Choosing Wisely
NOTE: From 1 January 2023, the Australian Commission on Safety and Quality in Health Care (the Commission) became the custodian of a range of Quality Use of Medicines (QUM) functions with the Choosing Wisely website is now hosted by the Australian Commission on Safety and Quality in Health as part of the redesign of the Quality Use of Diagnostics, Therapeutics and Pathology program.
Tests, Treatments and Procedures to Question – Public Information Sheet
What is Choosing Wisely Australia?
The goal of Choosing Wisely is to improve the quality and safety of health care in Australia by promoting conversations between doctors and their patients on avoiding wasteful or unnecessary medical tests and treatments. Not all tests add value for the patient and some can be costly or harmful. Choosing Wisely encourages shared decision-making, supporting consumers to be proactively engaged in their own care including discussions around tests, treatments and intervention options.
The Choosing Wisely messages have been developed by RANZCO ophthalmologists and are highly technical in nature. This Public Information Sheet aims to help patients understand these same messages and what they can do to choose wisely.
Board Approved Choosing Wisely Recommendations
Recommendation 1: 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, or 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.
References:
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.
Recommendation 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.
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.
References:
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.
Recommendation 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.
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.
References:
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.
Recommendation 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.
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.
References:
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: https://ranzcodev.dev.nucleoserver.com/images/documents/policies/CPG004_Intravitreal_Injections.pdf.
Recommendation 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.
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.
References:
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
Recommendation 6: Do not use corneal cross linking for every patient with keratoconus.
It is indicated when there is clear evidence of progression via change in refraction, anterior and posterior topographical data and tomographic data. In younger patients’ consideration can be given to cross-linking without evidence of progression if there is a strong index of suspicion that progression will occur without intervention.
References:
Brown, S. E., Simmasalam, R., Antonova, N., Gadaria, N., & Asbell, P. A. (2014). Progression in keratoconus and the effect of corneal cross-linking on progression. Eye & contact lens, 40(6), 331-338.
O’brart, d. P. S. (2014). Corneal collagen cross-linking: A review. Journal of optometry, 7, 113-124.
Hashemi, H., Khabazkhoob, M., & Fotouhi, a. (2013). Topographic keratoconus is not rare in an Iranian population: the Tehran eye study. Ophthalmic epidemiology, 20(6), 385-91.
Hersh, P. S., Stulting, R. D., Muller, D., Durrie, D. S., & Rajpal, r. K. (2017). United states multicentre clinical trial of corneal collagen crosslinking for keratoconus treatment. Ophthalmology, 124(9), 1259-1270.
Witting-Silva, C., Chan, E., Islam, f. M. A., Wu, T., Whiting, M., & Snibson, G. R. (2014). A randomised, controlled trial of corneal cross-linking in progressive keratoconus. Ophthalmology, 121(4), 812-821.
Recommendation 7: Do not use topical antibiotics pre or post intravitreal injections.
Topical antibiotics (either before or after intravitreal injection) have not been found to decrease the risk of endophthalmitis.
References:
Hunyor, A. P., Merani, R., Darbar, A., Korobelnik, J., lanzetta, P., & Okada, A. A. (2017). Topical antibiotics and intravitreal injections. Acta ophthalmologica, 96(5), 435-441.
Cheung Csy; Wong Awt, Kertes Pj, Devenyi Rg, lam Wc. Incidence of endophthalmitis and use of antibiotic prophylaxis after intravitreal injections. Ophthalmol [internet]. 2012 aug:119(8):1609-14.
Milder E, Vander J, Shah C, Garg S. Changes in antibiotic resistance patterns of conjunctival flora due to repeated use of topical antibiotics after intravitreal injections.
Ophthalmol [internet]. 2012 jul:119(7):1420-4.
Kim sj, toma ks. Ophthalmic antibiotics and antimicrobial resistance. A randomized, controlled study of patients undergoing intravitreal injections. Ophthalmol [Internet]. 2011 jul(7);118:1358–1363.
Recommendation 8: Do not investigate systemically well patients with a first, uncomplicated episode of acute anterior uveitis.
No investigations are necessary for the first episode if there is a negative system review. Appropriate investigations to consider if the episode fails to settle/persists despite a course of topical steroid treatment, is a second episode or the history suggests a possible underlying cause, are as follows:
FBC
U and E
LFT
ESR
CRP
ACE
Syphilis serology
HLA B27
CXR
Other tests are expensive, and the yield is very low.
References:
Agrawal, R. V., Murthy, S., Sangwan, V., & Biswas, J. (2010). Current approach in diagnosis and management of anterior uveitis. Indian journal of ophthalmology, 58(1), 11-19.
Mackay KM, Lim LL and van Gelder RV. Rational laboratory testing in uveitis: A Bayesian analysis using geographic prevalence estimates of uveitis etiologies. Survey of Ophthalmology 2021
Forooghian, F, Gupta, R, Wong, D, Derzko-dzulynsky, l. (2006). Anterior uveitis investigation by Canadian ophthalmologists: insights from the Canadian national uveitis survey. Canadian journal of ophthalmology, 41(5), 577-589.
Recommendation 9: Topical steroids should not be used unless infection has been ruled out in any patient with red eye.
Undiagnosed red eye should never be treated with topical steroids in any patient where infection must be ruled out.
References:
Tan, S. Z., Walkden, A., Au, l., Fullwood, C., Hamilton, A., Amruddin, A., Armstrong, M., Brahma, A. K., & Carley, F. (2017). Twelve-year analysis of microbial keratitis trends at a uk tertiary hospital. Eye,31(8), 1229.
Watson, S., Cabrera-aguas, M., & Khoo, P. (2018). Common eye infections. Australian prescriber, 41, 67-72.
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