As documented in The Current State of Vision Care report there are currently 18 ophthalmological specialists in the South West LHIN. Seventeen are located in London and one individual with a fellowship in oculoplastic surgery functions as a comprehensive ophthalmologist and does some specialized work out of Grey-Bruce (Owen sound and Hanover). All specialists are trained fellows.
London provides subspecialty care (medical and Surgical) in the following disciplines:
o Orbit and Oculoplastics o Neuro-ophthalmology o Uveitis
o Cornea and External disease o Glaucoma
o Paediatrics
o Vitreo retinal surgery
In addition, some specialized diagnostic procedures are available only in London:
o Electrophysiology
o Fundus autofluorescence
o Fluoroscein and Indocyanine Angiography including wide field angiography o Heidelberg Retinal Tomograph (HRT)HRT
o Corneal topography and pachymetry o Ocular Ultrasonography
o Anterior segment OCT
o Hess screen and synoptophore testing Future Need for Specialized Ophthalmology
From an eye disease perspective, significant eye diseases requiring medical and/or surgical treatment are
cataracts, glaucoma, macular degeneration and DR. All of these are expected to grow in volume as the population ages. The bulk of care provided for patients with these diseases is provided by comprehensive ophthalmologists, although disease detection and the monitoring (and in the case of glaucoma, management) of stable disease is provided by optometrists as well. In each disease a proportion of patients will require specialized expertise for successful management (medically and surgically) and will be referred to subspecialists.
Specialization can take two forms: a fellowship trained specialist in a specific sub-specialty area or a
comprehensive ophthalmologist with a specific interest in a particular area of ophthalmology. As noted earlier, in many cases sub-specialists also do some general ophthalmology work.
Sub-specialists in London are also faculty members of Western University and as such their work lives include teaching and research through Lawson Health Research Institute in addition to their clinical work. Depending on how they divide their time, clinical work may account for most or a small part of their time. Mentoring medical residents is usually integrated into their clinical practice time.
As noted in the current state report, the only hospital with a sub-specialist outside of London is an oculoplastics specialist who works out of Grey Bruce Health Services (Owen Sound) and Hanover and District Hospital. This is seen as a continuing need in this area of the LHIN. As with most sub-specialists, this role includes a combination of sub-specialty and comprehensive ophthalmology work and this is expected to continue to be the case. The need for a comprehensive ophthalmologist with a special interest in glaucoma has also been identified for the Grey Bruce catchment area.
In the following table the number of sub-specialist in London are noted in the first column. In the second column the FTE is an estimation of the time spent in doing speciality clinical work. In a number of cases this is less than the number of specialists because of the amount of general ophthalmology work they do. Non-clinical work has
37 not been estimated in this table. The volume allocations of adult cataract surgery cases was used as a proxy for time spent doing comprehensive ophthalmology.
Table #6 Ophthalmic Sub-specialists in London, current and future needs, FTE Current Areas of Clinical
Sub-specialization in London (number of sub-specialists = n)
Current number of specialists (FTE)
Future Clinical Need (FTE)
Orbit and Oculoplastics (n=1) 1 FTE 1 FTE
Neuro-ophthalmology (n=2) 1.5 FTE 2 FTE
Uveitis (n=3) 1 FTE 1 FTE
Cornea and External disease (n=4) 2 FTE 2 FTE
Glaucoma (n=3) 1.75 FTE 2 FTE
Paediatrics (n=2) 2 FTE 3 FTE
Vitreo retinal surgery (n=4) 3.5 FTE 3.5 FTE
Total sub-specialists n=19 Total = 12.5 FTE 14.5 FTE
From a specialty care perspective, most procedures and treatments area available in London – but not all. There are specific procedures that need to be referred elsewhere – certain ophthalmologic cancers for example are treated in Toronto with both pre and post Toronto-based care being provided by local specialists. This is expected to continue.
In addition to the areas of specialization listed above, an ophthalmologist with expertise in complicated anterior segment surgery who deals with complicated cataracts which require non-standard lens is seen as a current service gap. These patients are currently referred to Credit Valley Hospital in the Mississauga - Halton LHIN.
Future State Recommendation 19.0
A new comprehensive ophthalmology position with a special interest and expertise in complicated anterior segment surgery should be recruited by St. Joseph’s Ivey Eye Institute and the Department of Ophthalmology of Western University.
Target of Recommendation:
St. Joseph’s Health Care London
Department of Ophthalmology, Western University South West LHIN
Financial and Resource Impact:
Resources to support a new medical position including office and clinic space, operating room time and related resources
As applicable, research space and resources
Intended Outcome:
Specialty ophthalmic services will meet the changing needs of the population of the South West LHIN and beyond.
Paediatric Ophthalmology
Paediatric patients are defined as patients between the ages of 0-16 years of age. Although paediatric
ophthalmology is a specialty area, general or comprehensive ophthalmologists also work with paediatric patients.
What distinguishes the scope of practice undertaken by a specialist is the complexity of the case, the stability of the patient, the experience of the ophthalmologist and the equipment and clinical support available to him/her.
Strabismus surgery is the most common procedure performed on paediatric patients. Although paediatric ophthalmologists are members of the Division of Paediatric Surgery at London Health Sciences Centre (LHSC) and their positions are funded through the Ministry’s AFP (Alternate Funding Program) for LHSC’s Children’s Hospital
38 physicians, their offices and non-surgical work is based at St. Joseph’s Hospital. Paediatric ophthalmology clinics are not held at LHSC.
At the present time LHSC is currently reviewing the configuration of its ambulatory paediatric surgery clinics and how they can be reconfigured to better meet the needs of children and families. This is the outcome of recent clinical strategy work. There is an opportunity for paediatric ophthalmology to be part of this initiative and to thereby establish a clinical presence at LHSC and at the Children’s Hospital beyond the surgical operating room work.
Future State Recommendation 20.0
LHSC/St. Joseph’s paediatric ophthalmologists should be asked to actively engage in the ambulatory paediatric surgery clinic work at LHSC with a view to being able to offer paediatric ophthalmology clinics at LHSC’s Children’s Hospital.
Target of Recommendation:
St. Joseph’s Health Care London
London Health Sciences Centre – Children’s Hospital Department of Ophthalmology, Western University South West LHIN
Financial and Resource Impact:
Time commitment on the part of the paediatric ophthalmologists to participate in the redesign process
If the process results in an agreement between LHSC and St. Joseph’s to offer paediatric ophthalmology clinics at LHSC, both a financial and resource impact analysis would need to be undertaken.
Intended Outcome:
Paediatric ophthalmology will be a part of the comprehensive range of specialized children’s services provided though the Children’s Hospital of the London Health Sciences Centre.
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Upon review the need for an additional paediatric ophthalmologist has been identified to ensure service needs are met and to improve wait times. To support recruitment of an additional paediatric ophthalmologist operating room time will need to be allocated and an approval from the MOHLTC branch responsible for AFP agreements needs to be obtained. Funds also need to be made available by LHSC and St. Joseph’s to support office and clinic space for this individual.
In Ontario it is the Children’s Hospitals and academic health sciences centres that account for most paediatric ophthalmology work. As a result paediatric ophthalmic surgery takes place in eight of the 14 LHINs in Ontario and they are regional programs – typically drawing patients from outside their home LHIN. The South West LHIN is typical in that the two LHINs on either side [Erie St. Clair and Waterloo Wellington] do not offer this service.
The provincial target wait time for paediatric ophthalmic surgery is 182 days (or 6 months). For the province as a whole this target wait time has never been met since the MOHLTC started collecting wait time data in October 2011. Having said this, the wait times as posted by the MOHLTC vary.
39 Table 6.0 Wait Times for paediatric ophthalmic surgery
Provincial Wait Time [based on data for July, August and September 2014]
(9 out of 10 patients complete their procedures in this time) 190 LHIN specific Wait Time times
LHIN Wait time (in days)
South East 79
Central 100
Mississauga Halton 126
Hamilton Niagara Haldimand Brant (HNHB) 145
Toronto Central 159
South West 208
Central West 220
Champlain 417
Source: MOHLTC Wait Time web site November 2014
The wait time for paediatric ophthalmic surgery in the South West LHIN at 208 days is slightly more than the provincial average of 190 days. It is significantly shorter than the wait time in the Champlain LHIN and significantly longer than the wait time in several other LHINs. Provincially there is significant inequity in wait times.
The following graph profiles paediatric ophthalmic surgery wait times from October 2011 to September 2014 and shows that throughout 2013 wait times in the South West were lower than the provincial average but they have increased since January 2014.
Figure 6.0
40
St. Joseph’s and the Department of Ophthalmology Western University should recruit an additional paediatric ophthalmologist to address current needs in paediatric ophthalmology .
The recruitment of a third pediatric ophthalmologist will provide the opportunity to provide on-site access at Children’s Hospital for inpatient and urgent/emergent assessments of children. This is currently lacking.
Future State Recommendation 21.2
With the recruitment of a third pediatric ophthalmologist steps should be taken to provide inpatient and urgent/emergent assessments of children.
Target of Recommendation:
St. Joseph’s Health Care London London Health Sciences Centre
Department of Ophthalmology, Western University South West LHIN
Ministry of Health and Long-Term Care
Financial and Resource Impact:
Resources to support a new medical position including office and clinic space, operating room time and related resources
As applicable, research space and resources
Intended Outcome:
Specialty pediatric ophthalmology services will be able meet the future needs of the children’s population of the South West LHIN and the Southwest region.
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Configuration of Specialized Ophthalmology Services
In contrast to comprehensive ophthalmology services which tend to serve a largely local population (as defined by the hospitals from which they work or provide call), specialized ophthalmology services serve a much larger, regional catchment area. This was documented in some detail in the Current State of Vision Services report.
The implications of this are important from a patient access perspective. For example, at the present time, two retina specialists from London travel to Kitchener-Waterloo to provide retina clinics. Kitchener-Waterloo has recently attracted a glaucoma specialist as has Windsor. Windsor has also attracted another retina specialist.
In terms of a future state, there may be a continuing need for outreach clinics of this type if the volume of cases does not grow significantly. If it does then a local service may be required as per the recent glaucoma specialist recruitment in Kitchener-Waterloo. The need to think and plan regionally not only applies to Kitchener-Waterloo
41 in the east but also to Erie St. Clair LHIN area, especially Windsor, Sarnia and Chatham to the west and to the North Simcoe Muskoka LHIN area to the east of Owen Sound.
Within St. Joseph’s there are times when a patient needs to see more than one sub-specialist for care and a more coordinated approach to patient navigation should be considered.
In addition, it is not unusual for a person with complex eye care needs to have other medical complexities associated with their health care. When this leads to surgical procedures being performed by St. Joseph’s Health Care London-based ophthalmic sub-specialists, the procedure needs to be completed at London Health Sciences Centre (LHSC) because they have the on-site back-up support should complications arise, whereas St. Joseph’s does not. This is particularly applicable to children and all ophthalmic procedures involving children are done at LHSC. However, for adults the current situation presents complications as LHSC does not have current ophthalmic equipment and special arrangements sometimes need to be made to bring equipment in. OR time and related services can be difficult to negotiate as the ophthalmologists are located at St. Joseph’s, not LHSC and do not have on-going working relationships with LHSC-based providers. When a patient has a complicated medical situation and a complicated eye problem to be corrected, it is very difficult to address both at the same time. This can lead ophthalmologists deciding to opt to transfer their patient to a hospital other than LHSC. LHSC staff and physicians together with St. Joseph’s staff and physicians need to be engaged to address this situation and decide what the future course of action will be.
Future State Recommendation 22.1
When multiple disciplines and/or multiple sub-specialist ophthalmologists are involved in providing care to a specific patient, in the interests of providing patient-centred care, steps should be taken to plan and coordinate care among all the ophthalmologists involved in the patient’s care, as well as with referral sources, related medical disciplines such as endocrinology, and LHSC when multiple medical co-morbidities are involved.
Target of Recommendation:
St. Joseph’s Health Care London
Related medical disciplines involved with a patient receiving sub-specialist ophthalmic care Referral sources to St. Joseph’s sub-specialist ophthalmologists
Financial and Resource Impact:
Time and resources to design, introduce and maintain coordinated care for patients
Intended Outcome:
People with complex or multiple needs will experience, coordinated, patient-centred care.
Future State Recommendation 22.2
Steps should be taken by LHSC and St. Joseph’s to assess their current capacity to address surgical procedures involving patients with complex medical and complex eye care needs at LHSC and determine, in the best interests of patient care, what capacity building is needed to serve this population or what alternatives need to be put in place.
Target of Recommendation:
St. Joseph’s Health Care London London Health Sciences Centre
Financial and Resource Impact:
Resources needed to undertake the current state surgical capacity assessment Resources needed to build capacity if that is the decision that is made
Intended Outcome:
People with complex eye and complex medical needs will receive the level and quality of care they need.
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