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Controversy: confusion reins over eye injection guidelines

Following a series of controversial news reports, RANZCO has sought to clarify its position on nurses and optometrists performing intravitreal injections in Australia and New Zealand, amid claims its views on the issue have not been accurately represented in the media.

An article published by Optometry Australia on 5 August states that RANZCO is “developing guidelines for health professionals other than ophthalmologists to give anti-VEGF injections in hospitals”. An almost identical article was published on Mivison, while a similar article titled “Optometrists to give anti-VEGF?” was published by NZ Optics.

RANZCO CEO Dr David Andrews was quoted extensively in the stories about the proposed guidelines. In one article he reportedly said the College believed appropriately trained nurses, as well as optometrists and orthoptists, could adequately cover an existing treatment shortfall in some New Zealand District Health Boards, under the supervision of ophthalmologists.

He was also reported to have said that a number of nurses were already administering injections, as well as some GPs in New Zealand and that RANZCO wants one set of guidelines for both countries, despite having different medical systems.

Insight approached Andrews to discuss the proposed guidelines, however he declined to comment further, stating: “We are not making any more comment in relation to the proposed anti-VEGF Guidelines, simply because there is nothing to yet comment on.”

Insight has subsequently obtained a statement from RANZCO president Associate Professor Heather Mack sent to members in response to the media coverage. The statement seeks to “inform” recipients of RANZCO’s position on the matter, listing seven points.

Among those, Mack says RANZCO has been asked to provide an opinion on non-ophthalmologists in New Zealand performing intravitreal injections and is consulting widely. This includes seeking advice from the Australian and New Zealand Retinal Specialist Interest Group.

She asserts that RANZCO advocates the highest standards of safety and quality care for patients undergoing intravitreal injections, and that ophthalmologists have the appropriate medical and ophthalmic expertise to perform the procedure safety.

Mack then goes on to state: “Recent press in NZ Optics, Mivision or through Optometry Australia have not represented RANZCO’s long standing and unchanged position in this regard.”

Despite Andrews’ comments, the official RANZCO statent does not make specific reference to the development of guidelines, or the prospect of non-ophthalmologists performing the procedure in Australia.

Since RANZCO’s subsequent clarification, the articles have not been corrected, updated or removed; they rain as first published without any clarification.

Not acceptable

Australian Society of Ophthalmologists (ASO) president Dr Peter Sumich addressed the matter in his newsletter column to members on 15 August. He believed Andrews “misspoke without qualifying the statement and RANZCO has released a clarifying statement following the interview”.

“The background is that New Zealand government slashed their funding for intravitreal injections. This has resulted in a flood of patients overflowing public services and reduced service provision in rote and rural areas. It is creating a macular degeneration service disaster of their own creation,” he said.

“David Andrews was referring to recent discussions aimed at helping the New Zealand Branch avoid further slippage of standards if they continue with nurse injecting.”

Regardless of the confusion, Sumich said the ASO and the Australian Medical Association agreed that task substitution by non-medically trained practitioners is not acceptable.

“The question arises then — what to do with rote and rural settings? What to do when public services cannot cope? The answer is not to lower clinical standards,” he said.

“In Australia, the current Medicare rebate is adequate to allow ophthalmic specialists to fly into these rote towns and deliver them best practice. The New Zealand medical system is different to ours.

“If they want guidelines for task substitution by nurses, then they should be written by their New Zealand branch for local use. The Australian branch of RANZCO should not feel compelled to participate in the failures of New Zealand sovereign government health policy any more than we should be involved with medical services in Namibia or Chad or the NHS.”

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