In New Zealand, nurse-delivered IVIs are already well established, with nurses and junior doctors delivering anti-VEGF injections in most hospitals, confirmed Dr Sarah Welch, Eye Health National Clinical Network co-lead. “I would have thought within Te Toka Tumai, 80–90% of the injections are delivered by nurses. Ophthalmologists still make the decision about the need to treat, the drug to use and the interval between injections. At the end of every course of injections the patient is reviewed, in most cases by a doctor and in some cases by a nurse practitioner or another practitioner working with a doctor and following guidelines to determine the ongoing plan.” Some of the drugs are specialist only and they need to have the application approved by a senior medical officer, she added.
In Auckland, some GPs have performed IVIs, said Dr Welch. “Often they had a previous interest in eyes or have spent some time in the eye department, but we don’t have any at the moment.” However, she said New Zealand’s larger, more readily available nursing workforce makes nurses a logical choice for delivering IVIs, whereas Australian funding arrangements present different challenges.
In New Zealand, where the distances are smaller and rural GPs are already overburdened, asking them to also do injections wouldn’t really be fair, she said. “In smaller centres where there is no eye clinic… some GP practices are used as sites for injections but nurses still do the procedure. I think it sits better with the nursing workforce who tend to follow protocols and antisepsis protocols better than doctors.”
A senior New Zealand nurse practitioner (NP), who preferred to remain anonymous, agreed with Dr Welch and asked why anyone would prioritise GPs delivering IVIs over ophthalmic nurses. “Why would you put this on an already stretched professional group when you have a skilled group of ophthalmic nurses who are willing and able to do this?” But there’s no reason a GP can’t perform IVI if they have a special interest, they said. “We had a GP who came into our clinic to inject and we would do it again. But if these GPs are working in the community, can they perform and read OCTs? How can they assess and make decisions about extending treatment intervals, as ophthalmic nurses do? Or would they purely be a ‘technician’ performing the injection under the direction of an ophthalmologist?”
The NP pointed out that current nurse-led services have been key to helping reduce waitlists and free up ophthalmologists. “They can’t manage without us! We have around five all-day injection lists, five to six days per week, run by nurses and junior doctors, as well as nurse injectors available for ‘add-on’ for any new patient injections generated in the clinic. This frees up the ophthalmologist to actually see the patients and manage their treatment plan.
“We already have an NP and some senior ophthalmic nurses running clinics to see the patients and are in the process of training more senior ophthalmic nurses to help support the demand.”
GPs vs optoms
A New Zealand optometrist and senior academic who wished to remain anonymous said if there is an option for a GP or an optometrist to perform IVI, they would rather the optom. “But the more the merrier! I would think in New Zealand, GPs would benefit from working alongside an optometrist to advise on the need or suitability of requiring an IVI.”
It is important to note that allowing optometrists to perform IVI does not mean that they will all suddenly start offering it, they said. “The profession has a very long history of safe practice within self-imposed limits. Not even all optoms have prescribed an oral medication yet and that change was over a decade ago! There is variability in the severity of keratitis or uveitis that an individual optometrist will manage and this works just fine.”
However, Australia’s proposed GP model appears to leave treatment decisions with ophthalmologists. Since some New Zealand optometrists can already make those decisions and prescribe anti-VEGF agents, an optometrist-led model here is fundamentally different, said the senior academic. “The RANZCO 2030 and beyond [plan] has similar verbiage on ‘permitting’ other groups to do things under surveillance, rather than allowing proper improvements to efficiency of care through autonomous practice. In Australia, ophthalmology has been able to more tightly protect its turf. In New Zealand, we are fortunate to work more collaboratively for the benefit of the population we all serve.”