The potential for optometrists to monitor glaucoma in community practice was the subject of a presentation by Professor Robert Harper at the AOP’s Hospital and Specialty Optometrists Conference (HSOC) 2024.
Harper was delivering the Paul Spry Memorial Lecture, this year entitled Glaucoma, optometry, and the interface of primary and secondary care.
He began his presentation by discussing glaucoma monitoring, citing the Bristol Shared Care Glaucoma Study, which took place three decades ago.
The study provided the first evidence of community optometry being used to measure glaucoma, Harper said.
In the present day, glaucoma care has a “light supply” of qualified staff and is hampered by NHS logistics, but is in high demand due to population demographics, he added.
“There is a substantial capacity problem in the hospital eye service in secondary care, and a great opportunity, as has already commenced, for primary optometry to be more engaged,” Harper later told OT.
He added that this need has become “much more pressing than ever before.”
There is a huge amount of potential for optometry in terms of glaucoma shared care, Harper believes.
Optometry is a large and regulated profession with colleagues who are interested in extended roles and are in a good position to take on postgraduate training, he noted.
There is expected to be a 44% increase in demand for glaucoma care between 2015 and 2035, Harper said.
A strong evidence base
Looking back on 2024, Harper said that the country had voted for change with the result of the general election and the formation of the Labour government.
The optometry sector has been lobbying the government, Harper said, adding that Specsavers hopes to devolve glaucoma services into primary care through its network of more than 900 UK practices.
There is a current emphasis on upskilling within the profession, with funding available for professional certificates and the expansion of the independent prescribing qualification, Harper shared.
He cited the 2021 Transforming glaucoma care pathways: current glaucoma accreditation in UK optometry study as further evidence of the success of glaucoma care in optometry.
The recent Primary Eyecare Glaucoma Service (PEGS) pilot study at Manchester Royal Eye Hospital showed that 94% of glaucoma patients reviewed in the community were suitable for ongoing monitoring in primary care, Harper added.
He noted examples of good practice that already exist, including a community glaucoma service that was launched in Scotland in 2023 and the ability for optometrists in Wales to now filter referrals and monitor glaucoma via WGOS4.
“We’ve got monitoring and treatment with higher levels of autonomy. The higher the level of training and accreditation, the greater autonomy, and arguably, the greater efficiency within the clinic,” Harper said.
The “right clinician, right professional, right setting, right training and accreditation” are what is needed, Harper emphasised, adding: “That doesn’t seem to me to be an unreasonable way of looking at things. Our services of the future need that sort of model.”
He noted that progress is “about collaboration. It is about integration. It is about people recognising that this problem cannot be solved using traditional measures.”
“People need to show the spirit of collaboration,” Harper believes.
Glaucoma in deprived communities
Detection of glaucoma is “a tricky issue,” Harper admitted.
He noted that there are 13 million General Ophthalmic Services (GOS) sight tests yearly in England alone, with more than 95% of glaucoma referrals made by optometrists.
“Referral filtering works,” Harper believes.
However, he added, “we need to think about the people who are not presenting for eye examinations, because these become the people who present very late,” he said.
“There are significant issues there. We talk a lot about equality, but we don’t talk a great deal about inequality.”
Patients living in the most deprived areas face the worst health outcomes, Harper reminded attendees, adding that these patients may be less likely to be prescribed glaucoma medication.
Lack of access to primary care often leads to late presentation, he emphasised, adding that practitioners must consider the patients that they are not currently seeing.
Harper would like to see glaucoma care made economically viable for optometrists in deprived areas, he told OT, as well as the ability for patients in these areas to feel confident attending practices for eye examinations “on a regular basis.”
“I’d like to see some dispelling of the myths around the availability of free sight testing, and to see a sense in which the primary care optometrist is seen as that first port of call, whatever the level of affluence, so that we don’t have a scenario where people present late because they haven’t been to their optometrist for 10 years,” he added.
This scenario would avoid patients presenting with conditions that required immediate surgery, which could have been picked up years earlier had they attended practice, Harper said.
A more innovative GOS model in England, taking lessons from Scotland and Wales, could assist towards this goal, Harper believes.
He emphasised that the GOS fee should be increased in order to empower optometrists to offer a higher level of care and not feel that they have to justify their businesses via other means.
This would also improve perceptions of the importance of eye care among patients, Harper said.
He added that “we need to think about the gap between those who have and those who have not.”
Harper also cited a study from more than 20 years ago, which concluded that “glaucoma should be included among conditions targeted in policy aimed at reducing social inequalities in health.”
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