To refer or not to refer? That is the question
How optomap can aid optometrists in practice
In the complex and evolving world of health care, the relationship between independent optometrist practices and hospital eye clinics is arguably relegated to a peripheral regard - clouded by role interpretations and impeded by territorial wariness.
The introduction of emerging technologies, utilised in both sectors, frequently leads to an increase in referrals and an overload at hospital clinics, according to Simon Browning of Simon Browning Optometrists in Bedford.
He suggests that this is particularly true with the introduction of optomap® ultra-widefield technology from Optos into optometric practices, because ultra-widefield retinal imaging has equipped community practitioners with a far greater clinical scope. He explains that in half a second optomap reveals 82% of the retina in a high definition, digital, single capture, non-contact image. The scan quickly and easily shows 200 degrees of the retina, potentially revealing a significant increase in peripheral pathologies and functional anomalies.
“We have long been taught that the traditional way of looking at the eye was adequate, not really knowing any better. With the advent of the Optos system, we learned that there is a whole world out there, and we have not paid attention to the fact that the periphery of the retina is actually fundamentally important,” says Mr Browning.
"With the advent of the Optos system, we learned that there is a whole world out there, and we have not paid attention to the fact that the periphery of the retina is actually fundamentally important"
He is concerned that optometrists can equip a patient with a false sense of security by traditionally examining the eye and declaring it healthy. He asserts that the patient will assume the entire eye is well, even if flashes or floaters suddenly occur, because he has just recently seen his optician, who told him that his eyes were healthy. “Actually, one could be doing more harm than good. Unless you tell the patient that you are basing a statement of health on only the 10% or 35% of the eye you see, you are in danger of being dreadfully misleading,” he says.
He suggests that the expanding opportunity to acquire more information enhances the entire exam process and enables the optometrist to provide a higher quality of care. “I was incredibly excited because I realised that I had never seen so much of the retina before and suddenly this system was allowing me to see so much more. The periphery is a vital part of the picture. The single (optomap) image that includes the macula is essentially a map that you can methodically work through, directing not only where you may need to focus more attention during the exam, but also what may be around the bend or in the future, if you will, for the patient. It is revolutionising.”
"Historically, when optometrists bring technology such as optomap into their practice, the begin to see more that is unfamiliar and so they refer these patients to specialists. This then creates a flooding of the clinics and, I believe, mostly reciprocates resentment"
He points out that an optometrist, or technician, can obtain views even further into the periphery with eye steering. With an Optos device, an independent practitioner may be utilising a variety of new modalities including a colour composite, red channel (choroidal), green channel (‘red-free,’ sensory retina), as well as autofluorescence (ref 1). “With optomap,” he explains, “the red and green channels allow for efficiency in being able to differentially diagnose. For example, a CHRPE will not be confused with a naevus because it can be seen in both layers.”
Mr Browning, who lectures widely on ultra-widefield and autofluorescence (AF) retinal imaging, has been at the forefront of intensive research on the subject. “AF is the game changer and has revolutionised the way I practice. AF doesn’t only show what’s there, it shows you real time metabolic functionality,” he explains, underscoring that, while the colour image may show a normal eye, the AF image may reveal areas of hyperfluorescence indicating that unless a course change is made, structural damage will occur. Optometrists with the far peripheral view and AF are now seeing the first indications of a problem and can counsel patients to make dietary and lifestyle changes.
He notes that traditional methods of examining the retina are accomplished via a significantly smaller field of view and a thorough examination becomes much more time-consuming and portions may yet be missed. However, this exciting influx of additional information that optometrists are able to see in the eye via ultra-widefield imaging, may also prove disconcerting.
"I am building rapport and really just reassuring ophthalmologists that I do not want to be overwhelming their clinics with my patients because I may not entirely comprehend what I am seeing on the image"
Mr Browning explains that optomap technology enables optometrists to view anomalies and pathologies with which they may not be clinically familiar, and motivated by a desire to best serve the patient, they refer them on to the hospitals. He suggests that this results in a rather dubious regard from the clinical community about optometrists acquiring cutting edge or advanced diagnostic equipment. Browning asserts that he has experienced encouraging successes in cultivating positive relationships in the secondary sector. By first acknowledging the common goal of better patient care and clinical outcomes, Browning takes a somewhat grassroots approach to neglected opportunities of communication between optometrists and ophthalmologists.
Mr Browning, who has utilised optomap since the early days of the technology, has applied a method that builds rapport with the local clinics and cultivates interdisciplinary teamwork. “I identify doctors I feel I can work with and show them sample optomap images – either by bringing them directly to the clinic or taking them out to lunch," he says, adding: “I share with them what I think I’m seeing and then ask them what they think. In this way I am building rapport and really just reassuring them that I do not want to be overwhelming their clinics with my patients because I may not entirely comprehend what I am seeing on the image.”
Mr Browning suggests that by respecting the clinical concerns rather than dismissing them, he establishes a positive conversation about the technology that goes a long way towards successful future collaborative practices.
Mr Browning notes that if he has identified a change or a pathology in the eye that he is fairly certain is not an emergent issue, he will share those images with the ophthalmologist for confirmation that the patient should be monitored for the amount of time that is appropriate. “I let them know at the outset what I believe I am seeing in the image and that it is not my intention to refer the patient at that time, but to monitor them if that is recommended. I let them know that I am seeking their opinion,” he says.
Mr Browning says that in this way, he is partnering with the hospital clinic and alleviating an unnecessary burden. He notes that this process can be streamlined further if the ophthalmologist has installed the review software on his laptop. “I simply email the image to him, he opens it to easily review and this expedites his evaluation and recommendation to monitor or refer,” adds.
The process of cultivating communication which Mr Browning offers, is an important opportunity to strengthen the optometrist’s knowledge base. In discussion over an optomap image, the ophthalmologist may suggest a publication relating to the identified condition or pathology. “I then go and read this paper, or research the subject, and as I learn more, it makes me a better optometrist and results in better patient care,” he says.
He notes that consequently, if and when the patient is evaluated and treated at the hospital clinic, the ophthalmologist will generally refer the patient back to him for regular care knowing that he has the ability to go back and electronically compare the image for accurate change. “We have all these wonderful diagnostic tools within the optomap system and it has allowed us to see and learn more and we can better monitor questionable areas. If we see something that really just needs to be watched for a time, we show the patient what it is and give them the opportunity to go to the hospital to be monitored or stay in the community where we can monitor with optomap. More often than not, they will choose to remain in the community.”
Mr Browning adds that the hospital clinic is then typically happy to be operating in this way because they know that they are not being burdened with the task of general monitoring. As the need arises, they can trust that they can send their patients to Browning’s clinic to be effectively followed up. This then becomes a practice builder. “Optomap sends a very clear message to the hospital about the level of my practice and as the level of trust increases,” says Mr Browning, adding: “The ophthalmologist can comfortably send his private patients to me for general care.”
Mr Browning notes that optomap imaging in UWF colour and AF is valuable to determine whether a patient needs to be referred for immediate treatment, but also can indicate if further diagnostics or other optomap iterations are required (eg UWF fluorescein angiography for diabetes or AMD and ICG for polypoidal, CSCR, Uveitis and other inflammatory eye disease processes). These types of procedures must be conducted in ophthalmology or hospital settings and will guide treatment decisions made by the medical professional.
Emerging studies on both UWF FA and ICG are positioned to strongly direct hospitals to utilise these optomap modalities for best care in earlier detection and treatment. Independent practitioners with optomap will be critically positioned to see the earliest indicators of these types of pathologies and the referral process via optomap images will be streamlined.
For Mr Browning, optomap has been an important component in the AF research in which he has participated. This research has brought him to the leading edge of discovery in connecting changes in the retina and what occurs in the brain in such diseases as Alzheimer’s and dementia. “One of the most exciting possibilities in the way ahead is that we are establishing this link between changes in the retina and the onset of dementia. This will allow earlier intervention with medicines that restrict changes in the brain.” He underscores how optometrists are experiencing increasing opportunities such as these, to contribute to advances in medicine and improve patient care. “It is a staggering thought really that optometrists could be the earliest to intervene in these types of diseases – but we won’t be able to do that unless we are imaging the periphery.”
"He underscores that taking the initial step to identify ophthalmologists and establish dialogue outside the formal clinic is an important avenue to cultivating rapport, building trust and ensuring interdisciplinary and collaborative teamwork"
Mr Browning emphasises that optomap ease-of-use and rapid image acquisition brings efficiency to the independent practice, recovering time to see more patients and invest quality time into patient education as well as giving opportunities to expand the optometrist’s knowledge base. He underscores that taking the initial step to identify ophthalmologists and establish dialogue outside the formal clinic is an important avenue to cultivating rapport, building trust and ensuring interdisciplinary and collaborative teamwork.
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Mr Browning has run his own practice in Bedford for over 30 years. He has previously held posts in the Association of Optometrists and the College of Optometrists. He has been co-chair of his PCT Professional Executive Committee and worked as the Clinical Governance Lead for the Bedfordshire Primary Care Trusts.