Encountering potential glaucoma as an IP optometrist

The question:

‘An 80-year-old male patient presented for a Minor Eye Conditions Service (MECS) appointment with eye pain and discomfort in both eyes. During history and symptoms, it transpired that he had been referred for suspected glaucoma a year previously during a domiciliary appointment, but had not taken the referral letter to his GP. His pressure was 27mmHg, and he had extensive visual field loss and optic nerve damage. How would you manage?’

OT’s panel says...

Ankur Trivedi (AT): In this situation, the practitioner needs to ask themselves: do I have a higher qualification in glaucoma, as well as an IP qualification? Do I have good links with a local consultant ophthalmologist, ideally with a specialism in glaucoma?

Timely management to preserve the remaining visual field and optic nerve is a concern, but given the possible recent escalation of symptoms of ‘pain and discomfort,’ you would want to look at the possibility of there being a primary angle closure element with a higher intraocular pressure (IOP) today.

Van Herick could be used to gauge the angle, but better would be gonioscopic examination to investigate that. Is there any evidence of a narrow or closed angle, or any peripheral anterior synichae (PAS)?

Further questioning is needed on pro-dromal symptoms, or previous similar episodes. Evidence of iris whorling and/or glaukomflecken would be evidence of previous significant episodes of acute raised IOP.

I would want to know whether there is a Glaucoma Enhanced Case Finding or Glaucoma Enhanced Referral Service in the area.

Ceri Smith-Jaynes (CSJ): There are many reasons for eye pain. At 27mmHg, the pressure isn’t currently high enough to be causing pain, but it could reach a much higher peak out of clinic hours.

I’ll be referring him for glaucoma, but the urgency will depend on whether I think the pain is caused by raised IOP. Acute glaucoma rarely occurs simultaneously in both eyes (although I have seen one patient in the past who this had happened to).

His age is a risk factor. If he is a high hyperope or East Asian, my level of suspicion is raised. If he has mature cataracts, I’ll be concerned, but if he is pseudophakic he’s unlikely to get angle closure. Certain medications will also raise suspicion.

Taking a detailed history and symptoms is crucial here, including: do your eyes go red? Is your vision affected? Does the vision go foggy? Does this happen at the same time as the pain? Is the pain in both eyes at the same time? Does it always happen at the same time of day or night? How long does it last? What sort of pain?

The eye pain will need a full clinical work-up; I’ll be especially interested in the anterior chamber and angles with the slit lamp. We have OCT, but I can only really image the temporal and nasal angles with it. I’m not able to do gonioscopy.

I may be an independent prescriber, but I wouldn’t treat glaucoma, ocular hypertension or primary angle closure myself. I don’t have a higher qualification in glaucoma and it’s not in my scope of practice.

College of Optometrists’ guidance on independent prescribing states: “Optometrist independent prescribers may issue private prescriptions for any licensed medicines for conditions affecting the eye and the tissues surrounding the eye. This must be within your area of expertise and competence.”

It adds that your ‘scope of practice’ is the limit of your own knowledge, skills and experience, in which you can be sure that you are practising safely, effectively and lawfully.   

For me, treating glaucoma just isn’t in my scope of practice. Those with a glaucoma diploma might handle it themselves. Kevin’s words ring in my ears from a lecture he gave: ‘Know your limits.’

Kevin Wallace (KW): I’m glad to hear that Ceri has listened to me. That is an important point – both for legal reasons and just practically, it is important to practise safely. Clearly this patient needs to be treated for glaucoma, and in the absence of anything indicating angle closure I would refer him urgently, flagging the advanced field loss. Obviously primary open angle glaucoma is not an urgent condition but this patient has been left too long, so as Ankur says, it is important to get prompt treatment to retain as much vision as possible.

Diagnosis of glaucoma can only currently be made by an ophthalmologist, so it doesn’t matter if you have a glaucoma qualification. With this level of IOP I wouldn’t normally initiate treatment, but if the patient cannot be seen fairly soon then it would be appropriate to discuss the case with a local ophthalmologist and ask whether they would like to you initiate treatment.  

In this case it doesn’t sound like the pain or discomfort is related to glaucoma, so after ruling that out I would do the usual investigations to look for common conditions like dry eyes and meibomian gland dysfunction, as well as considering something more significant like uveitis.