Referral refinement for glaucoma
Rustom Bativala on referral refinement in practice
When it comes to setting up a referral refinement system for suspect glaucoma patients in practice, practitioners have to be prepared to invest the time and resources in becoming highly skilled and proficient in this area. It is not something that you can pick up by doing a little here and there – once you start to referral refine, you have to be confident that you are able to do it accurately.
Before you establish a referral refinement scheme, you will need to demonstrate to your locality that you are competent at it. The best way to demonstrate competency is to complete a postgraduate qualification in glaucoma. I completed the diploma some years ago, and it was an excellent vehicle for having formal recognition of competency, as well as giving me the confidence I needed to know that I was refining correctly.
In the beginning
In tandem with studying for a postgraduate qualification in glaucoma, optometrists need to engage with their local eye services, knowing their local systems and protocols, and understand the particular needs of the local population.
Furthermore, I would encourage all optometrists who are thinking about specialising in glaucoma referral refinement to approach their local hospital eye department and to tell them about what they are thinking of doing.
Equipment is important
In my opinion, before practitioners begin referral refining, they should ensure that they have access to the right equipment, as well as be able to demonstrate how to use it and how to interpret the results.
For me, the minimum essential pieces of equipment that optometrists must have for referral refinement is a Goldmann applanation tonometer and Humphrey visual field analyser – I highlight these because both tools are the uniform standards throughout the hospital eye service.
Next, optometrists must be able to provide central corneal thickness measurements (CCT). This is important as CCT is a risk stratification measurement for glaucoma development and needs to accompany refined glaucoma referrals in the modern day.
The next essential skill that has to be learned by everyone working in glaucoma is gonioscopy. This is a difficult skill to acquire and, if I’m honest, took me a number of years to become expert, performing hundreds of gonioscopic examinations in a wide variety of patients, with and without disease.
"Before practitioners begin referral refining, they should ensure that they have access to the right equipment, as well as be able to demonstrate how to use it and how to interpret the results"
Practitioners also need to develop the skills and have the tools required to be able to assess for obvious neuro-ophthalmic disease as these diseases can present as suspect glaucoma.
I stress that the slit lamp that practitioners use when refining for glaucoma must be of excellent quality and at the very least good enough to detect subtle iris transillumination defects. I use a Haag-Streit slit lamp, which, again, is a tool that is uniform in hospital eye departments.
Optometrists should also consider investing in imaging equipment, at least a digital camera. This is important because having photographic documentation of the optic nerves is useful for many reasons. Photos of the optic discs support refined referrals and how urgent the need is for HES assessment.
In my opinion, the most common mistake that practitioners make in glaucoma referral is solely referring on pressures (IOP), unless they are very elevated. I would strongly recommend that if practitioners are concerned, they re-measure IOPs, even a few times, especially if they feel that the optic nerve is healthy. Again, the only caution that is necessary when IOP is elevated, is making sure that the patient is not developing angle-closure or has secondary signs responsible for the raised pressure.
Three steps to success
- Speak to your local eye hospital about your intentions
- Upskill by completing a post graduate diploma in glaucoma
- Invest in the right equipment.