A critical relationship

How important is the relationship between optometrists and ophthalmologists in delivering the best possible glaucoma services to patients?

It is critical. It is only recently that the role of optometrists has been increased with respect to glaucoma. Prior to about 2009, the inference was that the system, under which most optometrists worked, led to an unacceptably high false positive rate. The positive fall out of the response to the National Institute for Health and Care Excellence (NICE) guidance of 2009 led to a greater understanding of the contractual arrangements of NHS sight testing. This has led to numerous enhanced referral schemes around England, but they are dependent on individual clinical commissioning group’s (CCG) perceptions of local needs. Scotland has a well-developed primary care ophthalmic services contract with a national specification for clinical decision-making and referral in glaucoma.

The major public health risk to people with glaucoma is the challenge to follow-up those already under treatment because of stretched resources in hospital eye services. Thus, reducing unnecessary referral by better data collection and decision making in the community and using optometrists to do this by appropriate structures, including funding, and clearer referral guidance is the first step.

Future steps are likely to add to and introduce schemes for community follow up of ocular hypertension (OHT) and low risk glaucoma, which will require good levels of communication especially if the patient requires referral for a change of management plan that might include possible surgical intervention.

How does the relationship currently work and how can it be improved?

For us it is great. We have CCG-funded schemes for enhanced referral, OHT monitoring and stable community management of glaucoma. Optometrists receive reports on what we do, we communicate electronically and we have full discharge summaries. All Herefordshire optometrists delivering on these schemes are qualified to the College of Optometrists Professional Certificate in Glaucoma.

As new glaucoma treatments are developed, especially in the areas of surgical intervention such as trabecular micro-bypass, these lines of communication and criteria to refer back to hospital will need to be clear. In addition, once patients have been successfully treated with trabecular micro-bypass and discharged to community follow-up, the optometrist will need to know what to look for in the event of change.

The major public health risk to people with glaucoma is the challenge to follow-up those already under treatment because of stretched hospital eye services’ resources

We have one consultant locally using trabecular micro-bypass alongside cataract surgery with good outcomes and a reduction in the need for topical medication. We see many patients with intractable ocular surface disease from prolonged topical preservative toxicity, which can cause issues with patient compliance. It would be great for optometrists to hear more about the role trabecular micro-bypass stents have to play in long term glaucoma management. We are looking forward to some wider disseminated continuing education and training in this area.

How should optometrists be talking to patients about their options?

We can be more questioning in terms of target referral criteria and the management of frank ocular surface disease because compliance may lead to earlier re-referral for consideration of trabecular micro-bypass stent surgery.

What role can optometrists play in providing glaucoma aftercare?

We are already doing more in non-surgical follow-up but I would have a clearer idea of when to refer someone back socially if it looks like a minimally invasive trabecular micro-bypass stent might improve the outcome and compliance.