Commissioning Policy. Vitreous Floaters. Date Adopted: 19 th April 2017 Version:

Transcription

1 Commissioning Policy Date Adopted: 19 th April 2017 Version:

2 Title of document: Authors job title(s): Document Control Policy IFR Manager Document version: Supersedes: Clinical Approval received from: November 2016 Clinical Approval date received: Discussion and Approval by Clinical Policy Review Group (CPRG): Discussion and Approval by CCG Commissioning Executive: CPRG 13 th December th February 2017 Date of Adoption: 19 th April 2017 Publication/issue date: February 2019 Review due date: Equality Impact Assessment Screening (date completed): Earliest of either NICE publication or three years from approval. April 2020 In Development Version Control Version Date Reviewer Comment /03/2018 IFR Coordinator /10/2018 Commissioning Policy Development Support Officer Rebranded to BNSSG CCG Smoking and BMI references updated, BNSSG branding refreshed, PALS update. Approved on 14 th February 2019 by Commissioning Executive. Page 2

3 THIS TREATMENT IS NOT ROUTINELY COMMISSIONED FOR ANY PATIENTS AND EXCEPTIONAL FUNDING PANEL APPROVAL MUST BE SOUGHT PRIOR TO REFERRAL Policy General Principles THIS POLICY RELATES TO ALL PATIENTS Funding approval will only be given in line with these general principles. Where patients are unable to meet these principles in addition to the specific treatment criteria set out in this policy, funding approval will not be given. 1. Funding approval must be secured by primary care prior to referring patients for assessment. Referring patients to secondary care without funding approval having been secured not only incurs significant costs in out-patient appointments for patients that may not qualify for surgery, but inappropriately raises the patient s expectation of treatment. 2. On limited occasions, the CCG may approve funding for an assessment only in order to confirm or obtain evidence demonstrating whether a patient meets the criteria for funding. In such cases, patients should be made aware that the assessment does not mean that they will be provided with surgery and surgery will only be provided where it can be demonstrated that the patients meets the criteria to access treatment in this policy. 3. Where funding approval is given by the Exceptional Funding Panel, it will be available for a specified period of time, normally one year. 4. Funding approval will only be given where there is evidence that the treatment requested is effective and the patient has the potential to benefit from the proposed treatment. Where it is demonstrated that patients have previously been provided with the treatment with limited or diminishing benefit, funding approval is unlikely to be agreed. 5. Patients with an elevated BMI of 30 or more may experience more post-surgical complications including post-surgical wound infection so should be encouraged to lose weight further prior to seeking surgery ) 6. Patients who are smokers should be referred to smoking cessation services in order to reduce the risk of surgery and improve healing. (ASH, 2016) 7. In applying this policy, all clinicians and those involved in making decisions affecting patient care will pay due regard to the need to eliminate unlawful discrimination, harassment, victimisation, etc., advance equality of opportunity and foster good relations between people who share a protected characteristic and those who do not. In particular, due regard will be paid in relation to the following characteristics protected by the Equality Page 3

4 Act 2010: age, disability, sex, gender reassignment, marriage or civil partnership, pregnancy and maternity, race, religion or belief and sexual orientation. Background Floaters are small shapes that some people see floating in their field of vision. They can be different shapes and sizes and may look like: tiny black dots small, shadowy dots larger cloud-like spots long, narrow strands Patients may have many small floaters in their field of vision or just one or two larger ones. Most floaters are small and quickly move out of the field of vision. Floaters are often most noticeable when looking at a light-coloured background, such as a white wall or clear sky. They are caused by pieces of debris which float in the vitreous humour and can cast shadows on the retina. Floaters sometimes occur without a person noticing them. This is because the brain constantly adapts to changes in vision and learns to ignore floaters so they don't affect vision. In most cases, floaters don't cause significant problems and don't require treatment. Vitreous floaters do not lead to blindness and in many cases the individuals complaining of them have normal visual acuity (Tan, Mura, Oberstein, & al, Jun 2011). The surgical interventions carried out for vitreous floaters are vitrectomy or laser vitreolysis (Carlsson, Mar 2011). Vitrectomy refers to the surgical removal of some of the vitreous fluid in the eye and the filling of the void with an inert substance. Laser vitreolysis refers to the use of a laser to either disrupt the floater itself or to disrupt the fibres that are maintaining the position of the floater to allow it to float out of the field of view. The research evidence regarding laser vitreolysis is limited to case series. One case series identified that laser vitreolysis was effective in only 37.5% of patients by one or more line of visual acuity (Martinez-Sanz & al, May 2009). Risks Before having a vitrectomy, the eye will be numbed with a local anaesthetic. During the procedure, the vitreous humour will be removed from the vitreous body of the eye and replaced with saline solution. Page 4

5 As the vitreous humour is mostly made up of water, the patient generally won't notice any difference to their vision after having a vitrectomy. However, possible complications may include: retinal tears retinal detachment cataracts (cloudy patches in the lens of the eye) Laser vitreolysis may be a simpler and safer alternative to vitrectomy for persistent floaters. However, there hasn't been much in-depth research into the treatment, and its safety and effectiveness is still uncertain. (NHS Choices, 2014) Red flags The following findings are of particular concern and should be referred for assessment: Sudden onset of floaters or Sudden onset of flashers or Sudden onset of floaters and flashers Photopsias Loss of vision, diffuse or focal (visual field defect) Recent eye surgery or eye trauma Eye pain Loss of red reflex Abnormal retinal findings (Brady, 2017) POLICY CRITERIA NOT COMMISSIONED EXCEPTIONAL FUNDING PANEL APPROVAL REQUIRED Treatments for are not routinely commissioned. This includes: Vitrectomy Laser Vitreolysis Eye drops and medications Red flags The following findings are of particular concern and should be referred for assessment without the need for an IFR funding application : Sudden onset of floaters or Sudden onset of flashers or Sudden onset of floaters and flashers Photopsias Page 5

6 Loss of vision, diffuse or focal (visual field defect) Recent eye surgery or eye trauma Eye pain Loss of red reflex Abnormal retinal findings (Brady, 2017) Patients who are not eligible for treatment under this policy may be considered on an individual basis where their GP or consultant believes exceptional circumstances exist that warrant deviation from the rule of this policy. Individual cases will be reviewed at the CCG s Exceptional Funding Panel upon receipt of a completed application form from the patient s GP, Consultant or Clinician. Applications cannot be considered from patients personally. If you would like further copies of this policy or need it in another format, such as Braille or another language, please contact the Customer Services Team on: or or them on BNSSG.customerservice@nhs.net Connected Policies N/A This policy has been developed with the aid of the following references: Ash. (2016). Ash.org.uk. Retrieved Sept 24, 2018, from Brady, C. J. (2017, January). Floaters. Retrieved from Merck Manual: Carlsson, C. S.-K. (Mar 2011). Longterm follow-up of pars plana vitrectomy for vitreous floaters: complications, outcomes and patient satisfaction. Acta ophthalmologica, vol. 89 (no. 2); p Martinez-Sanz, & al, e. (May 2009). [Surgical solution to vitreous floaters visual problem]. Archivos de la Sociedad Espanola de Oftalmologia, vol. 84 (no. 5); p Newcastle and Gateshead CCG. (2016). Value Based Commissioning policies. Newcastle and Gateshead CCG. NHS Choices. (2014, November 21st). Floaters - Treatment. Retrieved from NHS Choices: Tan, H., Mura, M., Oberstein, L., & al, e. (Jun 2011). Safety of vitrectomy for floaters. American journal of ophthalmology, vol. 151 (no. 6); p Thelwall, S. P. (2015). Impact of obesity on the risk of wound infection following surgery: results from a nationwide prospective multicentre cohort study in England. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases,, vol. 21, no. 11, p e1. Page 6

7 OPCS Procedure codes For completion at a later date Page 7