HC Deb 19 April 2000 vol 348 cc1073-8

Motion made, and Question proposed,That this House do now adjourn.—[Mr. Pope.]

9.24 pm
Mr. David Crausby (Bolton, North-East)

I am grateful for the opportunity to raise the subject of macular eye disease and so, I hope, to increase awareness of a debilitating disease that is the most common form of registrable visual impairment among the elderly in the western world. Age-related macular degeneration affects 40 per cent. of people aged over 75, despite which it is relatively unheard of.

I first became aware of the problems associated with the disease when I was invited to attend a newly formed macular eye disease group in my constituency. Bolton macular disease group is a self-help organisation comprising people with a common aim of providing support for each other and discussing problems and exchanging ideas on how to cope with their difficulties. The group was formed with the help of the Bolton social services department's visual impairment team, which had done good work for those who suffer from impaired vision.

It is all too fashionable these days to criticise social services departments, and it is a pleasure to highlight the essential work that they do and to congratulate them on it. I pay tribute to the macular group in Bolton and similar groups around the country. They do a tremendous voluntary job in helping sufferers and their partners with advice and support. Most importantly, they reassure people who have the disease that they are not alone. The Bolton group is part of the national Macular Disease Society, which has many branches across the country.

To assist those who are unaware of the problems of macular degeneration, I shall briefly describe the disease. The human eye operates like a camera, the main difference being that a camera has a layer of film in the back while the eye has a layer of tissue—the retina. The image focused on the retina is converted to a digital image that is transmitted through the optic nerve to the brain, where it is perceived as sharply focused vision. The macula is found at the centre of the retina, where incoming rays of light are focused. The macula is responsible for what we see immediately in front of us—the vision that we need for detailed reading or writing. It controls our ability to appreciate colour.

The macula receives most of its nourishment from blood vessels in a deeper layer, which is separated from the macula by a membrane. If the membrane is damaged, the macula does not function properly. If the membrane breaks, new and abnormal blood vessels form to try to repair the damage, but they may bleed and displace the macula. The delicate cells of the macula can sometimes become damaged and stop working. No one seems to know why, but it tends to happen as we get older, although children and young people may also suffer from inherited macular degeneration: indeed, sometimes, several members of a family will suffer.

Macular degeneration impairs your ability to look straight ahead, Mr. Deputy Speaker. There is a blind spot in the centre of your vision. It is always there; it never goes away. It is as if someone were holding a coin six inches in front of your face. You cannot see around the spot, and it will not move away from the centre of vision, regardless of where you look.

Because macular degeneration is normally age-related, it usually involves both eyes, although not necessarily at the same time. For many people, the visual cells simply cease to function, just as the colours fade in an old photograph: that is known as dry degeneration. Fortunately, it is not a painful disease and it never leads to complete blindness, even though it is the most common cause of poor sight in people aged over-60. It never leads to complete loss of sight because only the central vision is affected, so those with macular degeneration will have enough side vision to get about and to maintain their independence. Dry degeneration accounts for the majority of cases; in effect, it is untreatable.

A significant minority of cases are of wet macular degeneration, which is much more severe. However, it is treatable if diagnosed early enough. AMD Alliance International estimates that more than 500,000 people in the UK suffer from various forms of the disease. Between 10 and 15 per cent. of those patients have wet AMD, but they can be treated if the disease is caught early enough.

Every year, throughout the world, 500,000 new patients develop wet AMD; between 40 and 60 per cent. of sufferers will develop the lesions that are the predominant sign of the disease. Patients with that condition lose their ability to read, drive and recognise faces in as little as two months or as long as two years.

Because wet AMD can cause profound and rapid loss of vision, it has been the subject of many years of research by scientists and clinicians throughout the world, and various new treatments have been promoted. New developments are upon us. Only last week, the United States Food and Drug Administration approved an exciting new treatment, and the European Union recommended approval of a treatment involving a combination of laser beams and the drug Visudyne.

Two centres in the UK—Liverpool and Aberdeen—have been taking part in international studies to evaluate photodynamic therapy, which is a new treatment for wet AMD. Last month, the brief results of the second year of the study were released. They demonstrated that the beneficial effects of photodynamic therapy had continued into the second year.

The therapy works by preventing the leaking blood vessels from causing further damage. The procedure takes place in an out-patient clinic and takes about 30 minutes. It starts with a 10-minute intravenous infusion of Visudyne—a light-sensitive dye that sticks to the inner lining of the new vessels. Five minutes after the infusion, the dye is activated by a light shone on to the surface of the eye. The activated dye then damages the vessels, causing them to close.

I should warn hon. Members that photodynamic therapy is beneficial only for certain categories of the disease and that treatment needs to be commenced within six months of the onset of visual deterioration. That is why it is so important to highlight the disease and to encourage awareness and early diagnosis. Of course, Visudyne offers a solution for only a small minority of those with AMD; a much larger majority of sufferers will continue to depend on visual aids, equipment and conventional treatment.

The normal first port of call for those who are experiencing problems with their vision is their optician. The introduction of free eye tests for the elderly from the beginning of this month is of immense importance in the early diagnosis of AMD. Regrettably, far too many elderly people simply could not afford to attend their optician regularly and they could have missed out on early treatment and support.

I am optimistic that regular eye testing will be most helpful in ensuring that people aged over 60 who are at risk of AMD will be able to receive regular eye examinations. The Royal National Institute for the Blind recommends that elderly people should have an eye test every two years. More frequent examinations will obviously result in patients with signs of eye disease being referred for the specialist treatment that they require.

I am concerned, however, that the standard of service from opticians is irregular. I am advised that they do not always effectively test for the disease. A standard optical test involves external examination and internal examination of the eye to detect signs of injury, abnormality or disease, and examination of the retina. The use of an ophthalmoscope would be expected to uncover macular degeneration when it is well established. There is, however, a test known as the Amsler grid, which is designed to map the field of vision and uncover any problems, but there is no requirement for an optician to use this test routinely. I would appreciate it if my hon. Friend the Minister were to investigate the situation.

The second port of call for those experiencing a visual difficulty is usually their general practitioner. They, like opticians, have to decide whether a referral to a consultant is appropriate. This can cause problems with people missing out if the GP is insufficiently trained in recognising when it is necessary to refer a patient to an eye consultant.

It is only when patients see an eye consultant that treatment becomes available, and it is by this time often too late effectively to treat the disease. There is still much that can be done, however, even when vision has deteriorated either through wet or dry degeneration. For example, the patient may be registered as blind or partially sighted, and only the consultant has the authority to make the registration decision. Registration automatically leads to referral to the local social services department, which will instigate action from its visual impairment team or its local equivalent.

If the consultant feels that the patient would benefit from the use of magnifiers or aids of any sort, a referral would be made to the low-vision aid clinic, which is usually part of the same hospital. That clinic will recognise that one of the main difficulties for a patient with AMD will be reading and examining small detail. The clinics are able to measure close as well as distance vision, and can prescribe magnifiers to assist with close work. The optometrist will also advise on the importance of correct lighting levels to enhance the patient's remaining vision.

In addition, virtually all social services departments will have a provision for visually impaired people. Their role is to assist these people in retaining their independence and quality of life. Social services will conduct an initial assessment of the individual's needs.

These days there are numerous aids and pieces of equipment for reading, writing, mobility and general daily life. They include closed circuit television, talking books, magazines and newspapers, big-button telephones, talking watches and clocks, tactile oven controls and even talking microwaves. There are clubs and societies such as the Macular Disease Society, which do such good work in Bolton and which first made me aware of this disabling disease.

My aim in initiating this debate on macular eye disease was to raise awareness of a disability that is so little known and yet affects so many people. I am eager to enlist the Government's support in highlighting and improving the services that are available to sufferers.

As I have said, there are some exciting treatments on the horizon, but the harsh reality is that for the vast majority it is too late to cure the disease. It is not too late, however, to provide modern visual aids. With such rapid strides being made in new technology, there will no doubt be many more exciting prospects available on the horizon.

9.39 pm
The Parliamentary Under-Secretary of State for Health (Ms Gisela Stuart)

I congratulate my hon. Friend the Member for Bolton, North-East (Mr. Crausby) on securing the time for this debate. I hardly need say that sight, and the risk of losing it, is an important subject. Age-related macular degeneration—or AMD—affects about 500,000 people in the United Kingdom, mainly, but not exclusively, the elderly.

Before I enlarge a little on what my hon. Friend has told us about the origins and effects of AMD, I join him in paying tribute to the voluntary organisation that he mentioned in his constituency. The national health service owes much to support given by interest groups that are often formed by the sufferers of particular diseases. Therefore, I extend my appreciation to the work of the Bolton Macular Disease Society.

I shall say a little about the Government's position on possible advances in the treatment of AMD. We have already demonstrated the priority that the Government attach to the eye care of the elderly by the reintroduction of free sight tests for everyone aged 60 or over, but we need to make sure that the national health service stays sensitive to new advances in the treatment of eye disease and can quickly identify the people who might benefit from them.

AMD is the most common cause of sight loss in people over 60. Although it is severely disabling—my hon. Friend described the condition graphically—it seldom leads to complete sight loss because only the central vision is affected. That means that most people with macular degeneration should have enough side vision to maintain a degree of mobility and independence.

I know that some concerns have been expressed that AMD is becoming more common among younger or middle-aged people. In fact, we have always known that people in their 40s contract this condition—congenital sight defects, glaucoma, diabetic retinopathy and AMD each account for about 10 per cent. of people registered blind under the age of 64. However, we are not aware of those figures changing significantly. AMD in particular, and loss of sight more generally, remain in most cases diseases of old age. Out of 300,000 people registered blind or partially sighted, two thirds are over the age of 75.

As macular degeneration is an age-related process, it often involves both eyes, although they may not be affected at the same time. Some people find that their visual cells simply stop working, with an effect—as my hon. Friend described it—a bit like the colours fading in an old photograph. That is known as "dry" degeneration. The dry type is the more common form—we estimate that it affects almost 90 per cent. of those with AMD. The onset of this condition tends to be slow and both eyes are usually affected symmetrically.

Vision tends to deteriorate gradually and the loss is not always severe. Unfortunately, there is not yet a proven treatment for the condition, but the worst effects can be alleviated with low vision aids such as magnifiers, telescopes and, increasingly, closed circuit television cameras that project an enlarged image on a display in front of the patient's eyes. Better lighting and large-print books can also be helpful.

The other type of macular degeneration is known as wet degeneration. It is less common—we estimate that it affects about 10 per cent. of patients with AMD—but it tends to have a more severe and rapid effect on the central area of vision. Blood vessels from one layer at the back of the eye grow in an abnormal fashion into the macular area. These blood vessels may leak or bleed causing a rapid and significant reduction in central vision. That tends to affect one eye at a time, but there is a risk of the same thing occurring in the other eye over the following months.

About 10 per cent. of people with wet AMD—in other words only a very small proportion of all AMD sufferers—might be suitable candidates for laser treatment. It is normally successful only if the condition is picked up early, and even then not all patients are suitable. Unfortunately, with laser treatment there is also the risk that lesions may continue to progress and that vision may become even worse after the treatment.

I am happy to say that, as my hon. Friend suggested, research is under way into a process that offers exciting prospects of increasing the accuracy and effectiveness of laser treatment. The treatment is known as photodynamic therapy and involves the use of a photosensitive dye, which, when activated in the back of the eye by a light source, closes abnormal retina blood vessels. The underlying abnormal blood vessels should then be easily identified and selectively destroyed without damaging the overlying sensory retina.

That research project, which is being conducted at the St. Paul's eye unit in Liverpool, is due to take two years and is now in its second year. As my hon. Friend said, the results so far are promising, but the key test will be whether the treatment offers real and, above all, lasting improvements to the patient's sight.

If, as we all hope, the outcome of the research is positive, we will, as my hon. Friend has emphasised, need to consider carefully whether that means that laser treatment could be provided more widely than it is now. How that consideration should best be done depends in part on the exact outcome of the research. The Government have established a new process for evaluating developments in medical science, and one option would be to ask the National Institute for Clinical Excellence to evaluate the new treatment. Whatever the process for evaluating the research, I can assure my hon. Friend that it will be as quick and as thorough as it needs to be for the welfare of AMD patients and the NHS as a whole.

I would not want to leave my hon. Friend or the House with the impression that the photodynamic project is the only research into AMD. There are no fewer than 19 projects looking at AMD and another 47 which have considered promising options such as sub-macular surgery have recently been completed. I sincerely hope that some of that research leads to more effective treatments for what is a very distressing condition.

If the treatment were endorsed, the next step would be to ensure that the people who might benefit from it were identified and referred as promptly as possible. The measures that we took last year to extend the eligibility for free NHS sight tests to people aged over 60 will be an excellent start.

Ophthalmic opticians, whom I know prefer to be known as optometrists, have practices on almost every high street. When testing someone's sight they are also required to conduct an examination of the health of the eyes. Opticians can already identify the signs of AMD and, with additional advice and training, could single out the cases of wet AMD that might be susceptible to the new treatment. I also envisage a system of local protocols with hospital ophthalmology departments to make sure that patients are referred promptly for treatment.

My hon. Friend mentioned the Amsler grid, which may be used in some cases to highlight visual distortions that may be symptomatic of AMD. That test is not a substitute for regular eye tests, which, if carried out at least every two years, should ensure that any signs or symptoms may be picked up in the early stages when treatment can be effective in preventing sight loss.

People under 60 are also eligible for NHS sight tests if they are on low incomes or predisposed to eye disease. Even for those on higher incomes the cost of a private sight test is seldom more than £18. In the past, we have collaborated with the Royal National Institute for the Blind on publicity campaigns encouraging people to have their sight tested regularly, and if it would help we would not hesitate to mount another effective campaign highlighting the risks to sight from AMD and the benefits of early diagnosis and prompt treatment.

We have also recently announced new measures to tackle the wide variations in service experienced by patients with cataracts. We have asked local services to put forward proposals for a slice of the £20 million that has been allocated for the next two years, which will help to modernise eye surgery. We believe that, with the elderly population increasing, improving the standard of eye care will represent a step towards improving the quality of their lives.

I hope that I have allayed my hon. Friend's fears that we may not be sufficiently responsive to advances in the treatment of this sight-threatening disease. Although we all hope very much that the research will fulfil its potential, I say as a note of caution that we cannot prejudge its outcome. If it is positively evaluated, we have the facilities to ensure that those people who might benefit are promptly identified and treated.

Question put and agreed to.

Adjourned accordingly at eleven minutes to Ten o'clock.