Sir,

I commend Ellis et al (Eye 2006; 20: 521–522) on very clever disguise of their own resistance to change by use of eloquent but nonscientific arguments, clichés, and anecdotes. In simple English, there are following questions that need to be answered before screening for any disease is considered:1

  1. 1

    Is the condition important for individuals or the community?

  2. 2

    Is there effective treatment or management of the condition?

  3. 3

    Is the condition's natural history, especially its evolution from latent to overt, understood?

  4. 4

    Is there a recognisable latent or early stage?

  5. 5

    Is there a valid and reproducible screening test?

  6. 6

    Are facilities available for management of the positive findings, both true or false?

  7. 7

    Is there an agreed management policy?

  8. 8

    Does this management favourably influence the course of the disease?

  9. 9

    Is the cost of case finding and management acceptable in relation to the overall costs of health care?

  10. 10

    Do the potential benefits to true positives outweigh the potential disadvantages for the false positives?

With latest results of antiangiogenic therapies,2 and advances in diagnostic technology,3 I believe the answer to all of the above, except questions 7 and 9, is already ‘yes’ for opportunistic screening of wet age-related macular degeneration (AMD) by trained optometrists. In fact, one of the world's top experts in AMD believes that a much wider screening solution in the population at risk of developing wet AMD should be sought (Personal communication, Dr N Bressler, Wilmer Eye Institute, Johns Hopkins University Hospital, Baltimore, MD, USA, April 2006). As far as cost of treatment is concerned, the growing use of intravitreal injection of diluted (1.25 mg) Bevacizumab (Avastin) in an outpatient setting as currently practiced in US (Observation at a Southern California University hospital, USA, April 2006) will bring down the cost dramatically. The attempt by the proposed patient pathway for detection and treatment of macular degeneration is to suggest a consensus for a management policy among the various health professionals, so that the answers to these questions also becomes ‘yes’ in the UK healthcare system. Ellis et al's article seems to be trying to object to that very consensus. The article left a ‘nagging feeling’ that it was their attitude to the use of an expert optometrist rather than the proposed pathway that was making ‘a bad situation worse.’

Could it be a case of professional rivalry between ophthalmologists and optometrists, I wonder?