure Financial Year Values 2011/ / / /2015 Commissioner Name No of Spells Cost in 's No of Spells Cost in 's No of Spells Cost in 's No of Spells Cost in 's BOLTON , , , ,057 BURY 84 55, , , ,869 CENTRAL MANCHESTER , , , ,430 HEYWOOD, MIDDLETON AND ROCHDALE 92 61, , , ,666 NORTH MANCHESTER , , , ,351 OLDHAM , , , ,021 SALFORD , , , ,086 STOCKPORT , , , ,584 TAMESIDE AND GLOSSOP , , , ,036 TRAFFORD , , , ,125 WIGAN BOROUGH , , , ,487 SOUTH MANCHESTER , , , ,501 Grand Total 1,726 1,158,093 1,814 1,204,024 1,934 1,233,073 2,148 1,354,213

10 Greater Manchester Clinical Commissioning Groups Cost and Activity for Common Benign Eyelid Lesions 2011/12 to 2014/15

11 Introduction Clinical Commissioning Groups (CCGs) across Greater Manchester have inherited Effective Use of Resources (EUR) policies from their predecessor Primary Care Trusts (PCTs). Consequently, there are varying positions regarding the commissioning of certain procedures/treatments across Greater Manchester. Work is now being undertaken by the North West Commissioning Support Unit s (NWCSU) Policy Team, led by the Greater Manchester EUR Steering Group to align EUR policies across Greater Manchester. Purpose of the Report This report aims to inform the Greater Manchester EUR Steering Group of the activity and spend on common benign eyelid lesions during financial years 2011/12, 2012/13, 2013/14 and 2014/15 for each CCG. Body of the Report The table attached at Appendix 1 provides details of each CCG s activity and costs on common benign eyelid lesions (Source Data: Inpatient Spell PbR, Primary Procedures). The following procedures were selected to inform the report: C11.1 Excision of lesion of canthus C11.2 Destruction of lesion of canthus C12.1 Excision of lesion of eyelid NEC C12.2 Cauterisation of lesion of eyelid C12.3 Cryotherapy to lesion of eyelid C12.4 Curettage of lesion of eyelid C12.5 Destruction of lesion of eyelid NEC C12.6 Wedge excision of lesion of eyelid C12.8 Other specified C12.9 Unspecified Conclusion The information contained in Appendix 1 has been produced in order to support the policy decision making process across Greater Manchester. The Greater Manchester EUR Steering Group is asked to review this information to assist the policy decision taken for the removal of common benign eyelid lesions across Greater Manchester.

12 Appendix 1 Activity Reports for Common Benign Eyelid Lesions procedures OPCS Codes Used : C11.1, C11.2, C12.1, C12.2, C12.3, C12.4, C12.5, C12.6, C12.8, C12.9. Source used : InpatientPbR Procedure Group Primary Procedure Financial Year Values 2011/ / / /2015 Commissioner Name No of Spells Cost in 's No of Spells Cost in 's No of Spells Cost in 's No of Spells Cost in 's BOLTON , , , ,057 BURY 84 55, , , ,869 CENTRAL MANCHESTER , , , ,430 HEYWOOD, MIDDLETON AND ROCHDALE 92 61, , , ,666 NORTH MANCHESTER , , , ,351 OLDHAM , , , ,021 SALFORD , , , ,086 STOCKPORT , , , ,584 TAMESIDE AND GLOSSOP , , , ,036 TRAFFORD , , , ,125 WIGAN BOROUGH , , , ,487 SOUTH MANCHESTER , , , ,501 Grand Total 1,726 1,158,093 1,814 1,204,024 1,934 1,233,073 2,148 1,354,213

13 Greater Manchester EUR Policy Statement Title/Topic: Removal of Common Benign Eyelid Lesions Date: June 2015 Reference: GM044

14 VERSION CONTROL Version Date Details Page number /09/2014 Initial draft N/A /10/2014 Branding changed following creation of North West CSU on 1/10/2014 All /11/2014 Amendments made following discussion of the Consultation feedback by the Greater Manchester EUR Steering Group on 19/11/2014: Section 2 Definition Detailed definition taken out and shorter definition added. 7 Section 4 Criteria for Commissioning Sentence added stating: The removal of common benign eyelid lesions for aesthetic reasons is not commissioned. The titles Urgent referral and Routine referral have been taken out and replaced by: o o A: Referrals for the treatment of common benign eyelid lesions may be made if there is any indication that these indicate underlying disease, sight threatening issues with the eye or there is doubt of the diagnosis and the lesion may not be benign in nature. Examples of reasons for referral include but are not exclusive to: B: The following criteria will require prior approval via the IFR route: Lid swelling and/or protrusion of the eye changed to read protrusion of the eye Bullet point added New and unexpected visual problems (e.g. double vision) Bullet point starting Ocular symptoms has been clarified to refer to an underlying condition or the potential for serious damage to the eye and significant redness: has been moved to a separate bullet point to read Significant redness in the absence of an obvious cause The additional criteria for Dermatocheliasis and Xanthelasma Palpebrum removed. Section 5 Description of Epidemiology and Need section reworded. Section 9 Mechanism for funding changed to monitored approval if meeting criteria for A and prior approval if meeting criteria for B. Section 14 Glossary Chalazion and Xanthelasma added /10 2

15 0.4 21/01/2015 Approved by GM EUR Steering Group to go out to Consultation N/A /06/2015 Changes made following the GM EUR Steering Group meeting on 20/05/2015 post Consultation: Section 2 - Definition the following paragraph added The first step in the management of most lesions will be self-care in the form of enhanced eyelid hygiene. Individuals will be expected to self-fund the products needed for good hygiene e.g. Baby shampoo or blepharwipes. 8 Section 4 - Commissioning Criteria Rapidly growing Visual field affected Ocular symptoms indicating either an underlying condition or the potential for serious damage to the eye The above moved from B to A B clarified to read Where the eyelid lesion is symptomatic referrals can be made using the prior approval through IFR route for the following criteria: The last bullet point in B amended to read Significant redness of the eye in the absence of an obvious cause Policy agreed by Greater Manchester EUR Steering on 20 th May 2015 subject to the above changes being made. 3

16 POLICY STATEMENT Title/Topic: Removal of Common Benign Eyelid Lesions Issue Date: Insert Month and Year approved by AGG Commissioning Recommendation: The removal of common benign eyelid lesions for aesthetic reasons is not commissioned. All suspected malignant lesions are excluded from this policy these should be managed via the 2 week wait. See Section 4: Criteria for Commissioning Date of Review: One year from the date of approval by Greater Manchester Association Governing Group and annually thereafter. Prepared By: The North West Commissioning Support Unit Effective Use of Resources Policy Team Approved By Greater Manchester Effective Use of Resources Steering Group Greater Manchester Chief Finance Officers / Greater Manchester Heads of Commissioning Greater Manchester Association Governing Group Bury Clinical Commissioning Group Bolton Clinical Commissioning Group Heywood, Middleton & Rochdale Clinical Commissioning Group Central Manchester Clinical Commissioning Group Date Approved 20/05/2015 Funding Mechanism GM EUR Steering Group recommended funding mechanism - Funding will be via monitored approval for referrals made and accepted in line with the criteria detailed in section 4 A) above. Referrals in line with section 4 B) will be via the IFR route for prior approval. 4

17 North Manchester Clinical Commissioning Group Oldham Clinical Commissioning Group Salford Clinical Commissioning Group South Manchester Clinical Commissioning Group Stockport Clinical Commissioning Group Tameside & Glossop Clinical Commissioning Group Trafford Clinical Commissioning Group Wigan Borough Clinical Commissioning Group 5

18 CONTENTS Policy Statement... 7 Equality & Equity Statement... 7 Governance Arrangements Introduction Definition Aims and Objectives Criteria for Commissioning Description of Epidemiology and Need Evidence Summary Rationale behind the Policy Statement Adherence to NICE Guidance Mechanism for Funding Audit Requirements Documents which have informed this Policy Links to other Policies Date of Review Glossary...11 References...11 Appendix 1 Evidence Review

19 Policy Statement The North West Commissioning Support Unit (NWCSU) has developed this policy on behalf of Clinical Commissioning Groups (CCGs) within Greater Manchester, who will commission the removal of common benign eyelid lesions in accordance with the criteria outlined in this document. In creating this policy the GMCSU has reviewed this clinical condition and the options for its treatment. It has considered the place of this treatment in current clinical practice, whether scientific research has shown the treatment to be of benefit to patients, (including how any benefit is balanced against possible risks) and whether its use represents the best use of NHS resources. This policy document outlines the arrangements for funding of this treatment for the population of Greater Manchester. Equality & Equity Statement The NWCSU /CCG has a duty to have regard to the need to reduce health inequalities in access to health services and health outcomes achieved, as enshrined in the Health and Social Care Act The NWCSU /CCG is committed to ensuring equality of access and non-discrimination, irrespective of age, gender, disability (including learning disability), gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, gender or sexual orientation. In carrying out its functions, the NWCSU /CCG will have due regard to the different needs of protected characteristic groups, in line with the Equality Act This document is compliant with the NHS Constitution and the Human Rights Act This applies to all activities for which they are responsible, including policy development, review and implementation. In developing policy the NWCSU policy team will ensure that equity is considered as well as equality. Equity means providing greater resource for those groups of the population with greater needs without disadvantage to any vulnerable group. The Equality Act 2010 states that we must treat disabled people as more equal than any other protected characteristic group. This is because their starting point is considered to be further back than any other group. This will be reflected in NWCSU evidencing taking due regard for fair access to healthcare information, services and premises. An initial Equality Analysis was carried out in Oct 2015 and reviewed following consultation during June For more information about the Equality Analysis, please contact policyfeedback.gmscu@nhs.net. Governance Arrangements Greater Manchester EUR policy statements will be ratified by the Greater Manchester Association Governing Group (AGG) prior to formal ratification through CCG Governing Bodies. Further details of the governance arrangements can be found in the Greater Manchester EUR Operational Policy. 1. Introduction This commissioning policy has been produced in order to provide and ensure equity, consistency and clarity in the commissioning of the removal of common benign eyelid lesions by Clinical Commissioning Groups in Greater Manchester. When this policy is reviewed all available additional data on outcomes will be included in the review and the policy updated accordingly. 7

20 2. Definition Benign lesions of the eyelid are those which do not affect the functioning of the eye or eyelids and will not develop into malignant disease. These include but are not limited to Chalazion (meibomian) cyst, dermatochelasis and xanthelasma. The first step in the management of most lesions will be self-care in the form of enhanced eyelid hygiene. Individuals will be expected to self-fund the products needed for good hygiene e.g. Baby shampoo or blepharwipes. 3. Aims and Objectives Aim This policy document aims to specify the conditions under which removal of common benign eyelid lesions will be routinely commissioned by Clinical Commissioning Groups in Greater Manchester. Objectives To reduce the variation in access to the removal of common benign eyelid lesions. To ensure that removal of common benign eyelid lesions is commissioned where there is acceptable evidence of clinical benefit and cost-effectiveness. To reduce unacceptable variation in the commissioning of the removal of common benign eyelid lesions across Greater Manchester. To promote the cost-effective use of healthcare resources. 4. Criteria for Commissioning The removal of common benign eyelid lesions for aesthetic reasons is not commissioned. A) Referrals for the treatment of common benign eyelid lesions may be made if there is any indication that these indicate underlying disease, sight threatening issues with the eye or there is doubt of the diagnosis and the lesion may not be benign in nature. Examples of reasons for referral include but are not exclusive to: Significant preseptal cellulitis / orbital cellulitis Atypical presentation, re-occurrence in same site, may require cancer exclusion Protrusion of the eye Rapidly growing Visual field affected Ocular symptoms indicating either an underlying condition or the potential for serious damage to the eye New and unexpected visual problems (e.g. double vision) Reduced light reflexes or abnormal swinging light test Symptomatically unwell CNS symptoms or signs 8

21 B) Where the eyelid lesion is symptomatic referrals can be made using the prior approval through IFR route for the following criteria: Persistent (more than 6 months and not responded to conservative treatment) There is significant pain as a direct result of the lesion There is a confirmed history of recurrent infection / inflammation Significant redness of the eye in the absence of an obvious cause Policy Exclusions All suspected malignant lesions are excluded from this policy these should be managed via the 2 week wait. The removal of common benign eyelid lesions for cosmetic reasons or outside of the criteria detailed above are not routinely commissioned. Funding may be considered on an individual patient basis, if there is evidence of clinical exceptional circumstances. Clinicians can submit an Individual Funding Request (IFR) if they feel there is a good case for exceptionality in line with the procedures described in the Greater Manchester EUR Operational Policy Exceptionality means a person to which the general rule is not applicable. Greater Manchester sets out the following guidance in terms of determining exceptionality; however the over-riding question which the IFR process must answer is whether each patient applying for exceptional funding has demonstrated that his/her circumstances are exceptional. A patient may be able to demonstrate exceptionality by showing that s/he is: Significantly different to the general population of patients with the condition in question. and as a result of that difference They are likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition. 5. Description of Epidemiology and Need The vast majority of eyelid lesions are harmless and self-limiting. Xanthelasma is often seen in people with high cholesterol or other fat (lipid) levels in the blood, and the lesions contain deposits that are high in fat (lipid-rich). Xanthelasma can occur in people of any race and of either sex. However, females seem to be more frequently affected than males. In addition, it is unusual for a child or teenager to develop xanthelasma; most individuals develop the condition in middle age. Approximately one half of patients with xanthelasma have high amounts of fats (lipids) in their blood, such as high cholesterol or high triglycerides. Dermatochalasis is a common finding seen in elderly persons and occasionally in young adults. Gravity, loss of elastic tissue in the skin, and weakening of the connective tissues of the eyelid frequently contribute to this lax and redundant eyelid tissue. These findings are more common in the upper eyelids but can be seen in the lower eyelids as well. Genetic factors and family traits may play a role in some patients. 9

22 6. Evidence Summary The vast majority of common benign eyelid lesions are harmless and self-limiting. Most removals are requested for aesthetic reasons; however, in some circumstances (see criteria above) removal is indicated for clinical or functional reasons. Full details of the Evidence Review are contained with Appendix Rationale behind the Policy Statement The vast majority of common benign eyelid lesions are harmless and although they may be unsightly there is no clinical reason for their removal. There are occasional circumstances in which the removal of a these lesions are indicated and these circumstances are listed in this policy. The policy does not allow lesions to be removed for solely aesthetic reasons. 8. Adherence to NICE Guidance NICE have not currently issued guidance on this treatment. 9. Mechanism for Funding Clinical Commissioning Group Bury Bolton Heywood, Middleton & Rochdale Manchester Central Manchester North Manchester South Oldham Salford Stockport Tameside & Glossop Trafford Wigan Funding Mechanism Funding will be via monitored approval for referrals made and accepted in line with the criteria detailed in section 4 A) above. Referrals in line with section 4 B) will be via the IFR route for prior approval. 10. Audit Requirements There is currently no national database. Service providers will be expected to collect and provide audit data on request. 11. Documents which have informed this Policy Individual CCG referral criteria and policy statements. Greater Manchester EUR Operational Policy. 12. Links to other Policies This policy follows the principles set out in the ethical framework that govern the commissioning of NHS healthcare and those policies dealing with the approach to experimental treatments and processes for the management of individual funding requests (IFR). Greater Manchester EUR Policy Statement - GM047 - Correction of Eyelid Ptosis 10

23 13. Date of Review One year from the date of approval by Greater Manchester Association Governing Group and annually thereafter. 14. Glossary Term Astigmatism Benign Chalazion Canthus Dermatochelasis Dermatitis Malignant Orbital septum Preseptal Xanthelasma Meaning A condition of unequal curvatures along the different meridians in one or more of the refractive surfaces (cornea, anterior or posterior surface of the lens) of the eye, in consequence of which the rays from a luminous point are not focused at a single point on the retina. (Of a disease) not harmful in effect. A chalazion is a small (2-8mm) fluid-filled swelling (cyst) in the eyelid. It is common and sometimes called a meibomian cyst or tarsal cyst. A chalazion is more common on the upper eyelid and can affect both eyes. It is not the same as a stye. The outer or inner corner of the eye, where the upper and lower lids meet Drooping of the eyelids. A medical condition in which the skin becomes red, swollen, and sore, sometimes with small blisters. Unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invading nearby parts of the body. A fibrous membrane attached to the margin of the orbit and extending into the lids, containing the orbital fat and constituting in great part the posterior fascia of the orbicularis oculi muscle. Infection involving the superficial tissue layers anterior to the orbital septum. Xanthelasma (xanthelasma palpebrarum) is a skin condition that develops flat yellow growths on the eyelids. The appearance is of yellow flat plaques over the upper or lower eyelids, most often near the inner canthus. References N/A 11

24 Appendix 1 Evidence Review Title/Topic: Removal of Common Benign Eyelid Lesions Ref: GM044 Search Strategy A search was undertaken for Chalazion (meibomian cyst or tarsal cyst),xanthelasma and Dermatocheliasis Most studies related to comparison of therapies and techniques and not reviewing the need for removal. Database Result NICE Xanthelasma mentioned in CG71 (managing familial hypercholesterolaemia) Not cited below NHS Evidence and NICE CKS The College of Optometrists Guidance: Chalazion (Meibomian Cyst) Version NICE CKS: Meibomian Cyst BMJ Practice summary: Stye and Chalazion (not cited below) Modernisation Agency Plastic Surgery Guidelines (not cited below) SIGN Cochrane York BMJ Clinical Evidence Nil found Nil found A prospective study of cost, patient satisfaction, and outcome of treatment of chalazion by medical and nursing staff Jackson TL, Beun L. Br J Ophthalmol Jul;84(7):782-5 Nil found BMJ Best Practice Stye and Chalazion section(not cited below) Nil specific found (reference in management of hypercholesterolaemia) General Search (Google) Various websites including NHS choices, patient.co.uk, and clinic sites Patient.co.uk guidance on Xanthelasma (Not cited below) Royal College of Opthalmologists Nil found Summary of the evidence The vast majority of benign skin lesions of the eyelid are harmless, many are self-limiting. removals are requested for aesthetic reasons however were a: lesion is causing a reduction of the visual fields OR should have resolved within 6 months and hasn t Most 12

25 These are considered indication for removal. The evidence Levels of evidence Level 1 Level 2 Level 3 Level 4 Level 5 Meta-analyses, systematic reviews of randomised controlled trials Randomised controlled trials Case-control or cohort studies Non-analytic studies e.g. case reports, case series Expert opinion 1. LEVEL 1 AND 5:REVIEW AND EXPERT OPINION The College of Optometrists Guidance: Chalazion (Meibomian Cyst) Version Aetiology Predisposing factors Symptoms Signs Differential diagnosis Blockage of Meibomian gland duct with retention and stagnation of secretion May occur spontaneously or follow an acute hordeolum (internal) Chronic blepharitis Rosacea Seborrhoeic dermatitis Pregnancy Diabetes mellitus Painless lid lump Usually single; sometimes multiple May be recurrent May rupture through the skin (Sometimes) blurred vision from induced astigmatism Well-defined, 2-8mm diameter subcutaneous nodule in tarsal plate Lid eversion may show external conjunctival granuloma Induced astigmatism may cause change in refraction Hordeolum (external or internal) Sebaceous cyst of skin Meibomian gland carcinoma (consider if lesion recurrent) Management by Optometrist Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere Non pharmacological Pharmacological Usually resolves spontaneously (may take weeks or months) If acute or pointing on to skin try traditional remedies such as hot spoon bathing If persistent, large or causing distortion of the cornea then refer for management by ophthalmologist Regular lid hygiene for blepharitis None (but see Clinical Management Guideline on Hordeolum [internal]) 13

26 Management Category B2: alleviation/palliation: normally no referral B1: routine referral to Ophthalmologist if persistent or recurrent, if causing significant astigmatism or if cosmetically unacceptable Possible management by Ophthalmologist Incision and curettage where appropriate Intra-lesion injection of steroid (may be preferred in children) Evidence base Goawalla A, Lee V. A prospective randomized treatment study comparing three treatment options for chalazia: triamcinolone acetonide injections, incision and curettage and treatment with hot compresses. Clin Exp Ophthalmol 2007;35: Results suggest that a single triamcinolone acetonide injection followed by lid massage is almost as effective as incision and curettage in the treatment of chalazia and with similar patient satisfaction and less pain and patient inconvenience (The Oxford 2011 Levels of Evidence = 3) 2. LEVEL 4/5: NICE CKS NICE CKS: Meibomian Cyst Explain that although it may be considered cosmetically unattractive, a meibomian cyst rarely causes serious complications. Meibomian cysts can resolve spontaneously or with conservative treatment. Advise the person to: Apply a warm compress (for example, using a clean flannel that has been rinsed with hot water) to the affected eye for 5 10 minutes. Repeat this three to four times daily for up to 4 weeks. Explain that this will help to liquefy the lipid content of the cyst, thus encouraging drainage of the cyst contents. Avoid excessively hot compresses (to avoid scalding, particularly in children). Gently massage the meibomian cyst after application of the warm compress (to aid expression of the cyst contents). This should be done in the direction of eyelash using clean fingers or cotton buds. Clean the affected eyelid twice daily (to clear debris and oily secretions from the eyelid and lashes). This can be performed by rubbing a moistened cotton bud (for example, using baby shampoo diluted 1:10 with warm water [one part shampoo to nine parts water]) along the lid margin. Do not prescribe an antibiotic (topical or oral). If the meibomian cyst does not improve or resolve after 3 4 weeks with conservative treatment, offer the following options (depending on clinical judgement and the person's preference): Referral to an ophthalmologist for treatment (depending on local referral criteria and service provision). A period of watchful waiting (for example after 6 months) and then consider referral. No treatment for example, if the meibomian cyst is small and asymptomatic. Manage any risk factors (if present) to reduce the risk of future episodes. Blepharitis Seborrhoeic dermatitis Acne rosacea For further information, see the CKS topics on Blepharitis, Rosacea, and Seborrhoeic dermatitis. 14

27 Refer people with recurrent meibomian cysts for whom prophylactic drug treatment is being considered. Admit the person if: There is significant preseptal cellulitis. There are signs or symptoms of orbital cellulitis (rare). Red flags for hospital admission include: o Lid (periorbital) swelling. o Protrusion of the eyeball (proptosis). o Double vision (diplopia) or impairment of eye movement (ophthalmoplegia). o Reduced visual acuity. o Reduced light reflexes or abnormal swinging light test. o Systemically unwell. o Central nervous system signs or symptoms (for example drowsiness, vomiting, headache, seizure, or cranial nerve lesion). 3. LEVEL 3: PROSPECTIVE COHORT STUDY A prospective study of cost, patient satisfaction, and outcome of treatment of chalazion by medical and nursing staff Jackson TL, Beun L. Br J Ophthalmol Jul;84(7):782-5.Abstract Aim: To study prospectively the outcome of conservative and surgical treatment of chalazia provided by medical and nursing staff. Methods: During a 5 month recruitment period all patients attending a district general eye hospital for treatment of chalazion were included in the study. 129 patients (217 visits) with chalazia were seen by either a senior nurse or a trainee ophthalmologist (senior house officer, SHO) or both. Patients received either conservative treatment or eversion of the eyelid with incision and curettage. Patients were mailed a questionnaire asking them if their cyst had resolved and how they rated their treatment. Marginal cost analysis was used to determine the cost of treatment. Results: The outcome of treatment could be determined in 170 of the 217 visits. Conservative treatment was successful for 29% of cysts while surgical treatment was successful for 72%. There was no significant difference in treatment outcome between nurse and SHO groups. Patients found nurse treatment acceptable with a high level of patient satisfaction. The marginal cost of treatment by a nurse was 9.91 pounds sterling per cyst compared with pounds sterling for SHOs. There were no surgical complications and no evidence of malignancy in six biopsies. Conclusions: Surgical treatment of chalazion is safe and effective and successfully treats approximately three quarters of selected cysts. With conservative treatment approximately one third of selected chalazia will resolve within 3 months. Nurse treatment of chalazion is safe, effective, and acceptable to patients. 15